Corrective Action Plans

Finding 396065 (2023-010)

Significant Deficiency 2023

NJ

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303

The New Jersey Department of Education (NJDOE) Office of Grants Management (OGM) understands the need to be compliant with FFATA reporting in accordance with the Uniform Guidance. Internal controls and processes are in place to ensure NJDOE’s FFATA reporting process is working efficiently and timely...

The New Jersey Department of Education (NJDOE) Office of Grants Management (OGM) understands the need to be compliant with FFATA reporting in accordance with the Uniform Guidance. Internal controls and processes are in place to ensure NJDOE’s FFATA reporting process is working efficiently and timely. This noncompliance finding is not due to a lack of controls within NJDOE but lies squarely on system issues at SAM.gov and the FFATA Subaward Reporting System (FSRS) sites and until the issues listed below are corrected on these federal system sites, NJDOE will continue to be noncompliant with timely FFATA reporting. Issues with the SAM.gov and FSRS sites: • SAM.gov has approved NJDOE’s local education agency (LEA) registrations without a ZIP+4, but FSRS reporting system for FFATA uploads requires ZIP+4 for each LEA. The two systems use the same database, which means information registered on SAM.gov feeds directly into the FSRS system. However, because FSRS batch uploads require a ZIP+4, those LEAs that were approved by SAM.gov without a ZIP+4 during the registration process, are rejected from the FFATA report batch upload. There is an option to manually load each LEA and their details into the system, but the process becomes incredibly time consuming, given the 700+ LEAs in the state, the number of federal awards granted, and the steps for identifying & removing rejected LEAs from the batch upload. • Issues NJDOE has with SAM.gov and FSRS have been shared with the federal helpdesk and a USED representative without avail, as the systematic issue remains unresolved and continues to delay our FFATA reporting process. • There are several rural LEAs in the state that do not have a ZIP+4. These LEAs will continue to be rejected from the batch upload, delaying our FFATA reporting process, if SAM.gov and FSRS do not come up with a viable solution. • There were a number of LEAs that were continuously rejected from the upload by FSRS for no obvious reasons. The error message received was the same exact error we receive for incorrect zip codes. After spending much time investigating the cause with the helpdesk support, it was identified that FSRS did not update their system to reflect the Congressional District code changes during New Jersey’s redistricting process. • The FSRS system rejects batch uploads if a single lower-case SAM UEIs is entered in the batch file. However, SAM.gov search box and the FSRS manual uploads are not case sensitive. Batch uploads are the only place where SAM UEIs are case sensitive. Further, this information is not included in any of the FSRS User Guides or manuals. I have shared this with the FSRS helpdesk, but no solution was provided. Again, this discrepancy in their system affects and delays our FFATA reporting processes. NJDOE dedicated personnel, including the director of OGM, continuously work with SAM.gov, FSRS system, and both system sites’ help desks, to bring to light the issues mentioned above in order to express the urgent need for corrective actions at the federal system sites to allow for timely FFATA reporting. In addition internal controls and procedures are in place at NJDOE related to FFATA reporting and corrective actions are constantly performed in real time to perform the below NJDOE Internal Controls and Procedures. Some of these procedures include reviewing internal SAM applications and troubleshooting with NJDOE’s local education agencies (LEAs) to correct data in the application and resubmit to the federal reporting system sites with more detail included below. NJDOE Internal Controls and Procedures: • Due to the large number of LEAs in the state (700+), each FFATA report must be submitted via batch upload, which saves an enormous amount of time it takes to input data manually for every single LEA, for every grant. To address this need and to expedite the process, our vendor has created a reporting tool that generates a FFATA batch report. • We have been contacting the federal helpdesk to address the issues on their sites and asking for support. Some of those tickets were closed without providing any support and most were not helpful. • We have created and implemented an in-house System for Award Management (SAM) application, mandatory for all of our federal grant recipients. This was done specifically for FFATA reporting purposes to ensure data in these applications are directly tied to the FFATA batch reports. • The SAM applications go through a thorough review process, where data entered by the districts is compared with the data registered with SAM.gov (applicants are required to upload a copy of their Entity Overview Record, issued by SAM.gov). • SAM applications are returned for changes whenever an applicant has entered data that is inconsistent with data on SAM.gov (i.e.. Incorrect SAM UEI, incorrect zip code, incorrect zip+4, incorrect City name). • We have asked many of our districts to contact SAM.gov and update their physical address information to include the full 9-digit zip code, which was SAM.gov reviewers’ oversight. Our school districts have commented that this process can take months. • We are communicating with our districts/applicants on a daily basis through the review summary checklist, outlining the changes that must be made, as well as by email and phone. • We have implemented an automatic messaging system, where applicants are reminded to update their SAM registration expiration date, multiple times a month leading up to their expiration date. Due to the system discrepancy in the FSRS system’s batch upload, we had to create a workaround pertaining to the district’s SAM UEIs. As stated above, SAM UEIs, in batch FFATA reports, are case sensitive while not case sensitive anywhere else in the two system sites. We have updated our instructions in NJDOE’s SAM application and have added another layer of application review, to ensure that all UEIs entered are in all capital letters. Because the federal helpdesk has ignored this discrepancy and did not resolve the issue, we are obligated to take additional steps and spend additional time on FFATA batch reports. COMPLETION DATE/ CONTACT PERSON Indeterminate – Completion based on federal implementation of fixes to SAM.gov and FSRS portal as noted in views. Martin Egan, Director NJDOE Office of Grants (609) 376-9089 Martin.Egan@doe.nj.gov

View Audit 305672

Finding 396064 (2023-009)

Material Weakness 2023

State of New Jersey

NJ

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303

The New Jersey Department of Education (NJDOE) Office of Grants Management (OGM) understands the need to be compliant with FFATA reporting in accordance with the Uniform Guidance. Internal controls and processes are in place to ensure NJDOE’s FFATA reporting process is working efficiently and timely...

The New Jersey Department of Education (NJDOE) Office of Grants Management (OGM) understands the need to be compliant with FFATA reporting in accordance with the Uniform Guidance. Internal controls and processes are in place to ensure NJDOE’s FFATA reporting process is working efficiently and timely. This noncompliance finding is not due to a lack of controls within NJDOE but lies squarely on system issues at SAM.gov and the FFATA Subaward Reporting System (FSRS) sites and until the issues listed below are corrected on these federal system sites, NJDOE will continue to be noncompliant with timely FFATA reporting. Issues with the SAM.gov and FSRS sites: • SAM.gov has approved NJDOE’s local education agency (LEA) registrations without a ZIP+4, but FSRS reporting system for FFATA uploads requires ZIP+4 for each LEA. The two systems use the same database, which means information registered on SAM.gov feeds directly into the FSRS system. However, because FSRS batch uploads require a ZIP+4, those LEAs that were approved by SAM.gov without a ZIP+4 during the registration process, are rejected from the FFATA report batch upload. There is an option to manually load each LEA and their details into the system, but the process becomes incredibly time consuming, given the 700+ LEAs in the state, the number of federal awards granted, and the steps for identifying & removing rejected LEAs from the batch upload. • Issues NJDOE has with SAM.gov and FSRS have been shared with the federal helpdesk and a USED representative without avail, as the systematic issue remains unresolved and continues to delay our FFATA reporting process. • There are several rural LEAs in the state that do not have a ZIP+4. These LEAs will continue to be rejected from the batch upload, delaying our FFATA reporting process, if SAM.gov and FSRS do not come up with a viable solution. • There were a number of LEAs that were continuously rejected from the upload by FSRS for no obvious reasons. The error message received was the same exact error we receive for incorrect zip codes. After spending much time investigating the cause with the helpdesk support, it was identified that FSRS did not update their system to reflect the Congressional District code changes during New Jersey’s redistricting process. • The FSRS system rejects batch uploads if a single lower-case SAM UEIs is entered in the batch file. However, SAM.gov search box and the FSRS manual uploads are not case sensitive. Batch uploads are the only place where SAM UEIs are case sensitive. Further, this information is not included in any of the FSRS User Guides or manuals. I have shared this with the FSRS helpdesk, but no solution was provided. Again, this discrepancy in their system affects and delays our FFATA reporting processes. NJDOE dedicated personnel, including the director of OGM, continuously work with SAM.gov, FSRS system, and both system sites’ help desks, to bring to light the issues mentioned above in order to express the urgent need for corrective actions at the federal system sites to allow for timely FFATA reporting. In addition internal controls and procedures are in place at NJDOE related to FFATA reporting and corrective actions are constantly performed in real time to perform the below NJDOE Internal Controls and Procedures. Some of these procedures include reviewing internal SAM applications and troubleshooting with NJDOE’s local education agencies (LEAs) to correct data in the application and resubmit to the federal reporting system sites with more detail included below. NJDOE Internal Controls and Procedures: • Due to the large number of LEAs in the state (700+), each FFATA report must be submitted via batch upload, which saves an enormous amount of time it takes to input data manually for every single LEA, for every grant. To address this need and to expedite the process, our vendor has created a reporting tool that generates a FFATA batch report. • We have been contacting the federal helpdesk to address the issues on their sites and asking for support. Some of those tickets were closed without providing any support and most were not helpful. • We have created and implemented an in-house System for Award Management (SAM) application, mandatory for all of our federal grant recipients. This was done specifically for FFATA reporting purposes to ensure data in these applications are directly tied to the FFATA batch reports. • The SAM applications go through a thorough review process, where data entered by the districts is compared with the data registered with SAM.gov (applicants are required to upload a copy of their Entity Overview Record, issued by SAM.gov). • SAM applications are returned for changes whenever an applicant has entered data that is inconsistent with data on SAM.gov (i.e.. Incorrect SAM UEI, incorrect zip code, incorrect zip+4, incorrect City name). • We have asked many of our districts to contact SAM.gov and update their physical address information to include the full 9-digit zip code, which was SAM.gov reviewers’ oversight. Our school districts have commented that this process can take months. • We are communicating with our districts/applicants on a daily basis through the review summary checklist, outlining the changes that must be made, as well as by email and phone. • We have implemented an automatic messaging system, where applicants are reminded to update their SAM registration expiration date, multiple times a month leading up to their expiration date. Due to the system discrepancy in the FSRS system’s batch upload, we had to create a workaround pertaining to the district’s SAM UEIs. As stated above, SAM UEIs, in batch FFATA reports, are case sensitive while not case sensitive anywhere else in the two system sites. We have updated our instructions in NJDOE’s SAM application and have added another layer of application review, to ensure that all UEIs entered are in all capital letters. Because the federal helpdesk has ignored this discrepancy and did not resolve the issue, we are obligated to take additional steps and spend additional time on FFATA batch reports. COMPLETION DATE/ CONTACT PERSON Indeterminate – Completion based on federal implementation of fixes to SAM.gov and FSRS portal as noted in views. Martin Egan, Director NJDOE Office of Grants (609) 376-9089 Martin.Egan@doe.nj.gov

View Audit 305672

Finding 396063 (2023-008)

Significant Deficiency 2023

State of New Jersey

NJ

Questioned Costs Subrecipient Monitoring Reporting § 200.303

The Department of Labor and Workforce Development (DLWD), as the prime recipient of the federal awards, will ensure that all first-tier subawards made to entities totaling $30,000 or greater will be entered timely into the FSRS in accordance with FFATA reporting requirements. The audit sample selec...

The Department of Labor and Workforce Development (DLWD), as the prime recipient of the federal awards, will ensure that all first-tier subawards made to entities totaling $30,000 or greater will be entered timely into the FSRS in accordance with FFATA reporting requirements. The audit sample selections in question were based on manual DLWD notice of awards that were not communicated correctly to staff who are responsible for entering the required subaward information into FSRS. Going forward, DLWD staff who are responsible for entering data into the FSRS will be copied on all emails containing the manual notice of award(s) once the notice is signed by the DLWD Commissioner. These email communications will trigger the information to be entered into the FSRS. COMPLETION DATE/ CONTACT PERSON April 4, 2024 Michael Varga (609) 351-3000 Michael.Varga@dol.nj.gov

View Audit 305672 Questioned Costs: $1

Finding 396059 (2023-006)

Material Weakness 2023

State of New Jersey

NJ

Questioned Costs Subrecipient Monitoring Material Weakness § 200.303

The Department of Labor and Workforce Development (DLWD) transitioned from a manual contract agreement process to a web-based grant administration system in recent years that employs the System for Administering Grants Electronically (SAGE) and IntelliGrants (IGX) applications. The DLWD FFATA Report...

The Department of Labor and Workforce Development (DLWD) transitioned from a manual contract agreement process to a web-based grant administration system in recent years that employs the System for Administering Grants Electronically (SAGE) and IntelliGrants (IGX) applications. The DLWD FFATA Reporting Unit has access to these automated systems and monitors them on a monthly basis to identify when new subaward contracts/agreements are approved in order to report required data in the FFATA system timely. DLWD corrective actions regarding FFATA reporting are expected to be fully implemented as of June 30, 2024. COMPLETION DATE/ CONTACT PERSON June 30, 2024 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

View Audit 305672 Questioned Costs: $1

Finding 396051 (2023-002)

Material Weakness 2023

State of New Jersey

NJ

Eligibility Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

The Reemployment Services and Eligibility Assessments (RESEA) policy and controls presently in place at the Department of Labor and Workforce Development (DLWD) require eligibility interviews to be conducted and eligibility review forms to be completed and signed by the participant and UI program re...

The Reemployment Services and Eligibility Assessments (RESEA) policy and controls presently in place at the Department of Labor and Workforce Development (DLWD) require eligibility interviews to be conducted and eligibility review forms to be completed and signed by the participant and UI program representative. DLWD implemented a new process that allows staff to electronically obtain signatures through Simpligov, beginning June 2023. This process requires that staff obtain all necessary signatures before a RESEA claimant record is completed. Supervisors are assigned to monitor this process in order to mitigate the risk associated with missing information on any single RESEA customer registration. DLWD will monitor this process to ensure that all interviews are properly documented, and forms are signed and electronically uploaded to its electronic case management system of record for future reference. During the initial rollout of this process, there were records that didn’t migrate to the case management system of record. This issue has now been addressed through training. DLWD has also developed dashboards that will assist with monitoring data entry. Monthly reviews of RESEA data entry will be conducted to identify possible errors. These RESEA process changes that will be implemented by DLWD will ensure compliance with regulatory standards and assist with maintaining the integrity of its data management process. COMPLETION DATE/ CONTACT PERSON June 30, 2023 Baden Almonor (609) 777-1042 Baden.Almonor@dol.nj.gov

View Audit 305672

Finding 396030 (2023-002)

None 2023

Jefferson County Local Development Corporation

NY

Subrecipient Monitoring

As noted above in the corrective action to finding 2023- 001, we have notified the organization of their subrecipient status; the requirement to conduct a single audit of its administration of their subaward; and the need to provide the JCLDC with a copy of the organization’s most recent audited fin...

As noted above in the corrective action to finding 2023- 001, we have notified the organization of their subrecipient status; the requirement to conduct a single audit of its administration of their subaward; and the need to provide the JCLDC with a copy of the organization’s most recent audited financial statements and federal single audit reports once completed. We will include these requirements in future subrecipient contracts.

View Audit 305635

Finding 396029 (2023-001)

Significant Deficiency 2023

Jefferson County Local Development Corporation

NY

Subrecipient Monitoring

In future grant awards, JCLDC staff shall review the use of such funds against the federal guidelines for determining whether the recipient is a subrecipient or a contractor. We have also taken action (in a letter dated February 26, 2023) to notify the organization of their subrecipient status and t...

In future grant awards, JCLDC staff shall review the use of such funds against the federal guidelines for determining whether the recipient is a subrecipient or a contractor. We have also taken action (in a letter dated February 26, 2023) to notify the organization of their subrecipient status and their requirement that they conduct a single audit in compliance with Government Accounting Standards and Uniform Guidance requirements.

View Audit 305635

Finding 396004 (2023-004)

Material Weakness 2023

Boys and Girls Clubs of Philadelphia, Inc.

PA

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.329

Out of over 182 compliance records requested, the organization was unable to provide 3 health assessments, all other requested documentation was provided. The missing health assessments were for high school students, who are not required to provide them to attend school and often do not have access ...

Out of over 182 compliance records requested, the organization was unable to provide 3 health assessments, all other requested documentation was provided. The missing health assessments were for high school students, who are not required to provide them to attend school and often do not have access to updated health assessments. We have been directed by the funding agency never to exclude these youth from participation for an inability to obtain a health assessment. BGCP has already taken steps to address these issues. The funding agency, PHMC has begun sending monthly compliance reports. Over the last three months, we have collected 42% of missing health assessments organization wide. Additionally, on our recent FY24 Admin review from PHMC, which included a full compliance report, all of our sites received overall scores of above 95%. We will continue to monitor compliance and follow-up with youth and families to complete needed items.

View Audit 305611 Questioned Costs: $1

Finding 395877 (2023-007)

Significant Deficiency 2023

City of Lawrenceville, Georgia

GA

Subrecipient Monitoring § 200.33 § 200.331

Corrective Action Plan: Management will ensure controls are put in place to adequately monitor all subrecipient monitoring requirements. Anticipated Completion Date: Fiscal Year 2024.

View Audit 305504

Finding 395835 (2023-008)

None 2023

Polson School District

MT

Subrecipient Monitoring School Nutrition Programs

FINDING 2022/2023-008: Audit Report Deadline (Repeated 2021-003) Response: After the last couple years of Business manager and auditor turnover this finding will be easily corrected for the 23-24 audit.

View Audit 305477

Finding 395808 (2023-001)

Significant Deficiency 2023

Aarp Foundation

DC

Questioned Costs Matching / Level of Effort / Earmarking Subrecipient Monitoring

Person responsible for corrective action Emily Allen, SVP Programs Corrective Action The Foundation concurs with this finding. We have worked with the U.S. Department of Labor and the matter is now closed. In February 2024, the Foundation repaid the $435,289 identified in this finding, and a mod...

Person responsible for corrective action Emily Allen, SVP Programs Corrective Action The Foundation concurs with this finding. We have worked with the U.S. Department of Labor and the matter is now closed. In February 2024, the Foundation repaid the $435,289 identified in this finding, and a modified final report has been filed. The Foundation will design and implement additional processes to ensure that earmarking requirements are monitored on a continuous basis by SCSEP staff. In the meantime, the Foundation has implemented additional controls to address the risks of noncompliance with earmarking requirements. Beginning with the March 2024 quarterly report (which was filed on April 9, 2024), all such reports will be reviewed by the Group Controller and Assistant National Director, SCSEP, with specific reference to the earmarking requirements. In the event of any report identifying a risk of noncompliance with the earmarking requirements, the Foundation will immediately raise the matter with our colleagues at the U.S. Department of Labor. Anticipated Completion Date Initial implementation completed, with further control enhancements to be in place by June 30, 2024

View Audit 305433 Questioned Costs: $1

Finding 395765 (2023-001)

Significant Deficiency 2023

Dutchess Community College

NY

Special Tests & Provisions Student Financial Aid Subrecipient Monitoring

CORRECTIVE ACTION PLAN Federal Award Findings and Questioned Costs Finding 2023-001 Student Financial Aid Cluster: Assistance Listing #84.007 Federal Supplemental Educational Opportunity Grants Assistance Listing #84.033 Federal Work-Study Program Assistance Listing #84.063 Federal Pell Grant Progra...

CORRECTIVE ACTION PLAN Federal Award Findings and Questioned Costs Finding 2023-001 Student Financial Aid Cluster: Assistance Listing #84.007 Federal Supplemental Educational Opportunity Grants Assistance Listing #84.033 Federal Work-Study Program Assistance Listing #84.063 Federal Pell Grant Program Assistance Listing #84.268 Federal Direct Student Loans Assistance Listing #93.364 Nursing Student Loans Federal agency – U.S. Department of Education Grant Period – Year ended August 31, 2023 Compliance Requirement: Special Tests and Provisions Criteria: The Gramm-Leach-Bliley Act (Public Law 106-102) (GLBA) requires the College, on an annual basis, to identify reasonably foreseeable internal and external risks to the security, confidentiality, and integrity of customer (student) information that could result in the unauthorized disclosure, misuse, alteration, destruction, or other compromise of such information, and assess the sufficiency of any safeguards in place to control these risks. At a minimum, the GLBA risk assessment should include consideration of risk in each relevant area of operations, including: Employee training and management. Information systems, including network and software design, as well as information processing, storage, transmission, and disposal. Detecting, preventing, and responding to attacks, intrusions, or other system failures. Condition: During our testing, we noted the following: While the IT Systems Team is the assigned resource for information security matters, the College communicated that it does not have a single qualified individual designated with the responsibility for implementing and enforcing the College’s information security program. An annual IT risk assessment was not performed. A vendor management program is not in place. Mobile device management is not in place. Backup media is not encrypted. A full set of policies and procedures is not in place. Cause: The expected documentation supporting the required controls to adequately confirm compliance with GLBA safeguards was not complete. Effect: Without demonstrable, documented controls supporting compliance with the GLBA standards for safeguarding the protected data, compliance with the law and the requirements in the federal PPA may not be assured. Context: Inquiry and observation of the information received from the College related to compliance with GLBA. Recommendation: The College should review the GLBA safeguarding rules and as soon as practical implement and document the controls necessary for compliance with the rule, focusing on the completion of a documented, thorough, and standardized risk assessment and management reporting framework. The College should perform comprehensive risk assessments on a regular basis, which is suggested to be at least annually, and at any significant change in infrastructure or business process. Contact Person Responsible for Corrective Action Plan: Donna Rocap, Associate Vice President of Administration Corrective Action Plan: The College agrees with the findings and is in process of developing a corrective action plan to address. In addition, the College has made it a top priority to hire both a Chief Information Officer and a Chief Information Security Officer but has experienced difficulty getting a qualified pool of candidates. Timing of Planned Corrective Action: The College expects to resolve this finding during its August 31, 2024 fiscal year.

View Audit 305421

Finding 395755 (2023-002)

Significant Deficiency 2023

Occk, Inc.

KS

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Auditors’ Recommendation: We recommend the Agency implement control activities and monitoring procedures to ensure monthly reports that are submitted to the funding agencies are accurately reflecting allowable grant costs. Action Taken: We agree with the finding and have taken the actions as outlin...

Auditors’ Recommendation: We recommend the Agency implement control activities and monitoring procedures to ensure monthly reports that are submitted to the funding agencies are accurately reflecting allowable grant costs. Action Taken: We agree with the finding and have taken the actions as outlined in finding 2023‐001 to fully address and improve the control process. Specifically, Agency management has reviewed the internal processes and enhanced control activities to ensure the mechanic salaries are accurately reported in the monthly operating reports going forward.

View Audit 305387 Questioned Costs: $1

Finding 395702 (2023-001)

Material Weakness 2023

Georgia Center for Oncology Research and Education

GA

Subrecipient Monitoring

The Organization will establish the appropriate personnel to ensure that subaward recipients are monitored on a more frequent basis to ensure it does not exceed the established budget for patients accruing to clinical trials for the federal award during that quarter.

View Audit 305327

Finding 395698 (2023-003)

Material Weakness 2023

Irvington Community Schools, Inc.

IN

School Nutrition Programs Internal Control / Segregation of Duties Subrecipient Monitoring

3. Finding 2023-003. Fund Balance Management Corrective Action: Previous audit year expenses were classified as “General” funds when they should have classified as “Food Service”. This, in aggregate, has led to an excess fund balance. Management, will work with the state on how to transfer the large...

3. Finding 2023-003. Fund Balance Management Corrective Action: Previous audit year expenses were classified as “General” funds when they should have classified as “Food Service”. This, in aggregate, has led to an excess fund balance. Management, will work with the state on how to transfer the large arrear fund balances between accounts. Management will also endeavor to assure that all ongoing expenses are allocated to the correct fund. Responsible Person/Position: Rod Iberg/COO and Linda Heidrich/Staff Accountant

View Audit 305326

Finding 395635 (2023-001)

Significant Deficiency 2023

Community Health Services, Inc.

CT

Special Tests & Provisions Subrecipient Monitoring Eligibility

Community Health Services, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are...

Community Health Services, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program and COVID-19 Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Item 2023-00.1 - Special Tests Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Repeat Finding Yes Action Taken The Center implemented internal controls to mitigate the risk of missing sliding fee discount documentation. The creation of this control consisted of designing a report that would identify all sliding fee discount applicants for the specified timeframe, as well as identify whether supporting documentation had been scanned into the patient's electronic health record. The Director of Development, Grants and Outreach or the Director of Finance and Grants Administration reviews all slide applications before they are scanned and entered into the electronic health record and applied to the patient's account. The Center will continue monthly internal auditing procedures where an Eligibility Specialist haphazardly selects slide applications from the previous month to ensure compliance. As a result of the repeated finding, the Center created an excel template that will accurately calculate and feed the slide result in effort to minimize manual calculation errors. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Dianna Kulmacz, CFO at (860) 808-8765.

View Audit 305248

Finding 395631 (2023-001)

Significant Deficiency 2023

Indiana Health Centers, Inc.

IN

Special Tests & Provisions Subrecipient Monitoring Eligibility

Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health...

Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program and COVID-19 Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Item 2023-001 - Special Tests Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Repeat Finding Yes Action Taken In 2023, IHC implemented each IHC site auditing five accounts per front office staff twice per month that will be reviewed by the Office Manager, Practice Manager, and Director of Operations, with any sliding issues being addressed with the respective front office staff with re education. As this has not resolved all the sliding fee issues, IHC will be implementing two-person verification for sliding fees provided for any eligible IHC patient. The following process will be followed for EVERY patient that presents with Proof of Income (POI). A. When a patient presents to the clinic and provides POI upon checking in or completing an Intake appointment, the Front Office Staff (FOS) will make a copy of the documents provided. B. The FOS will then calculate the income based on the POI provided, showing the work on the copy. C. The FOS will initial the document where the calculations were completed. D. They will then get a second person to verify the calculations were completed correctly and initial the document. E. The initial FOS employee will enter the information into the SFS section of the pt's chart. F. There will be a FOS SFS Two-Person Verification Log to track who verified each patients POI. G. The FOS SFS Two-Person Verification Log will be kept in the LMT Teams file for each site. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Mr. Tracy Nagel, CFO at (317) 576-1335. Sincerely yours, Mr. Tracy Nagel, Chief Financial Officer

View Audit 305245

Finding 395623 (2023-002)

Material Weakness 2023

Zane Trace Local School District

OH

Matching / Level of Effort / Earmarking Subrecipient Monitoring Cash Management

Establishing a better process for federal contract procurement and prevailing wage requirements. Working with outside consultant to ensure vendors meet the federal compliance requirements as well.

View Audit 305229

Finding 395603 (2023-003)

Significant Deficiency 2023

Southwest Organizing Project

IL

Subrecipient Monitoring § 200.332

Finding No. 2023-003 21.027: COVID - 19: Coronavirus State and Local Fiscal Recovery Funds Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate subrecipient risk a...

Finding No. 2023-003 21.027: COVID - 19: Coronavirus State and Local Fiscal Recovery Funds Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate subrecipient risk assessment policy will be put in place to evaluate and monitor subrecipients. Southwest Organizing Project will provide subrecipients with all required Federal awards identifiers. Edith Robles will ensure that Federal award identifiers are included in subrecipients grant agreements.

View Audit 305207

Finding 395602 (2023-002)

Material Weakness 2023

Southwest Organizing Project

IL

Subrecipient Monitoring § 200.332

Finding No. 2023-002 93.391, Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: ...

Finding No. 2023-002 93.391, Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate subrecipients risk assessment policy will be put in place to evaluate and monitor subrecipients. Southwest Organizing Project will provide subrecipients with all required Federal awards identifiers. Subrecipients will be required to provide a single audit when applicable and a signed statement if not applicable. Edith Robles will monitor receipt of single audits during the budgeting process and when closing out programs as well as record keeping for audit and reporting evidence.

View Audit 305207

Finding 395527 (2023-003)

Material Weakness 2023

Denver City Independent School District

TX

Internal Control / Segregation of Duties Subrecipient Monitoring

The person responsible for corrective action is Rick Martinez, Superintendent. Procedures have been implemented to assure the District has no significant deficiencies in internal controls or noncompliance in the future. The District has hired new personnel in key areas and have sought outside help f...

The person responsible for corrective action is Rick Martinez, Superintendent. Procedures have been implemented to assure the District has no significant deficiencies in internal controls or noncompliance in the future. The District has hired new personnel in key areas and have sought outside help from the Region Service Center. 79

View Audit 305182

Finding 395524 (2023-001)

Significant Deficiency 2023

Universidad Teologica Del Caribe, Inc.

PR

Questioned Costs Student Financial Aid Procurement, Suspension & Debarment

Institutional Comments on Findings and Recommendations: Compliance Requirements – Applicable After a Student Begins Attendance: The institution agrees with the auditors on this finding in which there were two (2) cases where the auditors noted that the institution failed to determine that the stud...

Institutional Comments on Findings and Recommendations: Compliance Requirements – Applicable After a Student Begins Attendance: The institution agrees with the auditors on this finding in which there were two (2) cases where the auditors noted that the institution failed to determine that the students withdrew within fourteen (14) days after the student’s last day of attendance. In one (1) of the two (2) cases the Date of Determination was twenty-two (22) days after the Last Day of Attendance and in the second case, the Date of Determination was Three (3) days after the Last Day of Attendance. All funds due to the Department, (for the first case $682.00 of Unsub. Direct Loan funds and in the second case $974.22 of Federal Pell Grant funds), were returned within the forty-five (45) days required timeframe as of the Date of Determination of each case. This process was evidenced to the auditors for their records. Actions Taken or Planned: The institution is fully aware of the Return of Title IV funds (R2T4) reporting requirements and deadlines. The issue related to this finding was identified as a lack in some Faculty notifying student absences within the fourteen (14) day timeframe to process an R2T4 in a timely manner as required. Although this issue was already discussed with them by the Dean of Academic Affairs, an additional follow up meeting would be held to remind them of the importance in monitoring student attendance and notifying student absences to the Registrar office within the required timeframes to fully comply with the R2T4 reporting requirements. Status of Corrective Actions on Prior Findings: The issue as related to this finding occurred in the past audit.

View Audit 305178 Questioned Costs: $1

Finding 395523 (2023-011)

Material Weakness 2023

Arkansas Baptist College

AR

Student Financial Aid Matching / Level of Effort / Earmarking Subrecipient Monitoring

Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to disbursing loans within aggregate loan limits. Responsible Administrators: Director of Financial Aid Effective: Immediately and ongoing

View Audit 305169

Finding 395516 (2023-010)

Material Weakness 2023

Arkansas Baptist College

AR

Student Financial Aid Subrecipient Monitoring Reporting § 200.512

Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to competing and submitting the audit. The College has a new CFO and Controller. These measures will ensure stability and a timely audit. Responsible Administ...

Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to competing and submitting the audit. The College has a new CFO and Controller. These measures will ensure stability and a timely audit. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective immediately and ongoing

View Audit 305169

Finding 395515 (2023-009)

Material Weakness 2023

Arkansas Baptist College

AR

Questioned Costs Student Financial Aid Eligibility

Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to calculating and awarding Pell. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Fin...

Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to calculating and awarding Pell. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing

View Audit 305169 Questioned Costs: $1

Corrective Action Plans

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