Corrective Action Plans

Finding 391559 (2023-006)

None 2023

NY

Special Tests & Provisions Subrecipient Monitoring Matching / Level of Effort / Earmarking

Finding No. 2023-006 Department(s): New York City Department of Housing Preservation and Development Program(s): Assistance Listing Number 14.239, HOME Investment Partnership Program Corrective Action(s): The Department of Housing Preservation and Development (HPD) continues to maintain processes ...

Finding No. 2023-006 Department(s): New York City Department of Housing Preservation and Development Program(s): Assistance Listing Number 14.239, HOME Investment Partnership Program Corrective Action(s): The Department of Housing Preservation and Development (HPD) continues to maintain processes and procedures supporting compliance with Housing Quality (HQ) inspection standards. HPD routinely conducts HQS inspections of HOME Investment Partnership Program assisted rental units and continues to maintain systems to facilitate and promote compliance with HOME inspection requirements; HPD inspects HOME units periodically and follows up on failed inspections routinely. Further, HPD continues to review program requirements and operations to enhance program oversight and ensure the timeliness of repairs. As part of HPD’s ongoing effort to accomplish complete and timely repairs of all HOME units, building owners are notified of failed inspections, and regularly provided with detailed reports identifying non-compliant conditions. HPD also continues to impress upon owners the critical importance of completing timely repairs of all HOME units. Building owners are notified of failed inspections and provided detailed reports regularly, identifying non-compliant conditions. With respect to the finding, HPD recognizes that in six (6) instances, the Certification of Repair was not submitted within the 90-day timeframe. HPD is currently sending out non-compliance letters and will continue to follow-up with the owner(s) until all required repairs are certified as complete. In addition, HPD will consider, on a case-by-case basis, documenting its rationale for not exercising extreme remedies (such as withdrawal of future funding) for failure to complete repairs within the 90-day cure period. Anticipated Completion Date: June 2023 and ongoing Person(s) Responsible for Implementation: Arabia Brown, Director, Tax Credit and HOME Compliance (212) 863-8204

View Audit 302042

Finding 391544 (2023-002)

Material Weakness 2023

Northern New Mexico College

NM

Subrecipient Monitoring

Responsible Official ‐ Denise Montoya, Vice President for Finance & Administration, Theresa Storey CFO, Nick Ekhart, Grant Manager; Stephanie Lovato; The college through the grants manager has increased communication which will alleviate this finding regarding compliance

View Audit 302021

Finding 391538 (2023-001)

None 2023

City of Tucker, Georgia

GA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

The Finance Department personnel will carefully review vendor status in the System for Award Management and produce documentation of eligibility for use of Federal Funds before procurement of goods and services.

View Audit 302016 Questioned Costs: $1

Finding 391531 (2023-103)

Significant Deficiency 2023

Espiritu Community Development Corporation

AZ

Subrecipient Monitoring Internal Control / Segregation of Duties

Condition and Context: The School used funding from the grant to complete renovation and construction projects. The School requested the contractors to provide certified payroll reports in the proposal meetings, however they did not obtain the reports from the contractors. Recommendation: The aud...

Condition and Context: The School used funding from the grant to complete renovation and construction projects. The School requested the contractors to provide certified payroll reports in the proposal meetings, however they did not obtain the reports from the contractors. Recommendation: The auditors recommend that the School establish a system of monitoring contracts for construction greater than $2,000 in which the wage rate requirement exists and verify the certified payroll reports are received prior to payment. Contact Name: Anastacia Europa Ruiz, Chief Operating Officer Corrective Action Planned: Moving forward, the management team will include the remittance of a certified payroll report in the scope of work when obtaining bids for federally funded construction projects as a primary condition of awarding the contract. Anticipated Completion Date: June 30, 2024

View Audit 302013

Finding 391515 (2023-102)

Significant Deficiency 2023

Espiritu Community Development Corporation

AZ

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.327

Condition and Context: The four quarterly reports were not filed within the 30 days required by the contract. Recommendation: The auditors recommend that the School establish a system of monitoring for the filing of all required reporting and that the chief operating officer review the monitoring ...

Condition and Context: The four quarterly reports were not filed within the 30 days required by the contract. Recommendation: The auditors recommend that the School establish a system of monitoring for the filing of all required reporting and that the chief operating officer review the monitoring list on a regular basis consistent with the timing of report filings. Contact Name: Anastacia Europa Ruiz, Chief Operating Officer Corrective Action Planned: The management team will establish a system for monitoring all required reporting deadlines. This system will be designed to track the filing requirements for each grant and contract, ensuring that deadlines are clearly identified and adhered to. The Chief Operating Officer will be designated as the responsible authority for overseeing the monitoring process. They will review the monitoring list on a regular basis, ensuring that all required reports are filed in a timely manner. The grant team will institute regular compliance reviews to assess our adherence to reporting deadlines and identify any areas for improvement. Anticipated Completion Date: June 30, 2024

View Audit 302013

Finding 391471 (2023-002)

Material Weakness 2023

University of Maryland Medical System Corporation

MD

Reporting Subrecipient Monitoring Material Weakness

University of Maryland Medical System Corporation and Subsidiaries Corrective Action Plan Year Ended June 30, 2023 University of Maryland Medical System Corporation and Subsidiaries (the Corporation) respectfully submits the following corrective action plan for the year ended June 30,2023. Audit p...

University of Maryland Medical System Corporation and Subsidiaries Corrective Action Plan Year Ended June 30, 2023 University of Maryland Medical System Corporation and Subsidiaries (the Corporation) respectfully submits the following corrective action plan for the year ended June 30,2023. Audit period: July 1, 2022 to June 30, 2023 MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE 2023-002 Reporting of Schedule of Expenditures of Federal Awards Assistance Listing Number 97.036 – COVID-19 – Disaster Grants – Public Assistances (Presidentially Declared Disasters) Recommendation: The Corporation’s policy and procedures should be designed to ensure expenditures are reported on the Schedule based on the date on which the expenditures are incurred as required by the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management will continue to refine internal procedures and practices. The COVID-19 pandemic grant programs included evolving expectations which did not follow the typical grant process. We will enhance procedures to review related report submissions, obligated worksheets, and incurred expenditures in conjunction with review of the Schedule to verify completeness and accuracy. Planned completion date for corrective action plan: September 30, 2024 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu

View Audit 301956

Finding 391459 (2023-001)

Significant Deficiency 2023

City of Westminster, Maryland

MD

Subrecipient Monitoring Reporting Significant Deficiency

The finance department experienced staff turnover and vacancies during the fiscal year, impacting the fiscal year end close processes. We have consulted with a fractional CFO and are now fully staffed. We are working to remedy the items noted above by assessing our current procedures and implementin...

The finance department experienced staff turnover and vacancies during the fiscal year, impacting the fiscal year end close processes. We have consulted with a fractional CFO and are now fully staffed. We are working to remedy the items noted above by assessing our current procedures and implementing changes for more effective and efficient financial reporting. We are also in the final stages of selecting new ERP software, which would be implemented during fiscal years 2025 and 2026 to allow for more streamlined processes to be implemented. We will be developing comprehensive year end close and audit preparation procedures that will ensure a timely close of the fiscal year.

View Audit 301948

Finding 391444 (2023-003)

None 2023

Cobb County Board of Health

GA

Subrecipient Monitoring § 200.330 § 200.332

Views of Responsible Officials and Planned Corrective Action: The Board agrees with this recommendation and will review monitoring procedures relating to subrecipients.

View Audit 301940

Finding 391398 (2023-005)

Significant Deficiency 2023

Bethany Lutheran College, Inc.

MN

Student Financial Aid Subrecipient Monitoring Significant Deficiency

Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.038, 84.268, 84.033, 84.007, 84.063 Recommendation: We recommend that the College review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There ...

Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.038, 84.268, 84.033, 84.007, 84.063 Recommendation: We recommend that the College review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College will review the updated GLBA requirements to ensure Bethany is compliant with all the WISP required elements. Name of the contact person responsible for corrective action: John Sehloff, Director of Information Technology Planned completion date for corrective action plan: June 30, 2024

View Audit 301916

Finding 391374 (2023-005)

Significant Deficiency 2023

Board of Education of Prince George's County Maryland

MD

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.344

Special Education-Grants for Infants and Families– Assistance Listing No. 84.181 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit fin...

Special Education-Grants for Infants and Families– Assistance Listing No. 84.181 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Infants and Toddlers Supervisor will conduct monthly reviews of outstanding purchase orders in Oracle, addressing issues promptly with the Business Operation Officer/Financial Analyst. Professional development sessions will be attended to enhance invoice scrutiny for allowable expenses within the grant period. Quarterly reminders and Financial Quarterly Review meetings will be instituted for supervisors, ensuring timely action on outstanding purchase orders. Following will be implemented: 1. Infants and Toddler Supervisor will hold monthly meetings with the Financial Analyst and the secretarial staff to ensure consistent actions are taken when generating purchase orders and processing invoices. 2. The Infants and Toddler secretary will review invoice dates against contracts and purchase orders to ensure they fall within grant timelines before submitting them to the supervisor for signature. 3. Infants and Toddler Supervisor will confirm that purchases made with grant funds are allowable and within the designated grant period. The Supervisor will cross-reference invoice dates against grant periods before signing and sending to accounts payable. 4. The infants and Toddler Supervisor will confirm the work being invoiced has been completed and vendor details are checked, and dates verified. 5. Grant Accountants will provide transaction detail reports (at least quarterly). The Infant and Toddlers Coordinating Supervisor will review and sign-off on the quarterly transaction reports. 6. The Financial Analyst will meet monthly with the Infants and Toddler Supervisor and Coordinating Supervisor to ensure grant allowable expenses are adhered to and invoicing is updated and falls within grant-specific timelines. Name(s) of the contact person(s) responsible for corrective action: Office of Infant and Toddlers/Coordinating Supervisor & Fiscal Analyst and Business Operation Office/Fiscal Analyst & Office of Infant and Toddlers/Coordinating Supervisor Planned completion date for corrective action plan: June 2024

View Audit 301912 Questioned Costs: $1

Finding 391341 (2023-004)

Significant Deficiency 2023

Board of Education of Prince George's County Maryland

MD

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.344

Special Education Cluster – Assistance Listing No. 84.027 & 84.173 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit finding: There is...

Special Education Cluster – Assistance Listing No. 84.027 & 84.173 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Infants and Toddlers Supervisor will conduct monthly reviews of outstanding purchase orders in Oracle, addressing issues promptly with the Business Operation Officer/Financial Analyst. Professional development sessions will be attended to enhance invoice scrutiny for allowable expenses within the grant period. Quarterly reminders and Financial Quarterly Review meetings will be instituted for supervisors, ensuring timely action on outstanding purchase orders. Following will be implemented: 1. Infants and Toddler Supervisor will hold monthly meetings with the Financial Analyst and the secretarial staff to ensure consistent actions are taken when generating purchase orders and processing invoices. 2. The Infants and Toddler secretary will review invoice dates against contracts and purchase orders to ensure they fall within grant timelines before submitting them to the supervisor for signature. 3. Infants and Toddler Supervisor will confirm that purchases made with grant funds are allowable and within the designated grant period. The Supervisor will cross-reference invoice dates against grant periods before signing and sending to accounts payable. 4. The infants and Toddler Supervisor will confirm the work being invoiced has been completed and vendor details are checked, and dates verified. 5. Grant Accountants will provide transaction detail reports (at least quarterly). The Infant and Toddlers Coordinating Supervisor will review and sign-off on the quarterly transaction reports. 6. The Financial Analyst will meet monthly with the Infants and Toddler Supervisor and Coordinating Supervisor to ensure grant allowable expenses are adhered to and invoicing is updated and falls within grant-specific timelines. Name(s) of the contact person(s) responsible for corrective action: Office of Infant and Toddlers/Coordinating Supervisor & Fiscal Analyst and Business Operation Office/Fiscal Analyst & Office of Infant and Toddlers/Coordinating Supervisor Planned completion date for corrective action plan: June 2024

View Audit 301912 Questioned Costs: $1

Finding 391307 (2023-008)

Significant Deficiency 2023

Chestnut Hill College

PA

Student Financial Aid Subrecipient Monitoring Significant Deficiency

Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.038, 84.063, 84.268, 84.379 Recommendation: The College should develop and implement an approved written information security program and verify there is a risk management section that describes how the College is identifying,...

Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.038, 84.063, 84.268, 84.379 Recommendation: The College should develop and implement an approved written information security program and verify there is a risk management section that describes how the College is identifying, assessing and communicating risks. In addition, there should be a description on the evaluation of safeguard sufficiency in mitigating risks. The information security program should also include the following: • IT Security Policy • Acceptable Use Policy • Incident Response Policy • Data Classification Policies • Vendor Management Policy • Patch Management Policy • Data Disposal Policy • Risk Assessment Policy • Logical Access and User Access Review Policies • Evidence of Review by CIO/CISO and responsibility of program Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The college will develop and implement an information security program to verify our risk management efforts. This plan will identify how we are identifying, assessing and communicating risks. Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson - Director of Financial Aid and Scott Seidman – Director of IT Planned completion date for corrective action plan: September 30, 2024

View Audit 301881

Finding 391258 (2023-002)

Significant Deficiency 2023

The Children's Home Society of Florida

FL

Subrecipient Monitoring Eligibility Significant Deficiency § 200.303

Identifying Number: 2023-002 – Eligibility Finding: The Code of Federal Regulations (CFR) Section 200.303(a) states the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the feder...

Identifying Number: 2023-002 – Eligibility Finding: The Code of Federal Regulations (CFR) Section 200.303(a) states the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with 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). The State of Florida’s Department of Financial Services’ State Projects Compliance Supplement Part Five: Internal Controls Section D. Eligibility states that recipients should develop Control Objectives to provide reasonable assurance that only eligible individuals and organizations receive assistance under state projects, that subawards are made only to eligible subrecipients, and that amounts provided to or on behalf of eligibles were calculated in accordance with project requirements. During our testing of participant eligibility, we noted that supervisory personnel did not properly review and approve their eligibility documentation prior to the participant entering the program for ten of 80 participants selected for eligibility testing. Corrective Actions Taken or Planned: Corrective measures were taken with the Program Leadership responsible for the eligibility documentation noted above. The following corrective actions are in the process of being implemented: • CHS’s Program Leadership and their teams will conduct a review of respective intake forms completed after July 1, 2023 to ensure that all were properly reviewed and approved. Any unapproved intake forms identified will be verified and retroactively approved by the designated supervisor. • In cases where there are instances of unapproved intake forms, the Program Leadership will collaborate with the respective Talent Business Partner to follow up with formal corrective action. Such corrective action will include: o A thorough review of the CHS policies and practices relative to the management and approval of intake forms. o Mandatory refresher education and training with all staff to ensure they understand the steps required to document review and approval of the intake process, as well as the importance of maintaining evidence that the process was adequately performed. Person(s) Responsible for Corrective Actions: Barbara McDonald, Chief Financial Officer and Chief Administrative Officer and Heather Brungardt, Chief Program and Clinical Officer Anticipated Completion Date for Corrective Actions: Implementation of the Corrective Actions outlined above will begin immediately to be completed by June 30, 2024.

View Audit 301878

Finding 391248 (2023-003)

Significant Deficiency 2023

Saint Elizabeth University

NJ

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

Common Origination and Disbursement (COD) Reporting Planned Corrective Action: The University’s Financial Aid Office will update the anticipated disbursement date to reflect the actual disbursement for 2022-23. We will review the current award year to ensure that the anticipated disbursement dates...

Common Origination and Disbursement (COD) Reporting Planned Corrective Action: The University’s Financial Aid Office will update the anticipated disbursement date to reflect the actual disbursement for 2022-23. We will review the current award year to ensure that the anticipated disbursement dates reflect the actual disbursement date. Person Responsible for Corrective Action Plan: Nicholas Capodice, Director of Financial Aid Anticipated Date of Completion: April 30, 2024

View Audit 301872

Finding 391243 (2023-002)

Significant Deficiency 2023

Saint Elizabeth University

NJ

Subrecipient Monitoring Significant Deficiency

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: The University’s IT Department will work to update procedures and controls to ensure any federal regulations of the FTC Safeguards Rule (16 CFR § 314.4(b)(1) - 16 CFR § 314.4(i)) that were found to be in partial compliance are reme...

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: The University’s IT Department will work to update procedures and controls to ensure any federal regulations of the FTC Safeguards Rule (16 CFR § 314.4(b)(1) - 16 CFR § 314.4(i)) that were found to be in partial compliance are remediated and brought into compliance. Some of these have already been remediated. We will work with other departments who administer third party vendor accounts to enforce MFA where there are gaps. A penetration test and the standing up of a tool to continuously monitor our network internally and those of third party vendors are already in startup phases Our information security program and risk assessment will be updated to reflect any recommendations offered by our auditors to fill any existing gaps in the 2023 audit. Person Responsible for Corrective Action Plan: Ron Loneker, Jr., Director, IT Special Projects Anticipated Date of Completion: May 31, 2024

View Audit 301872

Finding 391240 (2023-008)

Significant Deficiency 2023

City and County of Honolulu

HI

Subrecipient Monitoring § 200.332

Finding No. 2023-008: Subrecipient Monitoring (Significant Deficiency - Internal Control Over Compliance) Federal Award: 21.027 - COVID‐19 – Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Audit Recommendation: We recommend the City be more diligent in following its policies and proce...

Finding No. 2023-008: Subrecipient Monitoring (Significant Deficiency - Internal Control Over Compliance) Federal Award: 21.027 - COVID‐19 – Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Audit Recommendation: We recommend the City be more diligent in following its policies and procedures for on‐site monitoring of its subrecipients. We also recommend the City implement control procedures to review a subrecipient’s most recent single audit report to determine if any management decisions on findings or monitoring is necessary. Administration’s Comments: The City will follow policies and procedures for on-site monitoring of its subrecipients and also implement control procedures to review a subrecipient’s most recent single audit report to determine if management decisions on findings or monitoring is necessary. OER will perform a verification to ensure that the subrecipient takes timely and appropriate action on deficiencies detected through their Single Audit. Anticipated Completion Date: July 31, 2024 Contact Person(s): Denise Obrero, Mayor’s Office, Planner VII

View Audit 301866

Finding 391239 (2023-007)

Significant Deficiency 2023

City and County of Honolulu

HI

Subrecipient Monitoring § 200.332

Finding No. 2023-007: Subrecipient Monitoring (Significant Deficiency - Internal Control Over Compliance) Federal Award: 21.023 - COVID‐19 – Emergency Rental Assistance Program (ERA) Audit Recommendation: We recommend the City be more diligent in following its policies and procedures for on‐site...

Finding No. 2023-007: Subrecipient Monitoring (Significant Deficiency - Internal Control Over Compliance) Federal Award: 21.023 - COVID‐19 – Emergency Rental Assistance Program (ERA) Audit Recommendation: We recommend the City be more diligent in following its policies and procedures for on‐site monitoring of its subrecipients. We also recommend the City implement control procedures to review a subrecipient’s most recent single audit report to determine if any management decisions on findings or monitoring is necessary. Administration’s Comments: The City will follow policies and procedures for on-site monitoring of its subrecipients and also implement control procedures to review a subrecipient’s most recent single audit report to determine if management decisions on findings or monitoring is necessary. OER will perform a verification to ensure that the subrecipient takes timely and appropriate action on deficiencies detected through their Single Audit. Anticipated Completion Date: July 31, 2024 Contact Person(s): Denise Obrero, Mayor’s Office, Planner VII

View Audit 301866

Finding 391233 (2023-004)

Material Weakness 2023

City and County of Honolulu

HI

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking

Finding No. 2023-004: Reporting (Material Weakness - Internal Control Over Compliance) Federal Award: 14.218 - CDBG – Entitlement Grants Cluster Audit Recommendation: We recommend that the City establish procedures to ensure that subawards are uploaded to the FSRS system timely. Administration’...

Finding No. 2023-004: Reporting (Material Weakness - Internal Control Over Compliance) Federal Award: 14.218 - CDBG – Entitlement Grants Cluster Audit Recommendation: We recommend that the City establish procedures to ensure that subawards are uploaded to the FSRS system timely. Administration’s Comments: The City will establish and follow policies and procedures to ensure that subawards are uploaded to the FSRS system timely. City will establish roles to improve execution of the reporting process. Anticipated Completion Date: June 30, 2024 Contact Person(s): Timothy Ho, Department of Community Services, Planner VII Holly Kawano, Department of Budget and Fiscal Services, Federal Grants Coordinator

View Audit 301866

Finding 391227 (2023-003)

Material Weakness 2023

San Andreas Sanitary District

CA

Procurement, Suspension & Debarment Subrecipient Monitoring

Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The District is actively working to develop written policies that will guide future procurement and selection of firms that participate in these federally-funded projects, including debarment and confli...

Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The District is actively working to develop written policies that will guide future procurement and selection of firms that participate in these federally-funded projects, including debarment and conflict of interest procedures. We plan to implement new policies by end of F& 23/24. Implementation Date: June 2024 Name of Responsible Person: Hugh Logan, General Manager

View Audit 301852

Finding 391198 (2023-002)

None 2023

Boys and Girls Clubs of Puerto Rico INC

PR

Subrecipient Monitoring Equipment & Real Property Management

Finding No. 2023-002 Management Response: Management agrees with the finding. The Organization has spent $20,268.79 in equipment that falls under the capitalization requirements of the program. The amount that has not been capitalized is $9,409.93, consisting of computer equipment. Corrective Action...

Finding No. 2023-002 Management Response: Management agrees with the finding. The Organization has spent $20,268.79 in equipment that falls under the capitalization requirements of the program. The amount that has not been capitalized is $9,409.93, consisting of computer equipment. Corrective Action Plan:  A capitalization procedure for CDGB-DR will be added to our Finance Policy and Procedure Manual.  Perform the adjustments in our fixed assets subsidiary Contact Person: Antonio Rosario Manuel Joglar Nerma Albertorio Team: Accounting Manager and program leaders. Anticipated Completion Date: June 30, 2024

View Audit 301810

Finding 391170 (2023-003)

Material Weakness 2023

Mercy Health

MO

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.333 § 200.403

Finding 2023-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantors: State of Missouri, State Emergency Management Agency Arkansa...

Finding 2023-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantors: State of Missouri, State Emergency Management Agency Arkansas Division of Emergency Management Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (“FEMA”) Pass-Through Award Numbers and Award Periods: Project# 185883 P/W# 529 01/20/2020–09/14/2020 Project# 699963 P/W# 624 01/01/2022–07/01/2022 Project# 699667 P/W# 233 01/01/2022–07/01/2022 Project# 699670 P/W# 211 01/01/2022–07/01/2022 Condition: Adequate documentation was not retained to support the average unit cost applied to COVID-19 personal protective equipment (PPE) inventory usage charged to the FEMA program as Force Account Material (FAM) costs. In addition, for 12 of 40 non-FAM costs (including purchased equipment, purchased supplies and rental equipment) charged to the program, we noted adequate documentation was not retained to evidence review and approval of the expenditure for allowability. Views of Responsible Officials and Planned Corrective Actions: Mercy Health has a system to calculate average cost of inventory items. We rely on this system, but it was not tested as part of compliance. In addition, Mercy Health has a robust capital approval process (for all equipment) and financial approval thresholds. All COVID purchases were logged in the capital system (VFA) and approvals were documented. During this time, we changed approval systems from VFA to Strata. We will implement testing of our inventory system (Lawson) to ensure calculations are accurate. All review and approvals of capital equipment will be maintained in Strata. Responsible Party: Jill McCart, VP Accounting and Reporting Date of Completion: By 6/30/24

View Audit 301777 Questioned Costs: $1

Finding 391165 (2023-002)

None 2023

School District of Cambridge

WI

Subrecipient Monitoring Matching / Level of Effort / Earmarking

Finding #2023-002 – Elementary and Secondary School Emergency Relief Fund (ESSER) III Plan Condition: The District did not make its ESSER III Local Educational Agency (LEA) Plan Report readily and publicly available. Effect: By not making the plan available to the public, the District is effectivel...

Finding #2023-002 – Elementary and Secondary School Emergency Relief Fund (ESSER) III Plan Condition: The District did not make its ESSER III Local Educational Agency (LEA) Plan Report readily and publicly available. Effect: By not making the plan available to the public, the District is effectively not compliant with the Federal requirements for this program. Cause: The District was not aware of this requirement. Criteria: The OMB Compliance Supplement mandates a LEA to submit and make publicly available a plan for the safe return to in-person instruction and continuity of services, and the planned use of the ESSER III funding. Recommendation: The auditors recommend that the plan be made available on the District’s website. Response: We (the District) will upload the plan to the District’s website in order to make it publicly available. Cambridge School District’s Corrective Action Plan: The ESSER plans were posted on the district website until summer of 2023 when the website design was updated and information was migrated to new pages or eliminated if it was no longer relevant. As the ESSER LEA plan was associated with our COVID response plan and COVID related protocols were eliminated, the plan was removed. We were unaware that the plan needed to remain posted through the grant period. When we learned that the requirement to post the plan remains a requirement we promptly posted our WI DPI approved plan from DPI under the heading District Annual Notices. Contact Person: Margaret M. Banker, District Administrator/Business Manager Anticipated Completion Date: 9/01/2024

View Audit 301774

Finding 391146 (2023-004)

Material Weakness 2023

Ohio Institute of Allied Health, Inc.

IL

Questioned Costs Student Financial Aid Subrecipient Monitoring

FINDING 2023-4- Untimely Paid and Unpaid Credit Balances The Institute had Untimely Paid and Unpaid Credit Balances while Participating under the Zone Alternative and the Heightened Cash Monitoring 1 Payment Method A.Comments on Findings and Recommendations: The Institute agrees with the finding and...

FINDING 2023-4- Untimely Paid and Unpaid Credit Balances The Institute had Untimely Paid and Unpaid Credit Balances while Participating under the Zone Alternative and the Heightened Cash Monitoring 1 Payment Method A.Comments on Findings and Recommendations: The Institute agrees with the finding and Auditor's recommendation. B.Actions Taken or Planned We have revised the process of student stipends ofdisbursements. Each student whose account receives a disbursement whom results in a credit balance, will be given stipend prior to any draw down. We shall also make process and procedures with new third-party servicer to ensure stipend is sent prior to drawdown. Signed Betsy Bremke, Administrative Campus Director Date: _3/29/2024__

View Audit 301753 Questioned Costs: $1

Finding 391132 (2023-001)

Significant Deficiency 2023

City of Concord

CA

Procurement, Suspension & Debarment Subrecipient Monitoring

Finding Reference Number: SA2023-001 - Suspension and Debarment Documentation for Contracts and Subcontracts Assistance Listing Number: 21.027 Assistance Listing Title: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Name of Federal Agency: Department of the Treasury Federal Aw...

Finding Reference Number: SA2023-001 - Suspension and Debarment Documentation for Contracts and Subcontracts Assistance Listing Number: 21.027 Assistance Listing Title: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Name of Federal Agency: Department of the Treasury Federal Award Identification Number: SLFRP0424 • Fiscal Year of Initial Finding: 2022 • Name(s) of the contact person: Purchasing Manager • Corrective Action Plan: The purchasing division consists of (2) staff members. The division had turn over in both purchasing positions during fiscal year 2022/23. During this time, the documentation of disbarment checks by purchasing staff was not consistent. To strengthen this process, the City put multiple checks in place to ensure that City staff is aware of this requirement and is meeting this requirement: 1. Every Request for Proposal request that vendors certify that they are not on the exclusion list as part of the bidding or solicitation process. 2. When preparing a Request for a Purchase Order, departments have a checklist of "Required Documentation" to support the Requisition. A section has been added to check if the purchase will be funded by federal funds and, if yes, the department is to provide a screen shot of the disbarment check from sam.gov. 3. The REQUISITION/PO tracking sheet used by the Purchasing Account Clerk includes a column to mark that the disbarment check has been completed. 4. The instructions in the Purchasing Acct Clerk desk manual include instructions on how to complete a disbarment check as part of the "Creating a PO" script. • Anticipated Completion Date: June 30, 2024

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Finding 391130 (2023-002)

Significant Deficiency 2023

City of Concord

CA

Subrecipient Monitoring Reporting

Finding Reference Number: SA2023-002 - Federal Funding Accountability and Transparency Act (FFATA) Reporting Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant – Entitlement Grant COVID-19 - Community Development Block Grants/ Entitlement Grants-CV ...

Finding Reference Number: SA2023-002 - Federal Funding Accountability and Transparency Act (FFATA) Reporting Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant – Entitlement Grant COVID-19 - Community Development Block Grants/ Entitlement Grants-CV Name of Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-22-MC-06-0009 COVID-19 – B-20-MW-06-0009 • Fiscal Year of Initial Finding: 2022 • Name(s) of the contact person: Leng Powers • Corrective Action Plan: In April 2023, City staff received training on the FFATA website and reporting requirements. After review of the website, the website's requirements, and the FFATA reporting requirements, City staff assigned reporting roles to individuals in Housing and Finance to report within 30 days of executing agreements of $30,000 with sub-recipients. During Fiscal Year 2022/23, the City entered into contract with (3) sub-recipients for awards over $30,000. These contracts were officially executed in December2022/January 2023. The City has been working to obtain the UEI and other miscellaneous reporting information from the sub-recipients in order to complete the required FFATA report for FY2022-23. Going forward, the City will require the FFATA information to be included in the sub-awardee prior to executing the grant award. • Anticipated Completion Date: June 30, 2024

View Audit 301716

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