Corrective Action Plans

Finding 390566 (2023-003)

Significant Deficiency 2023

City of Lynwood

CA

Procurement, Suspension & Debarment Subrecipient Monitoring

2023-003 Procurement and Suspension, and Debarment – Internal Control Over Verification Against the System for Award Management (“SAM”) City’s Response City have verified the vendors but lack of sufficient documentation that shows the verification took place prior to awarding the contract. Corre...

2023-003 Procurement and Suspension, and Debarment – Internal Control Over Verification Against the System for Award Management (“SAM”) City’s Response City have verified the vendors but lack of sufficient documentation that shows the verification took place prior to awarding the contract. Corrective Action Plan: Ernie Hernandez, City Manager, will enhance the City’s practice in the suspension/debarment verification process going forward, and will save proper documentation starting Quarter Four, FY2023-24.

View Audit 301327

Finding 390562 (2023-004)

Significant Deficiency 2023

City of Lynwood

CA

Internal Control / Segregation of Duties Subrecipient Monitoring HUD Housing Programs

2023-004 Reporting – Internal Control and Compliance Over Reporting City’s Response City concurs with this recommendation. Corrective Action Plan: Gabriel Linares, Director of Community Development, will enhance the department’s policy/desk procedure to ensure timely filing of the CAPER and Sect...

2023-004 Reporting – Internal Control and Compliance Over Reporting City’s Response City concurs with this recommendation. Corrective Action Plan: Gabriel Linares, Director of Community Development, will enhance the department’s policy/desk procedure to ensure timely filing of the CAPER and Section 15011 reports starting Quarter Four, FY2023-24.

View Audit 301327

Finding 390559 (2023-002)

Significant Deficiency 2023

Atlantic University College, Inc.

PR

Procurement, Suspension & Debarment Subrecipient Monitoring Cash Management § 200.305

Manuals with respect to Cash Management procedures will be updated to reflect proper disbursement procedures in order to comply with regulations. No longer will drawdowns be made for the totality of the services contracted or items purchased unless the related invoice is fully due for payment. In al...

Manuals with respect to Cash Management procedures will be updated to reflect proper disbursement procedures in order to comply with regulations. No longer will drawdowns be made for the totality of the services contracted or items purchased unless the related invoice is fully due for payment. In all other cases drawdowns will be made as payments are due

View Audit 301324

Finding 390553 (2023-004)

Significant Deficiency 2023

Wilberforce University

OH

Cash Management Subrecipient Monitoring Reporting

Views of Responsible Officials and Planned Corrective Actions: We concur with the auditor’s finding. The University has engaged a third party to review the reconciliation procedures and to make recommendations on improvements to our current policy. The recommendations will also include any additiona...

Views of Responsible Officials and Planned Corrective Actions: We concur with the auditor’s finding. The University has engaged a third party to review the reconciliation procedures and to make recommendations on improvements to our current policy. The recommendations will also include any additional documentation that 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 of Business & Finance, Controller and Director of Student Financial Aid.

View Audit 301315

Finding 390521 (2023-002)

Significant Deficiency 2023

Mending Hearts, Inc.

TN

Subrecipient Monitoring Reporting

Management's Response This is Mending Hearts first federal grant with a subrecipient. We were unaware of the FFATA reporting requirement for subrecipients. Upon notification of the error, the FFATA was filed in the FSRS. Views of Responsible Officials and Corrective Action See response for findin...

Management's Response This is Mending Hearts first federal grant with a subrecipient. We were unaware of the FFATA reporting requirement for subrecipients. Upon notification of the error, the FFATA was filed in the FSRS. Views of Responsible Officials and Corrective Action See response for finding 2023-002 Anticipated Completion Date Completed on March 22, 2024

View Audit 301275

Finding 390515 (2023-023)

Material Weakness 2023

State of New Hampshire

NH

Subrecipient Monitoring § 200.332 § 200.501 § 200.521

HSEM concurs with the finding. Condition A: NH HSEM Mitigation and Recovery leadership has updated the award letter templates to ensure the necessary information is included as outlined in the condition. Conditions B – D: NH HSEM Mitigation and Recovery leadership updated the Risk Assessment Quic...

HSEM concurs with the finding. Condition A: NH HSEM Mitigation and Recovery leadership has updated the award letter templates to ensure the necessary information is included as outlined in the condition. Conditions B – D: NH HSEM Mitigation and Recovery leadership updated the Risk Assessment Quick Reference Guide (QRG) and Subrecipient monitoring QRG. A two hour in-person training was conducted on January 31, 2024, to Mitigation and Recovery staff which focused on conducting risk assessments and subrecipient monitoring. This will be reviewed with staff again during an upcoming Section meeting in March 2024.

View Audit 301259

Finding 390511 (2023-021)

Material Weakness 2023

State of New Hampshire

NH

Special Tests & Provisions Subrecipient Monitoring Cash Management

HSEM concurs with the finding. As a result of the audit, the practice of using individual emails to submit correspondence to FEMA was immediately addressed with staff and future correspondence will only be sent using the general shared email inbox. Regularly during staff meetings employees are remin...

HSEM concurs with the finding. As a result of the audit, the practice of using individual emails to submit correspondence to FEMA was immediately addressed with staff and future correspondence will only be sent using the general shared email inbox. Regularly during staff meetings employees are reminded to copy communications to the general shared inbox. Additionally, HSEM is currently working with the State’s Department of Information and Technology to gain access to prior staff’s emails. To note, the final paragraph in the Conditions section makes an incorrect statement regarding the submittal timeline requirements for Project Completion and Certification reports. PCCs are due within 90 days of project completion, not project obligation.

View Audit 301259

Finding 390506 (2023-017)

Material Weakness 2023

State of New Hampshire

NH

Subrecipient Monitoring § 200.332 § 200.501 § 200.521

Condition A: DHHS partially concurs. The review of expenditure details is an integral part of DHHS’ Subrecipient Monitoring and standard language is included in the templates for legal agreements. These five subrecipients were deemed low or no risk, examination of expenditure detail is considered ...

Condition A: DHHS partially concurs. The review of expenditure details is an integral part of DHHS’ Subrecipient Monitoring and standard language is included in the templates for legal agreements. These five subrecipients were deemed low or no risk, examination of expenditure detail is considered sufficient monitoring. All five of these subrecipients had the inclusion of the monthly detail requirement in the contracts and this was performed prior to the invoice being submitted to AP for payment. DHHS will re-evaluate current practices to ensure that the documentation is sufficient for the current subrecipient monitoring process. Regarding the two selections identified as having risk assessments which did not specify recommended monitoring procedures: The Risk Assessment Tool for one subrecipient was performed after the subaward award. However, as indicated on the Tool, programmatic monitoring activities were included in the contract. DHHS reviewed the monthly back-up documentation provided with the submitted invoices prior to sending them to AP for payment. The risk assessment tool for the second selection was performed after the subaward award. However, as indicated on the tool, programmatic monitoring activities were included in the contract. We reviewed the monthly back-up documentation provided with the submitted invoices prior to sending them to AP for payment. Condition B: DHHS partially concurs. The review of expenditure details is an integral part of DHHS’ Subrecipient Monitoring and standard language is included in the templates for legal agreements. The subrecipients were deemed low or no risk, therefore, examination of expenditure detail is considered sufficient fiscal monitoring. DHHS employs the review of expenditure details, as allowed under 200.332 (d)(1), as an integral part of the Departments Subrecipient Monitoring. A review of the expenditures provides monitoring for the following concerns: • The familiarity a subrecipient has utilizing Federal funds • The subrecipient management teams’ familiarity with Federal funding • Single Audit findings • Any prior return of funding due to non-compliance • The subrecipient’s compliance with the requirements of 200.300 and 302 • Whether the subrecipient has a new financial system DHHS will re-evaluate the risk response parameters to determine that the level of documentation is sufficient to ensure that the procedures performed would be able to identify noncompliance at the subrecipient level. Condition C: DHHS concurs. DHHS will be updating procedures to include contacting vendors to remind them of the deadline regarding the submission of their single audit in the Federal Audit Clearinghouse.

View Audit 301259

Finding 390504 (2023-016)

Material Weakness 2023

State of New Hampshire

NH

Reporting Subrecipient Monitoring

The Department underwent turnover and medical issues during the reporting period. The Department has hired additional program staff and arranged for annual training through a federal contractor to assist in reporting requirements. The Department is also in the process of procuring a new weatherizat...

The Department underwent turnover and medical issues during the reporting period. The Department has hired additional program staff and arranged for annual training through a federal contractor to assist in reporting requirements. The Department is also in the process of procuring a new weatherization and fuel assistance system which will assist in providing timely and accurate reporting data. The Department is also reviewing and updating policies and procedures, to include cross training and turnover contingencies.

View Audit 301259

Finding 390502 (2023-015)

Material Weakness 2023

State of New Hampshire

NH

Subrecipient Monitoring § 200.251 § 200.332 § 200.414 § 200.521

The Department Concurs with paragraph A – Since this same finding was reported in March of 2023 for FY22, items a, c, and d are now included on all federal subaward contracts and policies have been updated to reflect this. The Department will ensure b is also included going forward. The Department ...

The Department Concurs with paragraph A – Since this same finding was reported in March of 2023 for FY22, items a, c, and d are now included on all federal subaward contracts and policies have been updated to reflect this. The Department will ensure b is also included going forward. The Department concurs with paragraph B - The finding was a result of personnel turnover and medical issues. The Department has hired and trained additional program staff and updated policies to ensure programmatic monitoring and subsequent reports are done in a timely manner. The Department partially concurs with paragraph C. Fiscal monitoring was done for all 3 subrecipients during the federal program year. However, 1 subrecipient monitoring fell outside the state fiscal year so was not covered during the audit period. The Department has changed the wording on its risk assessment procedures to ensure no misinterpretation of the timeframe each subrecipient will be monitored in accordance with its risk assessment. The Department has also changed the requirements of the frequency of fiscal monitoring in each of the risk assessment categories. The Department Concurs with paragraph D – The Department is reviewing policies and procedures and will update them to ensure compliance with 2 CFR section 200.332(a), 2 CFR section 200.332(b) and 2 CFR section 200.521. The Department also created a tracking mechanism to ensure we receive, review, and issue management decisions (if required) in a timely manner. The Department concurs with Paragraph E - The Department is reviewing policies and procedures for both reporting and subrecipient monitoring to ensure data is tested and verified. The Department has already gained increased access to data in current software and is in the process of selecting a vendor for new software that will provide more testing and enhanced internal controls.

View Audit 301259

Finding 390494 (2023-011)

Material Weakness 2023

State of New Hampshire

NH

Subrecipient Monitoring § 200.332 § 200.501 § 200.521

Condition A: DHHS concurs. Pursuant to the Subrecipient Monitoring Policy, the risk assessment and determination of subrecipient monitoring activities is performed during the procurement process with the Grants Administrator and the Program Lead. It is the responsibility of Program to perform the ...

Condition A: DHHS concurs. Pursuant to the Subrecipient Monitoring Policy, the risk assessment and determination of subrecipient monitoring activities is performed during the procurement process with the Grants Administrator and the Program Lead. It is the responsibility of Program to perform the requested subrecipient monitoring. The Department provides annual training on the Subrecipient Monitoring Policy. We will reinforce the requirements of the Policy and the ramifications for the Department for the non-compliance in this year’s annual training. Regarding the incomplete Risk Assessment Tool, we will update the Subrecipient Monitoring Policy to include a secondary review of the Tool prior to implementation, as part of our internal controls. Condition B: DHHS does not concur. The Department employs the review of expenditure details, as allowed under 200.332 (d)(1), as an integral part of the Departments Subrecipient Monitoring. The Department’s review of the expenditures provides monitoring for the following concerns: • The familiarity a subrecipient has utilizing Federal funds • The subrecipient management teams’ familiarity with Federal funding • Single Audit findings • Any prior return of funding due to non-compliance • The subrecipient’s compliance with the requirements of 200.300 and 302 • Whether the subrecipient has a new financial system Standard language for the submission of expenditure detail is included in all templates for legal agreements. These subrecipients were deemed low or no risk, therefore, examination of expenditure detail is considered sufficient monitoring. Subrecipient monitoring activities are memorialized in the legal agreements. The Risk Assessment Tool provides a space for the monitoring activities to be selected, however, the Subrecipient Monitoring Policy does require the memorialization of the activities on the Tool for compliance, only to be memorialized in the legal agreement. Condition C DHHS partially concurs. As the subrecipient’s audit report had no findings, we are not required to issue a management decision letter. However, we will be updating our procedures to include contacting the vendors to remind them of the deadline regarding the submission of their single audit in the Federal Audit Clearinghouse.

View Audit 301259

Finding 390492 (2023-010)

Material Weakness 2023

State of New Hampshire

NH

Reporting Subrecipient Monitoring Material Weakness § 200.303

This function (FFATA reporting) has now been designated to our Federal Reporting Group, which will allow for redundancy in personnel. A new policy and procedure, which will include internal controls, will be developed and implemented.

View Audit 301259

Finding 390480 (2023-008)

Material Weakness 2023

State of New Hampshire

NH

Subrecipient Monitoring Reporting Material Weakness § 200.303

The Office of ESEA Title programs and Covid-19 education programs have established an internal process to sample and test reports compiled to ensure operations are executed as intended. These internal controls include a monthly reporting sign off Excel sheet, certification on each FFATA submission a...

The Office of ESEA Title programs and Covid-19 education programs have established an internal process to sample and test reports compiled to ensure operations are executed as intended. These internal controls include a monthly reporting sign off Excel sheet, certification on each FFATA submission and a secondary certification for accuracy verification, and a division wide process for FFATA filing and verification. Division wide training occurred on October 26, 2023. Due to grant award notification (GAN) changes and development within our grants management system (GMS), the FFATA process has also been developing and shifting; therefore the FFATA process will be revisited annually and updated as needed. A revised procedure for FFATA reporting will be completed prior to additional training being offered. To ensure that processes are being followed, newly hired staff is trained appropriately, and updates to the GAN process are considered within the FFATA process we will hold another training this spring, March 14th, 2024, prior to new subawards being issued.

View Audit 301259

Finding 390477 (2023-005)

Material Weakness 2023

State of New Hampshire

NH

Subrecipient Monitoring § 200.251 § 200.303 § 200.332 § 200.414 § 200.521

Corrective Action Planned (Condition A): The DAS analyzed the six items erroneously reported as subawards and noted the errors were isolated to two specific agencies, the Department of Health and Human Services and the Department of Environmental Services. In response to the prior year finding 20...

Corrective Action Planned (Condition A): The DAS analyzed the six items erroneously reported as subawards and noted the errors were isolated to two specific agencies, the Department of Health and Human Services and the Department of Environmental Services. In response to the prior year finding 2022-002, the DAS had strengthened internal controls related to the review and validation of amounts reported by individual state agencies as pass through expenditures. This included an additional control specifically verifying SLFRF pass through expenditures reported by each agency. The DAS will offer additional training relative to identification and reporting of subaward expenditures in its annual statewide Single Audit training and re-evaluate the precision of execution of controls over the validation of pass through reporting in assembling the SEFA for fiscal year 2024. Corrective Action Planned (Conditions B through E): The State largely concurs with the findings and recommendations and has implemented procedures to address the identified conditions already or will do so. With regards to condition B, The State will work with the individual agencies to ensure that individual agencies entering into such agreements clearly indicate the terms required by Uniform Guidance, including permitted indirect cost rates and whether the award is for R&D. The State has already begun this corrective action plan with the agencies. With regards to condition C, for a. and b. for payments by agencies, there are standard procedures for review and authorization of invoices and payments and those payments are documented. For c. The State has already implemented an agency wide framework for subrecipient monitoring. The State will provide re-training for those agencies that had not properly documented monitoring as outlined by the subrecipient risk assessments and ensure monitoring reports are documented. With regards to condition D, The State has already implemented an agency wide framework to help ensure policies and procedures are in place concerning Uniform Guidance Reports. We will work those agencies that had not documented the date received and the review of the Uniform Guidance Reports to ensure written documentation occurs. Where findings have been reported in the Uniform Guidance Report, ensure timely Management Letters are documented and provided with the summary review of Uniform Guidance Report.

View Audit 301259

Finding 390476 (2023-004)

Material Weakness 2023

State of New Hampshire

NH

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Corrective Action Planned (Condition A): The DAS would note the definition of a subaward per 2 CFR 200.1 specifies a subaward may be provided through any form of legal agreement, including an agreement that the pass-through entity considers a contract. State procurement policies require contracts,...

Corrective Action Planned (Condition A): The DAS would note the definition of a subaward per 2 CFR 200.1 specifies a subaward may be provided through any form of legal agreement, including an agreement that the pass-through entity considers a contract. State procurement policies require contracts, including contracts deemed subawards, greater than $10,000 are subject to legislative and executive branch approval prior to final execution. The resulting contracts are managed within the State’s financial system using purchase orders which in turn encumber funds. To support the testing of procurements, the State provided a detailed listing of purchase orders initiated during the audit period and in doing so clearly expressed the resulting population would include contracts considered subawards. Accordingly, the State deems the portion of selections identified as subawards to be reasonable and appropriate given the population sampled. However, the DAS will re-evaluate the precision of execution of controls over the validation of the subrecipient population in fiscal year 2024. Corrective Action Planned (Condition B): The State concurs with the findings and recommendations and has implemented procedures to address the identified conditions already or will do so. With regards to condition B, The State will work with the individual agencies to ensure that individual agencies maintain and document the search of SAM.gov for suspension and debarment.

View Audit 301259

Finding 390438 (2023-001)

Significant Deficiency 2023

Oregon Tech

OR

Student Financial Aid Subrecipient Monitoring Reporting § 200.303

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007 Recommendation: CLA recommends that the University enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting i...

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007 Recommendation: CLA recommends that the University enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting is completed accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management respectfully agrees on all findings and recommendations. Management will engage in additional staff training and is committed to consistent application of current policies and procedures to ensure enrollment reporting and monitoring of third-party service providers results in accurate and timely reporting by the third-party service provider. While the third-party service provider has a national monopoly on enrollment reporting, with other institutions of higher education also facing similar reporting issues by the third-party service provider, Management believes that enhanced training and internal procedures over enrollment reporting will mitigate accuracy and timeliness errors made by the third party service provider, resulting in the University meeting U.S. Department of Education requirements. Name(s) of the contact person(s) responsible for corrective action: Ashlie Pence Planned completion date for corrective action plan: June 30, 2024

View Audit 301235

Finding 390428 (2023-004)

Material Weakness 2023

Delaware State University

DE

Reporting Subrecipient Monitoring Material Weakness § 200.303 § 200.502 § 200.510

2023-004 Student Financial Aid Cluster – Schedule of Expenditure of Federal Awards (SEFA) Recommendation: We recommend that the University reevaluate its policies and controls related to the preparation of the SEFA to ensure its complete and accurate. Explanation of disagreement with audit finding: ...

2023-004 Student Financial Aid Cluster – Schedule of Expenditure of Federal Awards (SEFA) Recommendation: We recommend that the University reevaluate its policies and controls related to the preparation of the SEFA to ensure its complete and accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director will reevaluate the controls and set in place policies and procedures for SEFA completion. Name(s) of the contact person(s) responsible for corrective action: Director of Restricted Funds Accounting, Symone Merritt Planned completion date for corrective action plan: October 2024

View Audit 301226

Finding 390416 (2023-009)

Material Weakness 2023

Delaware State University

DE

Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking § 200.303

2023-009 Student Financial Assistance Cluster – Federal Assistance Listing Nos. 84.007, 84.063, 84.033 and 84.268 – Gramm-Leach-Bliley Act (GLBA) Recommendation: We recommend the University review is policies and procedures and update the information security plan to be GLBA compliant. Explanation o...

2023-009 Student Financial Assistance Cluster – Federal Assistance Listing Nos. 84.007, 84.063, 84.033 and 84.268 – Gramm-Leach-Bliley Act (GLBA) Recommendation: We recommend the University review is policies and procedures and update the information security plan to be GLBA compliant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division of Information Technology is reviewing the written policies and procedures needed to safeguard the University’s applications and data. This includes all 3rd party developed/ implemented applications as well. Name(s) of the contact person(s) responsible for corrective action: Executive Director of Network Services, Russel Weaver & VP/ Chief Information Officer, Darrell McMillion. Planned completion date for corrective action plan: June 2024

View Audit 301226

Finding 390385 (2023-001)

Significant Deficiency 2023

Fresno Madera Area Agency on Aging

CA

Subrecipient Monitoring § 200.332

The Agency agrees with the finding. It has been seeking qualified fiscal staff to address the staffing needs. A new fiscal staff member has been hired and will start employment on 4/2/24. The requisite fiscal reviews of subrecipients has been initiated with the intention of completing them as soon a...

The Agency agrees with the finding. It has been seeking qualified fiscal staff to address the staffing needs. A new fiscal staff member has been hired and will start employment on 4/2/24. The requisite fiscal reviews of subrecipients has been initiated with the intention of completing them as soon as practical.

View Audit 301199

Finding 390372 (2023-001)

Material Weakness 2023

Collins Career Center

OH

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.317 § 200.320 § 200.327

At the beginning of the project the Center did not plan on using federal grant funds. At the conclusion of the project, it was determined that the project could be paid for by federal funds.

View Audit 301193

Finding 390303 (2023-001)

Significant Deficiency 2023

Office of Hawaiian Affairs State of Hawaii

HI

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.318 § 200.319 § 200.320 § 200.327

OHA Procurement staff will verify all federal funded vendors are not suspended or debarred or otherwise excluded from participating in a transaction with OHA by checking the System for Award Management (SAM) Exclusions maintained by the General Servies Administration and available at SAM.gov. This ...

OHA Procurement staff will verify all federal funded vendors are not suspended or debarred or otherwise excluded from participating in a transaction with OHA by checking the System for Award Management (SAM) Exclusions maintained by the General Servies Administration and available at SAM.gov. This procedure was implemented on a go forward basis on March 13, 2024.

View Audit 301164

Finding 390273 (2023-006)

Material Weakness 2023

Commonspirit Health

IL

Student Financial Aid Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

REFERENCE: 2023-006 – Reporting – Common Origination and Disbursement (COD) System Student Financial Assistance Cluster (Assistance Listing Nos. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radi...

REFERENCE: 2023-006 – Reporting – Common Origination and Disbursement (COD) System Student Financial Assistance Cluster (Assistance Listing Nos. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Finding: Good Samaritan College of Nursing & Health Science did not perform its internal control over the requirement to submit Pell and Direct Loan origination and disbursement records to the Department of Education through the COD system, which consists of monthly COD reconciliations. CHI Health School of Radiologic Technology does not have a process in place for updating the COD system for actual disbursement dates. The COD disbursement information reported by CHI Health School of Radiologic Technology was based on “assumed” and “expected” disbursement dates and amounts, but is never updated for actual disbursement dates. Corrective Action Plan: This finding has been corrected for Good Samaritan. In May 2023, for April 2023 data, Good Samaritan implemented a formal monthly reconciliation process, including comparison of all systems for the period, a final review of G5 funds prior to draw down, a cover sheet noting any explaining any differences, proper sign off for preparation and review and the date by Good Samaritan management for presentation to the Compliance Oversight Committee. A year end reconciliation is also performed following the same process. CHI Health School of Radiologic Technology will review their processes to develop and implement internal controls that ensure compliance with federal regulations. Evidence of the internal control being performed will be retained. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science and Financial Aid Services (FAS) David Velasquez, Nuclear Medicine Technologist Coordinator (CHI Health School of Radiologic Technology) Completion/Expected Completion: April 2023 (Good Samaritan)/June 2024 (CHI Health School of Radiologic Technology)

View Audit 301158

Finding 390269 (2023-004)

Significant Deficiency 2023

Commonspirit Health

IL

Subrecipient Monitoring § 200.303

REFERENCE: 2023-004 – Subrecipient Monitoring Research and Development Cluster (Assistance Listing Nos. 12.420, 93.394, 93.650, 93.853, 93.866) Federal Grantor: U.S. Department of Defense, U.S. Department of Health and Human Services Facility: St. Joseph’s Hospital and Medical Center Finding: Whil...

REFERENCE: 2023-004 – Subrecipient Monitoring Research and Development Cluster (Assistance Listing Nos. 12.420, 93.394, 93.650, 93.853, 93.866) Federal Grantor: U.S. Department of Defense, U.S. Department of Health and Human Services Facility: St. Joseph’s Hospital and Medical Center Finding: While St. Joseph’s Hospital and Medical Center has controls in place to review and approve invoices prior to payment, the review was not precise enough to ensure duplicate invoices are not paid to subrecipients. St. Joseph's Hospital and Medical Center approved and paid duplicate invoices for 2 out of 35 selections. This error was identified by St. Joseph's and they are actively working on getting a refund from the subrecipient. The duplicate payments charged to the grant were $5,514. Corrective Action Plan: St. Joseph’s Hospital and Medical Center research administration identified the duplicate invoice request from the subrecipient and have been actively working with the subrecipient to receive a refund and adjust the federal reimbursement request. New procedures have been implemented for research administration to notify research finance of any incorrect payments and research finance will accrue for the adjustment. Person Responsible: Tomas Cortez, Grant Accounting Manager – St. Joseph’s Hospital and Medical Center Expected Completion: June 2024

View Audit 301158

Finding 390267 (2023-004)

None 2023

The Houston Food Bank and Subsidiaries

TX

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

Due to turnover and transitions in key positions, on-boarding of agencies did not include these three locations on the annual site visit schedule. In FY 2024 new procedures have already been implemented for on-boarding, new personnel have been assigned oversight of agencies, and two compliance depar...

Due to turnover and transitions in key positions, on-boarding of agencies did not include these three locations on the annual site visit schedule. In FY 2024 new procedures have already been implemented for on-boarding, new personnel have been assigned oversight of agencies, and two compliance departments, one in Accounting and one in Partner Services, have been fully established to monitor compliance.

View Audit 301154

Finding 390261 (2023-102)

Material Weakness 2023

Maricopa County Community College District

AZ

Questioned Costs Eligibility Student Financial Aid § 200.303 § 200.513 § 200.521

Cluster name: TRIO Cluster Assistance Listing number and name: 84.042 TRIO – Student Support Services 84.047 TRIO – Upward Bound Award numbers and years: P047A171009, September 1, 2017 through August 31, 2022 P047A170820, September 1, 2017 through August 31, 2023 P042A200873, P042A201342, and...

Cluster name: TRIO Cluster Assistance Listing number and name: 84.042 TRIO – Student Support Services 84.047 TRIO – Upward Bound Award numbers and years: P047A171009, September 1, 2017 through August 31, 2022 P047A170820, September 1, 2017 through August 31, 2023 P042A200873, P042A201342, and P042A200859, September 1, 2020 through August 31, 2025 P047A221154 and P047A221160, September 1, 2022 through August 31, 2027 Federal Agency: U.S. Department of Education Compliance Requirements: Eligibility Questioned costs: $5,612 Name of contact persons: Kristina Winterstein, Associate Controller, District Business Services Anticipated completion date: June 30, 2024 The District is aware of the importance of maintaining effective internal control over federal awards and ensuring compliance with applicable federal regulations. The District will work with the TRIO project directors at each college to review and revise existing procedures to require an independent and knowledgeable employee review and approve student eligibility determinations prior to awarding program services to them. The District will enhance communication and training efforts to ensure that the TRIO project directors and all staff administering the TRIO programs understand all eligibility requirements and related district-wide policies and procedures. As of March 21, 2024, the questioned costs for the program have been resolved.

View Audit 301142 Questioned Costs: $1

Corrective Action Plans

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