Corrective Action Plans

Finding 382828 (2023-004)

Material Weakness 2023

IN

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

Finding 2023-004 Information on the federal program: Subject: Education Stabilization Fund – Special Tests and Provisions - Wage Rate Requirements Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal A...

Finding 2023-004 Information on the federal program: Subject: Education Stabilization Fund – Special Tests and Provisions - Wage Rate Requirements Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D200013, S425D210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Special Tests and Provisions - Wage Rate Requirements Audit Findings: Material Weakness, Qualified Opinion Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Special Tests and Provisions – Wage Rate Requirements compliance requirements. The School Corporation did not include Davis Bacon wage rate requirements in its contract with vendor which includes labor. The School Corporation did not obtain the weekly payroll reports certifications from a construction company and its subcontractors for a building project. Context: The School Corporation expended $2,354,885 during the audit period on equipment acquisitions for a new HVAC system and chiller at the North White Middle-High School building which included labor installation costs subject to federal Davis Bacon wage rate requirements. Each project had a separate vendor for a total of two vendor contracts during the audit period subject to testing for Davis Bacon wage rate requirements. The vendor contracts did not include a Davis-Bacon clause prescribing federal wage rate requirements required for construction contracts with labor installation costs. The School Corporation did not have an internal control designed to collect the weekly payroll reports certifications from a construction company and its subcontractors, as applicable, for building projects to verify prevailing wages were being paid during the project period. Therefore, no review was performed by management to ensure that pay rates complied with the federal wage rate requirements. For the period July 1, 2021 through June 30, 2023, $925,844 was disbursed related to these building projects and charged to the ESSER II grant award (84.425D). For the period July 1, 2021 through June 30, 2023, $1,429,041 was disbursed related to these building projects and charged to the ESSER III grant award (84.425U). The construction payments represented approximately 80.1% of the Education Stabilization Fund expenditures for the audit period. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. The Corporation will make sure all contracts using federal dollars will have the Davis-Bacon clause written in the contract. The project manager will request weekly time sheets for all labor installation and verify the work has been completed. Responsible Party and Timeline for Completion: The Superintendent, Nicholas Eccles, will oversee the corrective action plan regarding the Davis-Bacon clause in future contracts which will be implemented by June 30, 2024. The Building/Maintenance Director, Dean Cook, will oversee the corrective action plan regarding the verification of time sheets for labor installation which will be implemented by June 30, 2024.

View Audit 296431

Finding 382826 (2023-003)

Material Weakness 2023

North White School Corporation

IN

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303 § 200.305

FINDING 2023-003 Information on the federal program: Subject: Education Stabilization Fund – Advance Draws Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identif...

FINDING 2023-003 Information on the federal program: Subject: Education Stabilization Fund – Advance Draws Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D200013, S425D210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs- Cost Principles Audit Finding: Material Weakness, Other Matters Condition: The School Corporation requested reimbursement prior to incurring expenditures under federal grant awards. An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Activities Allowed or Unallowed, Allowable Costs- Cost Principles compliance requirements. Context: During testing disbursements charged to ESF grants, we noted the ESSER I grant award, tracked in Fund 7940, and the ESSER III grant award, tracked in Fund 7932, had a positive cash balance of $2,718 and $35,661, respectively, at June 30, 2023 as a result of advance payments received during fiscal year 2023. The School Corporation submitted a request for reimbursement on November 15, 2022 for $21,745 from the ESSER I grant award and $565,876 from the ESSER III grant award, respectively. These requests for reimbursements were partially supported by disbursements incurred as of the date of the request, however, partially include requests for advance payments that were still not fully expended as of June 30, 2023. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. If there are any posting corrections after a reimbursement has been made and received, the Corporation Treasurer will contact IDOE (Indiana Department of Education) asking whether they would like the difference between the reimbursement and the new disbursement amount paid back to DOE or spent down within a specific time period. Responsible Party and Timeline for Completion: The Corporation Treasurer, Emma Conwell, will oversee the corrective action plan which will be implemented by June 30, 2024.

View Audit 296431 Questioned Costs: $1

Finding 382799 (2023-003)

Material Weakness 2023

Nettle Creek School Corporation

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.302 § 200.303 § 200.328 § 200.329

FINDING 2023-003 Finding Subject: Education Stabilization Fund – Reporting Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement an...

FINDING 2023-003 Finding Subject: Education Stabilization Fund – Reporting Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the following compliance requirements: Reporting The School Corporation had not designed, nor implemented a system of internal control to ensure that the annual Elementary and Secondary School Emergency Relief (ESSER) annual Data Collection reports (Reports) were complete and accurately submitted. The Reports were prepared by one employee without an oversight or review process in place to prevent, or detect and correct, errors. Additionally, for ESSER II, Year 1, annual report tested the School Corporation could provide supporting documentation that did not agree with the ESSER II, Year 1, annual report. The lack of internal controls was a systemic issue throughout the audit period. The noncompliance was isolated from ESSER 1I, Year 1 report. Contact Person Responsible for Corrective Action: Amber Rushton Contact Phone Number and Email Address: Phone Number: (765) 489-4543 Email: arushton@nettlecreek.k12.in.us Views of Responsible Officials: “We concur with the finding.” Description of Corrective Action Plan: The Business Manager will prepare annual reports for grants and the Director of Learning and/or Superintendent will review and sign-off reports before submission. Anticipated Completion Date: June 30, 2024

View Audit 296407

Finding 382796 (2023-001)

Significant Deficiency 2023

Hamilton Local School District

OH

Allowable Costs / Cost Principles Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

The district has contracted with the ESC of Central Ohio for an accountant to help with the timely filing of all federal grant requirements. By timely completing project cash requests we will be able to see if variances require changes in the grant budgets. This will minimize correcting entries in t...

The district has contracted with the ESC of Central Ohio for an accountant to help with the timely filing of all federal grant requirements. By timely completing project cash requests we will be able to see if variances require changes in the grant budgets. This will minimize correcting entries in the last week of the fiscal year where mistakes tend to happen in the rush to close the year.

View Audit 296403

Finding 382786 (2023-005)

None 2023

San Diego Christian College

CA

Student Financial Aid Cash Management Subrecipient Monitoring

Noncompliance with HCM 1 Monitoring Planned Corrective Action: SDCC currently operates under HCM2 status which requires that the College proves that sufficient compliance has been met prior to the reimbursement of all Title IV funds. As SDCC continues its efforts to move to HCM1 status, processes ...

Noncompliance with HCM 1 Monitoring Planned Corrective Action: SDCC currently operates under HCM2 status which requires that the College proves that sufficient compliance has been met prior to the reimbursement of all Title IV funds. As SDCC continues its efforts to move to HCM1 status, processes and procedures have been identified and will be implemented when authorization to operate under HCM1 status is received. Person Responsible for Corrective Action Plan: Kayleigh Reyes, Director of Financial Services Anticipated Date of Completion: Policies and procedures for HCM1 was provided during the audit.

View Audit 296385

Finding 382780 (2023-004)

Material Weakness 2023

San Diego Christian College

CA

Subrecipient Monitoring Material Weakness

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: • 16 CFR § 314.4(b)(1): To be completed by June 30, 2024. • 16 CFR § 314.4(c)(1-8): To be completed for SDCC-utilized systems that contain this feature by June 30, 2024. • 16 CFR § 314.4(d)(2): The College currently monitors in...

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: • 16 CFR § 314.4(b)(1): To be completed by June 30, 2024. • 16 CFR § 314.4(c)(1-8): To be completed for SDCC-utilized systems that contain this feature by June 30, 2024. • 16 CFR § 314.4(d)(2): The College currently monitors information systems internally through log review. External penetration testing will be conducted pending funds availability for this purpose. • 16 CFR § 314.4(e): To be completed by September 30, 2024. • 16 CFR § 314.4(h): To be completed by September 30, 2024. • 16 CFR § 314.4(i): To be completed by December 31, 2024. Person Responsible for Corrective Action Plan: Lisa Kopecky, Chief Financial Officer and Matt Owen, designated Information Security Officer Anticipated Date of Completion: Completion as noted above.

View Audit 296385

Finding 382773 (2023-006)

Material Weakness 2023

Lakeland School Corporation

IN

Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.334 § 200.403

FINDING 2023-006 Finding Subject: COVID-19 Education Stabilization Fund – Allowable Costs/Cost Principles Summary of Finding: The School Corporation did not have effective internal controls over the ESSER funds and there was noncompliance in regards to the ESSER funds. Employee pay did not equal wha...

FINDING 2023-006 Finding Subject: COVID-19 Education Stabilization Fund – Allowable Costs/Cost Principles Summary of Finding: The School Corporation did not have effective internal controls over the ESSER funds and there was noncompliance in regards to the ESSER funds. Employee pay did not equal what transferred and supporting documentation for substitute pay and payment of sick days when school was closed. Contact Person Responsible for Corrective Action: Jamesi Lemon and Melanie Summers Contact Phone Number and Email Address: (260) 499-2400; jlemon@lakelandlakers.net/msummers@lakelandlakers.net Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: INDIANA STATE BOARD OF ACCOUNTS 30 A spreadsheet has been created to track the substitutes and the classes they are covering. Pay scales are also now included in the employee handbooks, so pay can be calculated correctly and tracked. Any transfers of payroll expenses are now completed monthly to ensure the correct amounts are being charged to the ESSER funds. Anticipated Completion Date: Immediately

View Audit 296373

Finding 382767 (2023-005)

Material Weakness 2023

Lakeland School Corporation

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.303

FINDING 2023-005 Finding Subject: COVID-19 Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had a lack of internal controls over the ESSER reporting to the IDOE. There was no review process in place to prevent, or detect and correct, errors. Contact Person Responsi...

FINDING 2023-005 Finding Subject: COVID-19 Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had a lack of internal controls over the ESSER reporting to the IDOE. There was no review process in place to prevent, or detect and correct, errors. Contact Person Responsible for Corrective Action: Jamesi Lemon Contact Phone Number and Email Address: (260) 499-2400; jlemon@lakelandlakers.net Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: The Director of Business Operations and Director of Staff and Student Success will meet to review the annual data reports for accuracy before they are submitted to the IDOE. The meeting will be logged and reports signed off by both individuals. Anticipated Completion Date: Immediately

View Audit 296373

Finding 382741 (2023-001)

Material Weakness 2023

Management Council of the Ohio Education Computer Network

OH

Subrecipient Monitoring § 200.332

The Management Council will implement the following corrective actions: • Procedures will be put in place to analyze federal awards to properly determine whether expected disbursements should be categorized as subawards. • Policies and procedures will be put in place to properly administer the subaw...

The Management Council will implement the following corrective actions: • Procedures will be put in place to analyze federal awards to properly determine whether expected disbursements should be categorized as subawards. • Policies and procedures will be put in place to properly administer the subawards and monitor the subrecipients activity to ensure that grant requirements are being met.

View Audit 296335

Finding 382739 (2023-001)

Significant Deficiency 2023

District School Board of Pinellas County

FL

Subrecipient Monitoring Significant Deficiency

Planned Corrective Action - The district will review procedures in alignment with state and federal guidance. The district's FTE team will include the federal guidelines for documentation supporting student withdrawal and subsquent removal from the graduation cohort in their annual and ongoing trai...

Planned Corrective Action - The district will review procedures in alignment with state and federal guidance. The district's FTE team will include the federal guidelines for documentation supporting student withdrawal and subsquent removal from the graduation cohort in their annual and ongoing training with school-based staff responsible for this practivce. The district continuously adheres to the State of Florida documentation requirements and guidelines for inclusion for graduation cohorts. Anticipated Completion Date - 4/30/2024 Responsible Contact Person - Kevin W. Smith

View Audit 296328

Finding 382732 (2023-001)

Material Weakness 2023

Cardington-Lincoln Local School District

OH

Matching / Level of Effort / Earmarking Subrecipient Monitoring

Comply with Davis-Bacon Act for Federal Projects. The district will incorporate contract wording in all future contracts that enforce the Davis-Bacon act requirements. Final payments for projects requiring this documenation will not be made until all parts of the contract are fulfilled.

View Audit 296323

Finding 382710 (2023-001)

Material Weakness 2023

Weatherford Independent School District No. 26

OK

Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking

A copy of the Davis-Bacon Act requirement has been placed in the office of the federal program director. The director will be responsible for filling out the appropriate paperwrok before approving any federal funds to be used on projects that are classified as construction. The requirements of the...

A copy of the Davis-Bacon Act requirement has been placed in the office of the federal program director. The director will be responsible for filling out the appropriate paperwrok before approving any federal funds to be used on projects that are classified as construction. The requirements of the Davis-Bacon Act have also been shared with the Encumbrance Clerk and Treasurer for the purpose of checks and balances.

View Audit 296312

Finding 382694 (2023-007)

Material Weakness 2023

Muncie Community Schools

IN

Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

Finding 2023-007 – Education Stabilization Fund - Special Tests and Provisions - Wage Rate Requirement Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We wil...

Finding 2023-007 – Education Stabilization Fund - Special Tests and Provisions - Wage Rate Requirement Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all construction projects using federal funding will meet the wage rate requirements. Anticipated Completion Date: March 2024

View Audit 296252

Finding 382689 (2023-006)

Material Weakness 2023

Muncie Community Schools

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.302 § 200.303 § 200.328

Finding 2023-006 – Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all ESSER reports include accurate...

Finding 2023-006 – Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all ESSER reports include accurate information that agree to the underlying disbursement records. Anticipated Completion Date: Next ESSER reports due in FY24

View Audit 296252

Finding 382684 (2023-005)

Significant Deficiency 2023

Muncie Community Schools

IN

Internal Control / Segregation of Duties Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding 2023-005 – Title I Grants to Local Educational Agencies - Maintenance of Effort Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all ex...

Finding 2023-005 – Title I Grants to Local Educational Agencies - Maintenance of Effort Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all expenses are recorded correctly and any capital items over the threshold are properly recorded to capital object codes. Anticipated Completion Date: March 2024

View Audit 296252

Finding 382628 (2023-001)

Material Weakness 2023

Tipton Independent School District #8

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness

The Tipton School District will immediately implement the following controls to assure that the district has adequate internal controls in place should any future expenditures of federal funds for Capital Projects be made. The district will review the Federal Procurement and contractor requirements...

The Tipton School District will immediately implement the following controls to assure that the district has adequate internal controls in place should any future expenditures of federal funds for Capital Projects be made. The district will review the Federal Procurement and contractor requirements prior to submitting documents to use Federal Funds for Capital Projects. The district will provide training to staff to ensure compliance with all Federal Program Procurement including compliance with the Davis-Bacon Act (prevailing wage rate) requirements, and reviewing weekly certified payroll reports from the contractor or subcontractor. The district will ensure that all items are posted at the work site to confirm compliance. This corrective action plan will go into effect by March 11, 2024.

View Audit 296205

Finding 382620 (2023-001)

Significant Deficiency 2023

Flagler College, Inc.

FL

Student Financial Aid Subrecipient Monitoring Reporting

Student Financial Aid Cluster – Special Tests and Provisions – NSLDS Recommendation: We recommend that the College continue to enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting is complet...

Student Financial Aid Cluster – Special Tests and Provisions – NSLDS Recommendation: We recommend that the College continue to 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: The Office of the Registrar reports enrollment to NSLDS using the National Student Clearinghouse (NSC). The Registrar’s Office will collaborate with our Information Technology Department to identify and correct all students with erroneous program start dates. As recommended by CLA, the Registrar’s Office is reviewing its process for Clearinghouse submissions in collaboration with the Information Technology Department and Advising Office to ensure that the program-level enrollment effective dates are accurately reflected when a student submits a change of major. Names of the contact persons responsible for corrective action: Sheia Pleasant-Doine and Adam Doine Planned completion date for corrective action plan: May 3, 2024

View Audit 296201

Finding 382608 (2023-001)

Significant Deficiency 2023

Harlem United Community Aids Center, Inc. and Affiliates

NY

Special Tests & Provisions Subrecipient Monitoring Eligibility

Audit Period: June 30, 2023 The finding from the June 30, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number in the schedule. FINDING – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, Health Center Clust...

Audit Period: June 30, 2023 The finding from the June 30, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number in the schedule. FINDING – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, Health Center Cluster Programs (Assistance Listing Number 93.224/93.527/COVID-19 93.224) SIGNIFICANT DEFICIENCY Item 2023-001 –Special Tests and Provisions Recommendation: We recommend that proper training be given to employees and that sliding fee discounts be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. Action Taken Management will be training all registration personnel in teams meetings or one on one training sessions. The staff will be trained on how to appropriately monitor and use the sliding fee discounts. Staff will be shown how to maintain the applicable documentation to support the maintenance of the sliding fee discounts. In addition, a team of management and billing staff will be assigned to periodically review the process to ensure the Center always complies with the sliding fee regulations. Completion Date: July 1, 2024 If the Health Resources and Services Administration has questions regarding this plan, please call Tamisha McPherson, Executive Director of URAM at 212-803-2850.

View Audit 296188

Finding 382597 (2023-001)

None 2023

Martin Luther College

MN

Subrecipient Monitoring

The lack of written documentation of policies and procedures specific to GLBA requirements is being addressed by the Director of Information Technology and a campus-wide committee overseeing information security. The documented information security program has been drafted and will address the requi...

The lack of written documentation of policies and procedures specific to GLBA requirements is being addressed by the Director of Information Technology and a campus-wide committee overseeing information security. The documented information security program has been drafted and will address the required elements of GLBA . Final policies will be reviewed and approved by the Administrative Council, or president’s cabinet. The College is also planning to increase assurance procedures related to the GLBA requirements, with a mid-year review of the information security program as well as enhanced procedures during the interim audit.

View Audit 296159

Finding 382592 (2023-005)

Material Weakness 2023

Portage Township Schools

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.302 § 200.303 § 200.328

Finding 2023-005 – Education Stabilization Fund – Reporting Contact Person Responsible for Corrective Action: Linda Williams Contact Phone Number: 219-764-6209 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The PTS Office of Grants and Assessmen...

Finding 2023-005 – Education Stabilization Fund – Reporting Contact Person Responsible for Corrective Action: Linda Williams Contact Phone Number: 219-764-6209 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The PTS Office of Grants and Assessments will collaborate with the PTS Finance Office to establish a system of internal controls and separation of duties to ensure a thorough review prior to the submission of the Annual ESSER Data Report. Anticipated Completion Date: April 2024

View Audit 296149

Finding 382584 (2023-007)

Significant Deficiency 2023

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Reporting § 200.303

Beginning January 31, 2024, DDAP started having internal discussions to determine the most effective and efficient methodology to evaluate the internal controls of the SCAs' data being reported to DDAP during the federal grant period and in the PPRs. Steps currently being taken by DDAP include updat...

Beginning January 31, 2024, DDAP started having internal discussions to determine the most effective and efficient methodology to evaluate the internal controls of the SCAs' data being reported to DDAP during the federal grant period and in the PPRs. Steps currently being taken by DDAP include updating the SCAs' monitoring process for the next annual monitoring cycle for FY 2023-24. The goal is to have a sound methodology with formalized policies and procedures in place by April 2024 to ensure the data collected is sampled for accuracy going forward. To ensure accuracy of the information reported by the SCAs, which is included on the PPRs, DDAP will add verification of this data to the current SCA monitoring process. Specifically, the Project Officers who conduct SCA monitoring will: - Add a question to the SCA Pre-Submission packet: ‘How does your SCA track SOR-funded clients in order to accurately report them on the SOR Report?’ The SCA must specifically state how they are accounting for these clients and how they arrive at the data reported to DDAP. If DDAP determines the process is not acceptable, the SCA will be required to revise and resubmit. - During the virtual monitoring call, Project Officers will review the SCA’s written answer to the question, and ensure they have a full understanding of where the SCA keeps data on SOR-funded clients, and how they access this data to complete the SOR reports. - During the onsite monitoring visit, the Project Officers will take the most recently submitted SOR report and ask the SCA staff to duplicate the steps they used to arrive at the reported numbers. * If the SCA is able to demonstrate how clients are tracked and the steps used to determine the reported numbers produce results consistent with what was submitted in the report, the SCA’s submitted data will be considered verified. * If the SCA is unable to demonstrate how clients are tracked, and the steps used to determine the reported numbers do not produce results consistent with what was submitted in the report, the SCA will be required to implement a process by which they can accurately track this data and report client numbers. Any SCA required to implement a new client-tracking system will be required to submit backup documentation with their SOR reports, until such time as they are able to demonstrate to DDAP that they are accurately tracking clients and can demonstrate the steps used to determine their reported numbers. - This review process and results will be added to the Monitoring Report sent to the SCA at the end of the monitoring cycle, to reflect the SCA’s compliance status. Anticipated Completion Date: 09/30/2024 Contact Names: Susan Duff, Chief, Program Monitoring Division; Autumn Croasmun, Project Director for State Opioid Response III Grant; Tia Roebuck, Director, Division of Budget and Procurement

View Audit 296143 Questioned Costs: $1

Finding 382583 (2023-006)

Material Weakness 2023

Commonwealth of Pennsylvania

PA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.404

DOC will institute internal controls to review and monitor, on a quarterly basis, medical costs billed from the pharmaceutical vendor to ensure the billing is consistent with contract language. The review will be done by a Fiscal Management Specialist (FMS). The internal control will consist of the...

DOC will institute internal controls to review and monitor, on a quarterly basis, medical costs billed from the pharmaceutical vendor to ensure the billing is consistent with contract language. The review will be done by a Fiscal Management Specialist (FMS). The internal control will consist of the following: - Beginning with the December 2023 invoice, DOC will request fully executed procurement documents from the pharmaceutical contractor to verify acquisition costs. - The current contract language states that pharmaceuticals are billed at actual acquisition costs plus a dispensing fee. Therefore, the FMS will match the acquisition cost for the vendor for a sample of transactions to the invoices received from the vendor. - DOC will conduct this review on the pharmaceutical invoices for March, June, September, and December in each year continually. - DOC will document the review using an excel spreadsheet that has the universe of pharmacy orders by patient – matching the records and recording the date the review was done. All documents will be saved in an internal medical invoice folder. - Reviews will be completed by the last day of the month after the invoice is submitted. - Training on the new process will be done by March 31, 2024. Findings (or lack thereof) will be reported to DDAP by April 30th, July 31st, October 31st, and January 31st of each year via email. - If there are discrepancies, the vendor will be contacted immediately and a true-up will be requested in the next month’s invoices (either a credit or a debit depending on the discrepancy). DOC will continue to utilize PACE to complete full audits on reasonability of drug prices. DOC acknowledges, due to purchasing and distribution practices for the pharmaceutical vendor, Sublocade was not on prior reports. However, in the third and fourth quarter of 2023, Sublocade was added to the quarterly PACE audits for reasonability of drug prices. DOC has spoken with PACE and will now receive all quarterly audits and will be invited to all meetings between PACE and the contracted pharmaceutical vendor to discuss any findings. Anticipated Completion Date: 03/31/2024 Contact Names: Erica Benning, Director, Healthcare Services; Jodilynn Jacob-Byrd, Fiscal Management Specialist

View Audit 296143 Questioned Costs: $1

Finding 382581 (2023-015)

Material Weakness 2023

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Cash Management

Office of Admin.–SSBG: The Bureau of Financial Operations (BFO) will continue conducting during-the-award subrecipient monitoring for the SSBG based on the results of the documented risk assessment. As it relates to the cash management portion of the finding, given the relatively small amount of f...

Office of Admin.–SSBG: The Bureau of Financial Operations (BFO) will continue conducting during-the-award subrecipient monitoring for the SSBG based on the results of the documented risk assessment. As it relates to the cash management portion of the finding, given the relatively small amount of funds involved and the number of counties affected, DHS has determined that it is not economically feasible to change the payment methodology at this time. Anticipated Completion Date: 06/30/2024 Contact Name: Kelly Graham, Director, Div. of Financial Policy and Operations OPD-SSBG: Due to the COVID-19 global pandemic as well as staff turnover and vacancies in OPD, regular monitoring of SSBG grant recipients was not performed on schedule. However, with the hiring of a full complement of staff for the DHS Policy Office, including a Grant Administrator, we are in the process of creating and implementing a robust monitoring plan for all 19 of our grantees for calendar year 2024, including in-person monitoring, desk monitoring, data collection, and analysis. Anticipated Completion Date: 12/31/2024 Contact Name: Jessica Schneider, Exec. Policy Specialist I, Grants

View Audit 296143 Questioned Costs: $1

Finding 382570 (2023-022)

Significant Deficiency 2023

Commonwealth of Pennsylvania

PA

Subrecipient Monitoring Matching / Level of Effort / Earmarking

The following steps were taken to address this material weakness: - Finalize FFATA procedures to ensure a consistent FFATA review is being conducted in General Accounting. - Mangers will review FFATA preparer’s reports for completeness. - Review fiscal year end FFATA errors and make corrections need...

The following steps were taken to address this material weakness: - Finalize FFATA procedures to ensure a consistent FFATA review is being conducted in General Accounting. - Mangers will review FFATA preparer’s reports for completeness. - Review fiscal year end FFATA errors and make corrections needed so the FFATA reports are in FSRS and USAspending.gov. Anticipated Completion Date: 11/01/2024 Contact Names: Sandra Bruno, Integrated Financial Service Manager; Jamie Jerosky, Assistant Director

View Audit 296143

Finding 382568 (2023-014)

Significant Deficiency 2023

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring § 200.332 § 200.425

New Directions, Cash Grants The Office of Income Maintenance (OIM) is determining how it can incorporate onsite financial monitoring into the monitoring that is currently being conducted. This includes consideration of the specific areas the financial monitoring should cover and the scope of the mo...

New Directions, Cash Grants The Office of Income Maintenance (OIM) is determining how it can incorporate onsite financial monitoring into the monitoring that is currently being conducted. This includes consideration of the specific areas the financial monitoring should cover and the scope of the monitoring. After OIM develops the monitoring procedures, OIM will start the onsite monitoring. Anticipated Completion Date: 12/31/2024 Contact Name: Joel O’Donnell, Dir., Bureau of Program Support, OIM Real Alternatives Despite repeated attempts and efforts by the Office of Policy Development (OPD) to engage Real Alternatives in ongoing monitoring activities, as well as monitoring after the end of the grant for previous years, the grantee was uncooperative and unresponsive to our requests and therefore regular monitoring was not completed. Effective December 31, 2023, the Department of Human Services’ grant agreement with Real Alternatives ended and was not renewed. Anticipated Completion Date: Completed Contact Name: Jessica Schneider, Executive Policy Specialist I, Grants, OPD

View Audit 296143 Questioned Costs: $1

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