Corrective Action Plans

Finding 548695 (2024-012)

Significant Deficiency 2024

State of Utah

UT

Subrecipient Monitoring § 200.332

2024-012. Inadequate SLFRF Subrecipient Monitoring State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury To help staff at DEQ, DNR, and other agencies managing SLFRF funding improve their understanding of the subrecipient requirements and improve internal ...

2024-012. Inadequate SLFRF Subrecipient Monitoring State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury To help staff at DEQ, DNR, and other agencies managing SLFRF funding improve their understanding of the subrecipient requirements and improve internal controls to ensure compliance with these requirements, GOPB will review its ARPA Reference Guide and other ARPA SLFRF training materials to make sure these materials provide adequate guidance, policies, and procedures to agencies managing ARPA SLFRF funding. GOPB will specifically review guidance on the following: • Establishing and following agency policies and procedures to ensure compliance with subrecipient monitoring requirements. • Communicating required federal award information to sub-recipients • Evaluating each subrecipients risk of noncompliance with federal statutes, regulations, and the terms and conditions of the subaward. • Monitor subrecipients according to their assessed risk and as required by 2 CFR 200.332. As part of the process of reviewing these materials, GOPB will work with DEQ and DNR to understand specific areas of guidance, training, or compliance that need to be strengthened. After reviewing and updating the ARPA Reference Guide and other ARPA SLFRF training materials, GOPB will distribute the updated guide to all agencies managing ARPA SLFRF funding. Additionally, GOPB will hold a dedicated training session with both DEQ and DNR, focusing on key areas such as subrecipient compliance requirements, internal controls, risk-based monitoring, Single Audit requirements, and federal compliance standards. GOPB will also maintain a schedule of regular training, site visits, and reviews to ensure ongoing adherence to monitoring protocols and to reinforce internal controls across all agencies. Contact Person: Duncan Evans, Senior Managing Director of Budget and Operations, 801-538-1592 Anticipated Correction Date: November 30, 2024 State Agency: Department of Natural Resources The Department of Natural Resources will review the ARPA Reference Guide and other GOPB ARPA SLFRF training materials provided by Governor’s Office of Planning and Budget to ensure our agency is compliant with managing all SLFRF subrecipient requirements and improve internal controls. DNR will work with GOPB to ensure that key personnel in our agency are doing the following: • Gaining a better understanding of subrecipient requirements and associated internal controls. Water Resources will review the ARPA Reference Guide and GOPB ARPA SLRF training materials to identify internal control weaknesses so they can be addressed. The Finance Manager, Contract/Grants Analyst and Project Funding Section Manager at the Division of Water Resources will also meet directly with GOPB by December 16, 2024 to ensure we understand all subrecipient monitoring requirements. • Establishing and following written policies and procedures to ensure compliance with subrecipient monitoring requirements. The Finance Manager will establish written policies and procedures by December 16, 2024 to ensure compliance with subrecipient monitoring requirements. • Communicating required federal award information to sub-recipients. Federal award information is included in all ARP A contracts executed by the Division of Water Resources and has been since June 2023. Federal award information associated with ARPA contracts executed before June 2023 were subsequently distributed to those grant applicants so that all grantees have the required federal award information. We will continue to review and ensure we are compliant with this requirement. • Evaluating each subrecipient's risk of noncompliance with federal statutes, regulations, and the terms and conditions of the subaward. Since May 2024 Water Resources has been requiring each ARPA grant applicant to fill out a risk assessment questionnaire. We will continue to assess responses to our grant recipients. The Finance Manager and the Project Funding manager will distribute a risk assessment questionnaire to all other grant recipients who have not filled one out yet so we have this information on file for all of our ARPA grantees. This will be completed by December 16, 2024. • Monitoring subrecipients according to their assessed risk and as required by 2 CFR 200.332. The Finance Manager and the Project Funding Manager will meet prior to December 16, 2024 to determine if additional monitoring tools are necessary for any of our subrecipients, which could include site visits, technical assistance, or additional monitoring based upon potential risk. As part of the process of reviewing these requirements, DNR will work with GOPB to understand specific areas of guidance, training, or compliance that need to be strengthened. DNR will work closely with GOPB to ensure specific personnel are trained, focusing on key areas such as subrecipient compliance requirements, internal controls, risk-based monitoring, Single Audit requirements, and federal compliance standards. DNR will ensure that this corrective action plan is implemented and adhered to. State Agency: Department of Environmental Quality DEQ is in the process of hiring a new FTE, one of whose responsibilities will be to review and monitor DEQ’s compliance with sub-recipient monitoring requirements for ARPA and other federal funds. This will ensure that risk assessments, Single Audit report reviews, and other monitoring activities are completed timely, properly documented, and in compliance with federal requirements. Responsible Person: Craig Silotti, Finance Director, 801 536-4460 Anticipated Completion Date: January 31, 2024

View Audit 352012

Finding 548694 (2024-009)

Significant Deficiency 2024

State of Utah

UT

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

2024-009. Unallowable Cash Medical Assistance Benefit Issuances State Agency: Department of Workforce Services Federal Agency: Department of the Treasury All cases cited in error have been reviewed, and all corrective actions have been completed. One-on-one meetings with individual staff who took ap...

2024-009. Unallowable Cash Medical Assistance Benefit Issuances State Agency: Department of Workforce Services Federal Agency: Department of the Treasury All cases cited in error have been reviewed, and all corrective actions have been completed. One-on-one meetings with individual staff who took approval actions on these cases will be scheduled to discuss what led to the incorrect decision and review the policy and procedure for learning. In addition, all eligibility workers who manage refugee programs will receive training on common error elements. All one-on-one meetings and team training will be completed by April 30, 2025. Anticipated correction date: April 30, 2025 Responsible person: Muris Prses, Division Director, Eligibility Services Division, 801-889-9712

View Audit 352012 Questioned Costs: $1

Finding 548693 (2024-007)

Significant Deficiency 2024

State of Utah

UT

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

2024-007. Refugee Grant Expenditures Charged Outside Award Period State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The department will implement a more detailed and thorough review of transactions to ensure that costs are attributed to the applic...

2024-007. Refugee Grant Expenditures Charged Outside Award Period State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The department will implement a more detailed and thorough review of transactions to ensure that costs are attributed to the applicable period of performance in which the work was performed, and expenses were incurred and will ensure that costs are subsequently charged to the corresponding grant award. Anticipated correction date: January 31, 2025 Responsible person: Nathan Harrison, Executive Finance Director, 801-808-0676

View Audit 352012 Questioned Costs: $1

Finding 548692 (2024-006)

Significant Deficiency 2024

State of Utah

UT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

2024-006. TANF ACF-204 Report Does Not Match Supporting Documentation State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The report processes will be updated to add internal controls. The program manager will coordinate with finance staff to review...

2024-006. TANF ACF-204 Report Does Not Match Supporting Documentation State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The report processes will be updated to add internal controls. The program manager will coordinate with finance staff to review all finance documentation utilized for the report. Prior to submission of the report, it will be reviewed by division and finance leadership to ensure the report aligns with documentation and is correct. Anticipated correction date: December 31, 2024 Responsible person: Liz Carver, Division Director, 801-514-1017

View Audit 352012

Finding 548687 (2024-004)

Significant Deficiency 2024

Wilberforce University

OH

Cash Management Subrecipient Monitoring Reporting

We concur with the auditor’s finding. The University has engaged a third party to review our reconciliation procedures and to make recommendations on improvements to our current policy. The recommendations will also include any additional documentation showing proof that the reconciliation has been ...

We concur with the auditor’s finding. The University has engaged a third party to review our reconciliation procedures and to make recommendations on improvements to our current policy. The recommendations will also include any additional documentation showing proof that the reconciliation has been completed as timely as required. The Vice President of Business & Finance and the Director of Student Financial Aid will review the reconciliations. Monitoring reports will be completed and shared with senior management and relevant department leaders. Implementation date: Immediately. Persons Responsible: Vice President for Business and Finance, Controller, and Director of Student Financial Aid.

View Audit 352009

Finding 548679 (2024-002)

Significant Deficiency 2024

City of San Bernardino

CA

Subrecipient Monitoring Reporting

Subrecipient Agreements Significant Deficiency and Non-Material Noncompliance Recommendation: We recommend the City review 2CFR200 to ensure information required in subrecipient agreements is properly included. Corrective Action: The Housing and Homelessness Division is aware of the deficiency ident...

Subrecipient Agreements Significant Deficiency and Non-Material Noncompliance Recommendation: We recommend the City review 2CFR200 to ensure information required in subrecipient agreements is properly included. Corrective Action: The Housing and Homelessness Division is aware of the deficiency identified and is actively coordinating with the City’s legal department to incorporate the required information into the City’s subrecipient agreement templates. Staff will review the 2CFR200 and ensure the required information is incorporated into the City’s sub-recipient agreement templates. Person Responsible for Corrective Action: The Housing and Division Managers, Senior Management Analyst, City’s Legal Department. Anticipated Completion Date for Corrective Action: 8 Weeks from approval of this corrective action plan 2024-03 – Subaward Reporting Requirements for Federal Funding Accountability and Transparency Act (FFATA) Significant Deficiency and Non-Material Noncompliance Recommendation: We recommend the City implement a tracking system to remind staff of the various reports due and respective deadlines. Corrective Action: Develop and implement an agreement routing cover page or other tracking system for all agreements, including sub-recipient agreements. This system will consist of required action items, including various Federal, State, and Local reports due and respective deadlines necessary to comply with sub-award reporting requirements consistent with the Federal Funding Accountability and Transparency Act (FFATA) and other applicable reporting requirements. Person Responsible for Corrective Action: The Housing and Homelessness Division’s Senior Management Analyst Anticipated Completion Date for Corrective Action: 4 Weeks from approval of this corrective action plan.

View Audit 351999

Finding 548660 (2024-002)

Significant Deficiency 2024

Food Lifeline

WA

Allowable Costs / Cost Principles Subrecipient Monitoring Significant Deficiency § 200.303

Corrective Action: Management will track all grant expenditures using separate project codes for each award to ensure specific identification of the direct costs charged. Additionally, at the end of the reporting period, management will perform a reconciliation between the direct costs charged and t...

Corrective Action: Management will track all grant expenditures using separate project codes for each award to ensure specific identification of the direct costs charged. Additionally, at the end of the reporting period, management will perform a reconciliation between the direct costs charged and the total revenues earned under each award to ensure the amounts are consistent with those reported in the schedule of expenditures of federal awards. Anticipated Completion Date: June 30, 2025

View Audit 351990

Finding 548642 (2024-001)

Material Weakness 2024

Women in Safe Homes, Inc.

AK

Subrecipient Monitoring Material Weakness Reporting

Federal Award Finding: 2024-001 Material Weakness in Compliance and Internal Control over Reporting Name and Contact Person: Adrienne Gaines, Executive Director Corrective Action: WISH has evaluated and revised the processes and procedures regarding monitoring of grant reporting and deadlines, as we...

Federal Award Finding: 2024-001 Material Weakness in Compliance and Internal Control over Reporting Name and Contact Person: Adrienne Gaines, Executive Director Corrective Action: WISH has evaluated and revised the processes and procedures regarding monitoring of grant reporting and deadlines, as well as the processes for maintaining records supporting all grant reports, submission details, and corresponding approvals. Management will appoint an individual to oversee this for each grant. Proposed Completion Date: June 30, 2025

View Audit 351973

Finding 548637 (2024-007)

Significant Deficiency 2024

The Shaw University, Inc.

NC

Internal Control / Segregation of Duties Student Financial Aid Subrecipient Monitoring

Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu), University Registrar (Charee Ellison) Corrective Action: The University concurs with the finding and will monitor internal controls to ensure that the return of...

Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu), University Registrar (Charee Ellison) Corrective Action: The University concurs with the finding and will monitor internal controls to ensure that the return of Title IV funds is processed in accordance with federal regulations, specifically within the required 45-day timeframe after determining a student has withdrawn from the university. The university will establish a quarterly audit and monitoring system to review all Title IV fund returns, ensuring compliance with federal guidelines. Anticipated Completion Date: June 30, 2025

View Audit 351972

Finding 548626 (2024-002)

Significant Deficiency 2024

County of Kings, California

CA

Subrecipient Monitoring

Corrective Action Plan: The County (Human Services Agency) acknowledges that, at the time of the FY 2023/24 audit, there was no documented process for completing risk assessments, obtaining copies of single audit reports for each FFA, group home, and STRTP subrecipient, or issuing management decisio...

Corrective Action Plan: The County (Human Services Agency) acknowledges that, at the time of the FY 2023/24 audit, there was no documented process for completing risk assessments, obtaining copies of single audit reports for each FFA, group home, and STRTP subrecipient, or issuing management decision letters as part of a documented monitoring policy and procedure. The County (Human Services Agency) relies on CDSS to perform certain licensing and oversight functions as the single state agency for Title IV-E funds. The County (Human Services Agency) is responsible for and does review these audits and their findings. In response to this finding, the County (Human Services Agency) has established a documented process, implemented in FY 2024/25 documenting risk assessments, obtaining copies of the single audit reports for each FFA, group homes, and STRTPs subrecipient, and issuing management decision letters to ensure compliance. Anticipated completion date June 30, 2025. Contact Information of Responsible Official: Atonya Moore Deputy Director – Fiscal Kings County Human Services Agency 559-852-2214

View Audit 351967

Finding 548623 (2024-102)

Material Weakness 2024

Maricopa County Community College District

AZ

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.334 § 200.430 § 200.513 § 200.521

The District is aware of the importance of maintaining documentation that demonstrates expenditures charged to a program are allocable and allowable. The District will review existing procedures related to the review of temporary workers to ensure that documentation is available to demonstrate charg...

The District is aware of the importance of maintaining documentation that demonstrates expenditures charged to a program are allocable and allowable. The District will review existing procedures related to the review of temporary workers to ensure that documentation is available to demonstrate charges to programs comply with federal guidelines and regulations. The District also recognizes the importance of timely approval of time and effort in compliance with federal regulations. While the District does perform regular reconciliations of expenses to ensure allowability, the District will review and update procedures, as necessary, to continue to improve and document timely supervisory approvals after each bi-weekly payroll is processed in relation to finding 2024-01 in the District’s Report on Internal Controls and Compliance.

View Audit 351965 Questioned Costs: $1

Finding 548619 (2024-003)

Significant Deficiency 2024

City of West Sacramento

CA

Subrecipient Monitoring Reporting Significant Deficiency

The Finance Department is currently implementing procedures to ensure all frequent and infrequent federal compliance requirements are thoroughly reviewed and adhered with for ongoing federal programs.

View Audit 351958

Finding 548605 (2024-002)

Significant Deficiency 2024

City of Madera

CA

Subrecipient Monitoring HUD Housing Programs Period of Performance

Finding 2024-002 Special Tests and Provision – Internal Control and Compliance over Environmental Reviews (Significant Deficiency) Criteria: Title 24 U.S. Code of Federal Regulations sections 58.1, 58.22, 58.34, 58.35, and 570.604 require projects to have an environmental review unless they meet ...

Finding 2024-002 Special Tests and Provision – Internal Control and Compliance over Environmental Reviews (Significant Deficiency) Criteria: Title 24 U.S. Code of Federal Regulations sections 58.1, 58.22, 58.34, 58.35, and 570.604 require projects to have an environmental review unless they meet criteria specified in the regulations that would exempt or exclude them from environmental certification requirements. For projects where the environmental review was not performed, a written documentation that the review was not required must be prepared. Condition and Context: The City could not provide support that there was pre-award or post-award review of grant projects to determine if a project requires an environmental review or is categorically excluded from the environmental review requirements. The City did not have adequate internal controls to ensure compliance with the special test – environmental review requirements. Testing was performed over each requirement for the City. Out of a total population of twelve (12) projects, we selected a sample of four (4) projects to test for environmental reviews. Four (4) out of the four (4) projects tested did not have an exemption report prepared in a timely manner. The sample was not intended to be, and was not, a statistically valid sample. City’s Corrective Action Plan: The City will reinforce its standard operating procedure concerning Environmental Reviews (ER) and will reinsure that environmental reviews are properly completed for every awarded grant project. Contact person responsible for corrective action: Michael Lima, Finance Director Anticipated completion date: June 30, 2025

View Audit 351953

Finding 548601 (2024-001)

Significant Deficiency 2024

City of Madera

CA

Subrecipient Monitoring Reporting § 200.208 § 200.303 § 200.328 § 200.344

Finding 2024-001 Reporting – Internal Control and Compliance over Reporting (Significant Deficiency) Criteria: Code of Federal Regulations, Title 2 – Federal Financial Assistance, Subtitle A – Office of Management and Budget Guidance for Federal Financial Assistance, Chapter II – Office of Managem...

Finding 2024-001 Reporting – Internal Control and Compliance over Reporting (Significant Deficiency) Criteria: Code of Federal Regulations, Title 2 – Federal Financial Assistance, Subtitle A – Office of Management and Budget Guidance for Federal Financial Assistance, Chapter II – Office of Management and Budget Guidance, Part 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Subpart D – Post Federal Award Requirements: Performance and Financial Monitoring and Reporting Section § 200.328 Financial reporting. (a) The Federal agency must require only OMB-approved government-wide data elements on recipient financial reports. At the time of publication, this consists of the Federal Financial Report (SF-425); however, this also applies to any future OMB-approved government-wide data elements available from the OMB-designated standards lead. (b) The Federal agency or pass-through entity must collect financial reports no less than annually. The Federal agency or pass-through entity may not collect financial reports more frequently than quarterly unless a specific condition has been implemented in accordance with § 200.208. To the extent practicable, the Federal agency or pass-through entity should collect financial reports in coordination with performance reports. (c) The recipient or subrecipient must submit financial reports as required by the Federal award. Reports submitted annually by the recipient or subrecipient must be due no later than 90 calendar days after the reporting period. Reports submitted quarterly or semiannually must be due no later than 30 calendar days after the reporting period. (d) The final financial report submitted by the recipient must be due no later than 120 calendar days after the conclusion of the period of performance. A subrecipient must submit a final financial report to a pass-through entity no later than 90 calendar days after the conclusion of the period of performance. See also § 200.344. The Federal agency or pass-through entity may extend the due date for any financial report with justification from the recipient or subrecipient. Section § 200.303 Internal Controls The recipient and subrecipient must: (a) Establish, document, and maintain effective internal control over the Federal award that provides reasonable assurance that the recipient or subrecipient is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should align with the guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control-Integrated Framework” issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). (b) Comply with the U.S. Constitution, Federal statutes, regulations, and the terms and conditions of the Federal award. Condition and Context: For the Community Development Block Grants/Entitlement Grants Cluster, the City did not submit the reports within the required deadline: Report Type Award Number Period Date Due Date Submitted SF-425 Financial Program-wide reporting 7/1/2023 - 9/30/2023 10/30/2023 1/16/2024 SF-425 Financial Program-wide reporting 1/1/2024 - 3/31/2024 3/30/2024 7/24/2024 Four (4) quarterly financial reports were tested, and two (2) reports were not submitted by the required deadline. City’s Corrective Action Plan: The City has already taken steps to improve its processes/procedures to insure timely submission of all required SF-425 reports. Contact person responsible for corrective action: Michael Lima, Finance Director Anticipated completion date: June 30, 2025

View Audit 351953

Finding 548591 (2024-001)

Material Weakness 2024

The Connecticut Institute for the Blind, Inc.

CT

Questioned Costs Period of Performance Subrecipient Monitoring

Office of Management and Budget (0MB) AUDIT FINDINGS Federal Awards Findings: Finding Reference Number: 2024-001 Description of Finding: As per the Department of Health and Human Services, HRSA Notice of Award to the organization and the Construction Projects (HRSA-23-117) Program Guidance docu...

Office of Management and Budget (0MB) AUDIT FINDINGS Federal Awards Findings: Finding Reference Number: 2024-001 Description of Finding: As per the Department of Health and Human Services, HRSA Notice of Award to the organization and the Construction Projects (HRSA-23-117) Program Guidance document issued by HRSA, HRSA requires award recipients to seek prior approval through the Electronic Handbook for all pre-award costs. The organization incurred pre-award costs under the award; however, such costs were not submitted to HRSA for prior approval and thus, prior approval was not obtained. Statement of Concurrence or Nonconcurrence: The Organization is in agreement with this audit finding. Corrective Action: All grantor award guidelines will be reviewed by the Director of lnnovation & Grants and the Senior Director of Development to ensure all compliance requirements are interpreted and understood the same. If there is not a consistent understanding, then the Chief Development Officer wiIl review the guidelines. Name of Contact Person: Christine Leiby CFO; Telephone number: 860-769-3839; Email address: Christine.Leiby@oakhillct.org. Projected Completion Date: If the Office of Management and Budget requires any additional information or has questions regarding this Plan, please call Christine Leiby at the telephone number listed above.

View Audit 351933 Questioned Costs: $1

Finding 548583 (2024-005)

Material Weakness 2024

Dartmouth-Hitchcock Health and Subsidiaries

NH

Eligibility Procurement, Suspension & Debarment Subrecipient Monitoring

Management agrees with the finding regarding Cheshire Medical Center’s eligibility and allowable costs. Management will implement a control starting with the month ending April 30, 2025, to conduct a retrospective review of patient service revenue charges incurred during that month and allocate cost...

Management agrees with the finding regarding Cheshire Medical Center’s eligibility and allowable costs. Management will implement a control starting with the month ending April 30, 2025, to conduct a retrospective review of patient service revenue charges incurred during that month and allocate costs in a manner that aligns with the eligibility and income requirements of the award. Using this methodology, management will identify the eligible population and appropriately incur allowable expenses associated with the award. Management will initiate a bi-weekly process to review upcoming appointments and the most recent eligibility check on recurring patients. If, during this process, a patient is identified who requires an eligibility check based on award criteria (i.e., whichever is later: four weeks or the individual's next appointment), Management team will perform re-enrollment procedures to validate that the individual is still eligible. Leadership Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: June 30, 2025

View Audit 351922

Finding 548401 (2024-004)

None 2024

Dartmouth-Hitchcock Health and Subsidiaries

NH

Equipment & Real Property Management Subrecipient Monitoring § 200.313

Management agrees with the finding related to Equipment Management. Management conducted a biannual physical inventory count of specific federally purchased research equipment in Fiscal Year 2024. Management did not include all required fields within the clinical engineering database as required by...

Management agrees with the finding related to Equipment Management. Management conducted a biannual physical inventory count of specific federally purchased research equipment in Fiscal Year 2024. Management did not include all required fields within the clinical engineering database as required by 2 CFR section 200.313 (d) (1) such as the percentage of Federal participation in the project costs for the Federal award under which the property was acquired, asset location and the use and condition of the equipment. Management will update the clinical engineering database to include these fields within the details by June 30, 2025. Management did not verify the completeness of the listing against the entire federal equipment inventory. Management will establish a quarterly control in which Research Finance will reconcile federal equipment inventory within the clinical engineering database against the Corporate Finance federal equipment listing, starting with the quarter ending March 31, 2025. Leadership Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: June 30, 2025

View Audit 351922

Finding 548398 (2024-003)

None 2024

Dartmouth-Hitchcock Health and Subsidiaries

NH

Subrecipient Monitoring Procurement, Suspension & Debarment § 200.308

Management agrees with the finding related to Key Personnel Change Approval at our member, Cheshire Medical Center. The post-award management of this grant is currently handled outside of the Dartmouth Health Research Finance and Post-Award department. Management aims to centralize this function by ...

Management agrees with the finding related to Key Personnel Change Approval at our member, Cheshire Medical Center. The post-award management of this grant is currently handled outside of the Dartmouth Health Research Finance and Post-Award department. Management aims to centralize this function by December 31, 2025. In the interim, Dartmouth Health Management will provide training to award operational staff to implement policies that align with the centrally managed awards by June 30, 2025. Specifically, the Member will conduct a monthly review of key personnel efforts to identify any potential changes that require notification to the New Hampshire Department of Health and Human Services or any award sponsor in which the Key Personnel Change compliance requirement is required. Leadership Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: June 30, 2025

View Audit 351922

Finding 548202 (2024-002)

None 2024

Dartmouth-Hitchcock Health and Subsidiaries

NH

Subrecipient Monitoring Allowable Costs / Cost Principles HUD Housing Programs § 200.430

Management agrees with the finding related to effort certifications. Dartmouth-Hitchcock published a new effort policy on February 11, 2025, for all research staff to emphasize the importance of Principal Investigators and Research Staff certifying their efforts on grants promptly. Management will b...

Management agrees with the finding related to effort certifications. Dartmouth-Hitchcock published a new effort policy on February 11, 2025, for all research staff to emphasize the importance of Principal Investigators and Research Staff certifying their efforts on grants promptly. Management will begin implementing and enforcing the policy starting with the quarter ending March 31, 2025. Leadership Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: March 31, 2025

View Audit 351922

Finding 548012 (2024-001)

None 2024

Dartmouth-Hitchcock Health and Subsidiaries

NH

Subrecipient Monitoring HUD Housing Programs

Management agrees with the finding related to cost transfer approval. The Dartmouth-Hitchcock Office of Research Operations experienced significant turnover in Fiscal Year 2024. Management will provide training materials for all new and existing staff in both the Research Post-Award and Research Fi...

Management agrees with the finding related to cost transfer approval. The Dartmouth-Hitchcock Office of Research Operations experienced significant turnover in Fiscal Year 2024. Management will provide training materials for all new and existing staff in both the Research Post-Award and Research Finance areas to reemphasize the Cost Transfer Policy. Additionally, management will review the current policy on cost transfers to determine whether any updates are needed to better align with current business practices and compliance requirements by June 30, 2025. Leadership Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: June 30, 2025

View Audit 351922

Finding 548010 (2024-001)

Material Weakness 2024

County of Shasta

CA

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness

The County will implement procedures to ensure suspension and debarment checks are performed for all vendors. The County will also provide direction to staff involved in the preparation on contracts to ensure compliance. The County commits to mitigate the risks associated with engaging vendors who...

The County will implement procedures to ensure suspension and debarment checks are performed for all vendors. The County will also provide direction to staff involved in the preparation on contracts to ensure compliance. The County commits to mitigate the risks associated with engaging vendors who may be ineligible for federal funding.

View Audit 351917

Finding 547987 (2024-003)

Material Weakness 2024

Umpqua Public Transportation District

OR

Cash Management Subrecipient Monitoring Material Weakness § 200.302 § 200.328 § 200.329

Finding 2024-003 – Fiscal Management (Material Weakness) CFDA Title and Number: 20.513 (5310) Enhanced Mobility of Seniors and Individuals with Disabilities. Name of Federal Agency: Department of Transportation Internal Control over Compliance: Cash Management CFDA Title and Number: 20.509 (53...

Finding 2024-003 – Fiscal Management (Material Weakness) CFDA Title and Number: 20.513 (5310) Enhanced Mobility of Seniors and Individuals with Disabilities. Name of Federal Agency: Department of Transportation Internal Control over Compliance: Cash Management CFDA Title and Number: 20.509 (5311) Operating Assistance. Formula Grants for Rural. Name of Federal Agency: Department of Transportation Internal Control over Compliance: Cash Management Criteria: 2 CFR Part 200.302(b)(1) The financial management system of each non-federal entity must provide for the following: Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. 200.302(b)(2) Accurate, current, and complete disclosure of the financial results of each Federal award or program in accordance with the reporting requirements set forth in 200.328 and 200.329. Condition: During portions of the fiscal year, the District prepared reimbursement calculations relying on an internally developed spreadsheet tool, rather than using amounts solely obtained from the general ledger and supporting documentation. The reimbursement reports were prepared by management with limited review. Conflicts over review and other monitoring procedures occurred, and were not always resolved. Complete supporting documentation for the claimed costs were not always available. Claims and other financial reports due to ODOT were regularly submitted after the due dates. The late and/or unsubstantiated filings have resulted in lost claims for the District, and potential refunding of reimbursements received. Cause: Internal control procedures assuring timely and accurate preparation of reports and filing of the reimbursement requests were not designed or implemented adequately. Maintaining sufficient and accurate supporting documentation for each report was not possible because original data was not relied upon by management, to complete the reports and reimbursement requests. Effect or Potential Effect: The lack of effective internal control activities over cash management, including financial reporting, allowed for reporting and claims errors, from simple calculation errors to requests for reimbursements of unauthorized purposes. Improper financial reporting to the ODOT occurred regularly. Lack of timely filing of reimbursement requests for amounts claimed, resulted in lost revenues and claims that may be required to be returned. Questioned Cost: No Context: Delays in filing reimbursement claims, delays in filing financial reports to ODOT, and internal disputes regarding completion of grant reimbursement request procedures were evident. Weak or nonexistent controls over cash management, including fiscal management, may result in lost revenues and risks of creating unnecessary liabilities in the form of refunds due to ODOT. Repeat of a Prior-Year Finding: Yes Recommendation: The District should design and implement internal control policies and procedures for cash management, including fiscal management and financial reporting. Monitoring, information and communication control activities should also be designed and implemented as part of the effort the reduce the risk of continued matters of noncompliance related to cash management. District's Response: The District acknowledges the weaknesses and its intention of correcting weaknesses. Corrective Action Plan: The District’s General Manager resigned effective September 13, 2024. The Board has adopted a plan to procure qualified professional assistance to evaluate and restructure the organization and assist in daily management activities until a new General Manager can be hired and trained. Additional assistance for resolving these deficiencies has been offered by ODOT and accepted by the Board. Planned Implementation Date: October 31, 2024 Responsible Persons: District Board, Umpqua Public Transit District

View Audit 351895

Finding 547985 (2024-101)

Material Weakness 2024

Maricopa County

AZ

Subrecipient Monitoring Procurement, Suspension & Debarment Reporting § 200.303

Concur: The Maricopa County Human Services Department will update its procedures involving subaward actions as required by FFATA and Federal Uniform Guidance. These internal procedures will include reporting subaward actions equaling or exceeding more than $30,000 no later than month-end following t...

Concur: The Maricopa County Human Services Department will update its procedures involving subaward actions as required by FFATA and Federal Uniform Guidance. These internal procedures will include reporting subaward actions equaling or exceeding more than $30,000 no later than month-end following the subaward action. Additionally, the Department has updated all tracking listings and will ensure all grants contracted through other departments and amendments are included. On February 27, 2025, the Department completed and submitted the required FFATA form to USAspending.gov.

View Audit 351894

Finding 547950 (2024-009)

Material Weakness 2024

State of Hawaii Department of Health

HI

Subrecipient Monitoring Reporting

Reporting - FSRS Block Grants for Prevention & Treatment of Substance Abuse - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will meet with the program staff to complete the implementation of the policies and procedures relating...

Reporting - FSRS Block Grants for Prevention & Treatment of Substance Abuse - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will meet with the program staff to complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS system to comply with the Federal reporting requirements. Implementation Date: July 1, 2025 Responding Official: John Valera and Melanie Muraoka, Administrative Officer/Alcohol and Drug Abuse Division

View Audit 351885

Finding 547949 (2024-008)

Material Weakness 2024

State of Hawaii Department of Health

HI

Subrecipient Monitoring § 200.331

Subrecipient Monitoring Non-compliance with its inconsistent documented monitoring procedures. Corrective Action Plan: AMHD will review and revise their monitoring procedures to ensure that subrecipient expenditures are monitored and single audit reports are reviewed, as applicable. Implementation D...

Subrecipient Monitoring Non-compliance with its inconsistent documented monitoring procedures. Corrective Action Plan: AMHD will review and revise their monitoring procedures to ensure that subrecipient expenditures are monitored and single audit reports are reviewed, as applicable. Implementation Date: July 1, 2025 Responding Official: Chanel Daluddung, Performance, Information, Evaluation and Research Branch Chief, Adult Mental Health Division

View Audit 351885

Corrective Action Plans

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