Corrective Action Plans

Finding 374544 (2023-001)

Material Weakness 2023

South Florida Regional Transportation Authority

FL

Reporting Subrecipient Monitoring § 200.502 § 200.508 § 200.510 § 200.71

Condition: The SEFA for the year ended June 30, 2023 was not accurately prepared, as it originally included federal expenditures that were not on the cash basis. Planned Corrective Action: The corrective action has been implemented to revise internal procedures to prepare the SEFA on a cash basis fo...

Condition: The SEFA for the year ended June 30, 2023 was not accurately prepared, as it originally included federal expenditures that were not on the cash basis. Planned Corrective Action: The corrective action has been implemented to revise internal procedures to prepare the SEFA on a cash basis for future fiscal years. This includes the creation of a reconciliation schedule to the financial statements which are prepared on an accrual basis. Contact person responsible for corrective action: Jeremy Baker, Director of Finance Anticipated Completion Date: 1/15/2024

View Audit 294245

Finding 374517 (2023-001)

None 2023

Saddleback Valley Unified School District

CA

Questioned Costs Equipment & Real Property Management Procurement, Suspension & Debarment § 200.311 § 200.313 § 200.439

The District's procedure for purchases utilizing federal funds for goods in excess of $5,000 are submitted to the California Department of Education prior to purchase for approval. The District utilized COVID relief funds to upgrade classrooms with equipment consistent in the SVI classroom project. ...

The District's procedure for purchases utilizing federal funds for goods in excess of $5,000 are submitted to the California Department of Education prior to purchase for approval. The District utilized COVID relief funds to upgrade classrooms with equipment consistent in the SVI classroom project. While the components of the SVI project are under the $5,000 threshold for prior approval collectively they are over this threshold. The components being under the $5,000 threshold resulted in an oversight of the needed preapproval for these purchases. Fiscal Services is developing a checklist of required steps in the procurement process when federal funds are being considered to ensure prior approval, if needed, is sought prior to purchase. The checklist will include an area where each component is listed to include delivery cost and installation and will include acknowledgement of whether these components collectively create one asset. This will allow other staff reviewing the checklist to determine if preapproval based on cost may be needed. The checklist will require approval of the department head of the requesting department acknowledging understanding of the federal purchasing requirements for capital expenditure as well as, approval of the Director, Fiscal Services and the District's Assistant Superintendent of Business Services.

View Audit 294238 Questioned Costs: $1

Finding 374501 (2023-001)

Significant Deficiency 2023

National Endowment for Democracy

DC

Subrecipient Monitoring Reporting

NED management has been aware of the FFATA reporting requirements and takes a serious approach to FFATA regulations. NED's concerns regarding FFATA compliance are rooted in concern for personal and physical safety of our grantees working in the sphere of human rights and democracy, particularly thos...

NED management has been aware of the FFATA reporting requirements and takes a serious approach to FFATA regulations. NED's concerns regarding FFATA compliance are rooted in concern for personal and physical safety of our grantees working in the sphere of human rights and democracy, particularly those NED partners working in the world's most hostile authoritarian countries. As stated in our response to the FY2022 Audit, NED staff analysis of the potential reporting requirements recognized two significant risks to NED's partners and the success of its programs: 1) reporting all first-tier sub awardees would mean posting the identity of recipients and details of sensitive awards on a publicly accessible website, and 2) reporting NED partners as first-tier sub awardees of the Department of State (DOS) on a public website of federal funding accountability undermines the Congress' intentional decision to protect the independence of NED's programmatic decision-making when it crafted the NED Act. With the intention of balancing the legitimate concerns for our NED grantees with our desire to comply with the spirit of transparency and accountability rooted in FFATA, NED renewed discussions with Department of State officials to find a resolution to this issue. The leadership at NED and at State’s Bureau of Democracy, Human Rights, and Labor jointly assessed the issue to determine a long-term solution. Following the development of a Duty of Care policy outlining NED’s institutional obligations to “do no harm” with respect to the safety and security of our stakeholders, including NED grantees, NED management has since reached an agreement with our DOS Grants Officer to designate NED’s annual appropriation award as “sensitive” and therefore not subject to the annual FFATA reporting requirements. We have since received NED’s annual award for2024 with language matching several of our special funds DOS awards: “This award has been deemed sensitive and is not subject to the Federal Funding Accountability and Transparency Act (FFATA).” We expect the same terms to apply to our awards going forward which, ensuring a permanent resolution to this issue. Name of Responsible Official: Nancy Herzog, Title: VP, Grant Operations & Evaluation Date correction action executed: 11/29/2023.

View Audit 294218

Finding 374493 (2023-003)

Significant Deficiency 2023

Lighthouse Community Public Schools

CA

Procurement, Suspension & Debarment Subrecipient Monitoring School Nutrition Programs § 200.320

Views of responsible officials and Corrective Action Plan: Management of the School has noted the 2 CFR Section 200.320 to ensure that the procurement requirements are met.

View Audit 294202

Finding 374483 (2023-003)

Significant Deficiency 2023

Millersburg Area School District

PA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.318 § 200.320

Corrective Action Planned: When the District decides to utilize cooperative purchasing programs on noncompetitive purchasing arrangements when spending federal funds, it will ensure that it complies with its procurement policy. The District will document its process and how it complies with the pr...

Corrective Action Planned: When the District decides to utilize cooperative purchasing programs on noncompetitive purchasing arrangements when spending federal funds, it will ensure that it complies with its procurement policy. The District will document its process and how it complies with the procurement standards and keep such documentation with federal award budget/procurement documents. Anticipated Completion Date: Action has already been taken by the District to resolve the underlying issue of the finding for the year ending June 30, 2024. Contact Person Responsible: Eric S. Petery, Business Manager

View Audit 294158

Finding 374480 (2023-002)

Significant Deficiency 2023

Millersburg Area School District

PA

Subrecipient Monitoring Cash Management Reporting

Corrective Action Planned: The District will review and establish procedures that all required quarterly cash on hand and final expenditure reports are properly completed within the required time periods. A new federal programs coordinator has been hired and the District has consulted with an expe...

Corrective Action Planned: The District will review and establish procedures that all required quarterly cash on hand and final expenditure reports are properly completed within the required time periods. A new federal programs coordinator has been hired and the District has consulted with an experienced federal programs coordinator to train that individual. Procedures are now in place to ensure that the District files all quarterly cash on hand reports within 10 days of quarter ending and final expenditure reports within 30 days after the funds are expended, but no later than 30 days after the ending date of the project. All existing compliance issues related to filing deadlines are being addressed and corrected. Anticipated Completion Date: Acton has already been taken by the District to resolve the underlying issue of the finding for the year ending June 30, 2024. Contact Person Responsible: Eric S. Petery, Business Manager

View Audit 294158

Finding 374479 (2023-001)

Significant Deficiency 2023

Brattleboro Development Credit Corporation

VT

Reporting Subrecipient Monitoring Significant Deficiency

Audit Finding Reference: 2023-001 Improve Controls and Timing of Reporting Planned Corrective Action: The Organization currently has written Grant Management Policies, and Management agrees with this finding, that these policies do not adequately address the Federal Funding Accountability and Tran...

Audit Finding Reference: 2023-001 Improve Controls and Timing of Reporting Planned Corrective Action: The Organization currently has written Grant Management Policies, and Management agrees with this finding, that these policies do not adequately address the Federal Funding Accountability and Transparency Act (Pub. L. No. 109-282), as amended by Section 6202 of Public Law 110-252 which requires recipients (i.e., direct recipients) of grants or cooperative agreements to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System. The Organization will update its Grant Management Policies to address the requirements of the Federal Funding Accountability and Transparency Act, and once formally adopted, the Organization will distribute the new policies and procedures to necessary staff, as well as advise and train its staff on following such policies and procedures. Planned Implementation Date of Corrective Action: June 30, 2024 Person Responsible for Corrective Action: Director of Finance & Grant Management

View Audit 294142

Finding 374472 (2023-002)

Significant Deficiency 2023

Bay De Noc Community College

MI

Subrecipient Monitoring Special Tests & Provisions Allowable Costs / Cost Principles

Auditor Description of Condition and Effect. The most recent Gramm Leach Bliley Policy fails to address the implementation of safeguards to control the risks the institution identifies through its risk assessment, the testing or monitoring the effectiveness of the safeguards implemented, and the eva...

Auditor Description of Condition and Effect. The most recent Gramm Leach Bliley Policy fails to address the implementation of safeguards to control the risks the institution identifies through its risk assessment, the testing or monitoring the effectiveness of the safeguards implemented, and the evaluation and adjustment of its information security program in light of the results of the required testing and monitoring. As a result of this condition, the College is not meeting the safeguard requirements necessary to comply with the FTC. In addition, the lack of safeguard controls creates an increased risk to highly sensitive data that is possessed by the College. Auditor Recommendation. We recommend that the College implement procedures to ensure that all Gramm Leach Bliley Policies are met and verified by a second individual. Corrective Action. Currently, the College is reviewing the compliance requirements for the Gramm Leach Bliley Act and will amend the current policy to ensure that each safeguard is being addressed within the policy. Responsible Person. Jonathan Lane, Director of IT. Anticipated Completion Date. June 30, 2024

View Audit 294140

Finding 374462 (2023-002)

Significant Deficiency 2023

Latino Network

OR

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Subrecipient Monitoring

2023-002 Finding – Federal Award – Significant Deficiency in Internal Control over Compliance - Allowable Costs Context: Expenditures should be charged to the proper programs and allocated in accordance with the cost allocation plan and documentation of approval of any subsequent change to the alloc...

2023-002 Finding – Federal Award – Significant Deficiency in Internal Control over Compliance - Allowable Costs Context: Expenditures should be charged to the proper programs and allocated in accordance with the cost allocation plan and documentation of approval of any subsequent change to the allocation plan should be maintained. Recommendation: We recommend management implement procedures to ensure that costs charged to the grant follow the approved cost allocation and documentation of approved changes to allocations be maintained. Action Taken: Management concurs with the auditor’s finding and will enhance documentation protocols, standardize the approval process, and have regular reviewing and monitoring.

View Audit 294126

Finding 374435 (2023-005)

Material Weakness 2023

Lawrenceburg Community School Corporation

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.1 § 200.303 § 200.317 § 200.318 § 200.319

FINDING 2023-005 Finding Subject: Special Education Cluster (IDEA) – Procurement and Suspension and Debarment Summary of Finding: Procurement Federal regulations allow for informal procurement methods when the value of the procurement for goods or services does not exceed the simplified acquisition ...

FINDING 2023-005 Finding Subject: Special Education Cluster (IDEA) – Procurement and Suspension and Debarment Summary of Finding: Procurement Federal regulations allow for informal procurement methods when the value of the procurement for goods or services does not exceed the simplified acquisition threshold, which is customarily set at $250,000. However, Indiana Code 5-22-8 has a more restrictive threshold of $150,000 or less for when small purchase procedures may be used. This informal process allows for methods other than the formal bid process. The informal process is divided between two methods based on thresholds. Micro-purchases, typically for those purchases $10,000 or under, and small purchase procedures for those purchases above the micro-purchase threshold, but below the simplified acquisition threshold. Micro-purchases may be awarded without soliciting competitive price rate quotations. If small purchase procedures are used, then price or rate quotations must be obtained from an adequate number of qualified sources. If it is determined a single source provider can be used for a small purchase, documentation must be retained supporting the determination. The Cooperative did not adhere to the requirements necessary for them to be in compliance with the procurement of small purchases during the audit period. Suspension and Debarment The School Corporation did not have internal controls in place to ensure compliance with the suspension and debarment requirement. The Cooperative did not have adequate internal controls in place to ensure all applicable vendors were not suspended or debarred prior to entering into a covered transaction. As such, the Cooperative never entered into a contract, although their payments to the vendor exceeded $50,000. The Cooperative did not perform procedures to ensure that the vendor was not suspended or debarred from participation in federal programs. Contact Person Responsible for Corrective Action: Julie Dudley Contact Phone Number and Email Address: 812.537.7205 jdudley@lburg.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The ROD Special Education Cooperative will make notes in the Board Minutes regarding the fact that only one vendor can provide specific services prior to entering into a contract or purchasing said services. Each company providing services will be checked on the SAM.gov website to ensure that the vendor has not been suspended or debarred. This documentation will be provided to the ROD board for review, and our Superintendent is a member of that board. Anticipated Completion Date: February 1, 2024

View Audit 294097

Finding 374431 (2023-003)

Material Weakness 2023

Lawrenceburg Community School Corporation

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2023-003 Finding Subject: COVID-19 Emergency Connectivity Fund Program - Suspension and Debarment Summary of Findings: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Procurement and...

FINDING 2023-003 Finding Subject: COVID-19 Emergency Connectivity Fund Program - Suspension and Debarment Summary of Findings: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Procurement and Suspension and Debarment compliance requirement. The School Corporation did not have adequate procedures in place to ensure that vendors were not suspended or debarred before entering into a covered transaction. Suspension and Debarment Before entering into subawards and covered transactions with program funds, recipients are required to verify that such contractors and subrecipients are not suspended, debarred, or otherwise excluded. “Covered transactions” include, but are not limited to contracts for goods and services awarded under a non-procurement transaction (i.e. grant agreement) that are expected to equal or exceed $25,000. The verification is to be done by checking the Excluded Parties List System (EPLS), collecting a certification from that person, or adding a clause or condition to the covered transaction with that person. Two covered transactions were identified that equaled or exceeded $25,000. Both transactions, totaling $837,454 were selected for testing. For the noted transactions, the School Corporation did not verify the vendor’s suspension and debarment status before the payment due to the School Corporation not having any policies or procedures in place to verify that contractors were neither suspended nor debarred, or otherwise excluded or disqualified from participating in federal assistance programs or activities. The lack of internal controls and noncompliance were systemic issues throughout the audit period. Contact Person Responsible for Corrective Action: Julie Dudley Contact Phone Number and Email Address: 812.537.7205 jdudley@lburg.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: When purchasing goods or services using Federal dollars a search will be conducted to verify that the vendor is not suspended or disbarred from receiving federal funds. If the vendor is not located in the Sam.gov database; we will reach out to the vendor and request a statement verifying this. If a contract is signed between LCSC and the vendor; we will request that suspension and disbarment language be included in the contract. Anticipated Completion Date: February 2024

View Audit 294097

Finding 374411 (2023-001)

Significant Deficiency 2023

York College of Pennsylvania

PA

Student Financial Aid Reporting Subrecipient Monitoring

Corrective Action Planned: The College has noted the issue and it has since been rectified and has re-ran the process to provide the proper effective dates for withdrawn students to the National Student Clearinghouse. The College does report to the National Student Clearinghouse every 30 days. The C...

Corrective Action Planned: The College has noted the issue and it has since been rectified and has re-ran the process to provide the proper effective dates for withdrawn students to the National Student Clearinghouse. The College does report to the National Student Clearinghouse every 30 days. The College has reviewed their policies and procedures to ensure proper reporting requirement procedures to NSC and NSLDS. Training has been provided to those responsible for manual adjustments to records having extenuating circumstances. Name(s) of Contact Person(s) Responsible for Corrective Action: Eric Dinsmore, Senior Director of Financial Aid Anticipated Completion Date: As of January 2024, withdrawal student status change effective dates have been corrected. The College has reviewed reporting policies and procedures and has provided training to responsible parties for manual reporting whenever extenuating circumstances occur. The College will implement any additional necessary changes in 2024 fiscal year.

View Audit 294058

Finding 374389 (2023-005)

Significant Deficiency 2023

Bethany College

KS

Subrecipient Monitoring Special Tests & Provisions Significant Deficiency

Corrective Action Plan 2023-005: The College concurs with the finding and will formalize its written Information Security Program. Completion Date: Spring 2024 Contact Person: Joshua Bieber, Director of Information Technology

View Audit 293985

Finding 374382 (2023-003)

Significant Deficiency 2023

Bethany College

KS

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

Corrective Action Plan 2023-003: The College has obtained the required letter of credit from a local bank and will comply with federal heightened cash monitoring requirements. The College continues to work to positively align revenues and expenses. The College regularly monitors its cash flows and e...

Corrective Action Plan 2023-003: The College has obtained the required letter of credit from a local bank and will comply with federal heightened cash monitoring requirements. The College continues to work to positively align revenues and expenses. The College regularly monitors its cash flows and expense budgets both for timing and savings. Efforts continue to increase net student revenues to reduce the need for current-year contributions and other income for operating expenses. The College will continue to carefully plan and manage institutional financial aid to yield stronger net student revenues to support operations. Anticipated Completion Date: August 2024 Contact Person: Steven W. Eckman, President

View Audit 293985

Finding 374352 (2023-001)

None 2023

Regional Development Authority of Charleston Kanawha County West Virginia Metropolitan Region

WV

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.512

The Kanawha County Regional Development Authority of Charleston - Kanawha County will ensure that the data collection form will be submitted to the federal audit clearing house within 30 days of the aduit being issues.

View Audit 293960

Finding 374346 (2023-003)

Significant Deficiency 2023

Town of Bridgwater, Vermont

VT

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214

Annually

View Audit 293943

Finding 374345 (2023-002)

Significant Deficiency 2023

Town of Bridgwater, Vermont

VT

Subrecipient Monitoring Significant Deficiency Matching / Level of Effort / Earmarking § 200.302

Update grant spreadsheet monthly

View Audit 293943

Finding 374344 (2023-001)

Significant Deficiency 2023

Town of Bridgwater, Vermont

VT

Subrecipient Monitoring Allowable Costs / Cost Principles Significant Deficiency § 200.302

Adopt suggested policies as outlined by auditor

View Audit 293943

Finding 374343 (2023-001)

Significant Deficiency 2023

Lexington-Fayette Urban County Housing Authority

KY

HUD Housing Programs Subrecipient Monitoring Eligibility

Re: 2023-01 Audit Finding/Plan of Action The Lexington Housing Authority (LHA) proposes this corrective plan of action to address the late recertifications (13) and annual recertification (1) from the audit conducted by Rector, Reeder & Lofton PC, onsite at LHA September 25-29, 2023. ADDRESSING S...

Re: 2023-01 Audit Finding/Plan of Action The Lexington Housing Authority (LHA) proposes this corrective plan of action to address the late recertifications (13) and annual recertification (1) from the audit conducted by Rector, Reeder & Lofton PC, onsite at LHA September 25-29, 2023. ADDRESSING STAFFING Securing qualified candidates to fill Housing Management Specialist (HMS) positions throughout 2020, 2021 and 2022 was challenging for LHA. In some instances, positions were vacant for up to 12 months before they were filled. LHA will do the following to address staffing: • Seek to fill HMS positions within forty-five (45) days of the position going vacant. • Advertise to hire two full-time HMS positions for the two management teams with the most units in their management portfolio. • Continue to advertise open positions online, on social media and in the local newspaper. • Offer incentive bonus up to $1,500 to newly hired HMS, paying $750 to new hires after six month of employment and an additional $750 after 12 months of employment. • Over-time will be allowed on an as-needed basis to complete and process certifications. CERTIFICATION PROCEDURES Further, LHA housing management staff will adhere to the following procedures to facilitate timely completion of annual certifications. - HMS staff will continue utilize in-person interviews and mail (via USPS and email) to complete needed documentation for annual certifications. - All housing management staff may utilize electronic signature to attain required signatures when necessary. - The first day of each month housing managers will run the certification audit report to be shared with the Chief Operating Officer to monitor the status of in-progress and upcoming certifications. - July 1, 2023, LHA implemented quality control (QC) of public housing files to be conducted by a newly created compliance position. LHA' s compliance coordinator will complete 229 (25%) QC reviews of public housing files during FY2024 (July 1, 2023 - June 30, 2024). - At least once monthly on a rotating basis housing management staff from all offices will convene at a selected housing management office to complete and process certifications. This schedule will continue until all offices are up to date on certifications. LHA staff will apply these procedures as outlined to mitigate this finding to ensure compliance and proper documentation of future certifications. Contact Person: Andrea Wilson, Chief Operating Officer Anticipated Completion Date: June 30, 2024

View Audit 293932

Finding 374295 (2023-006)

Material Weakness 2023

Delphi Community School Corporation

IN

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

FINDING 2023-006 Finding Subject: Education Stabilization Fund - Reporting Summary of Finding: Management had not developed or implemented a system of internal control that would have ensured compliance with the grant agreement and the Reporting compliance requirement. The failure to establish an ef...

FINDING 2023-006 Finding Subject: Education Stabilization Fund - Reporting Summary of Finding: Management had not developed or implemented a system of internal control that would have ensured compliance with the grant agreement and the Reporting compliance requirement. The failure to establish an effective internal control system enabled material noncompliance to go undetected. Noncompliance with the grant agreement and the Reporting compliance requirement could result in the loss of future federal funds to the School Corporation. We recommended that the School Corporation's management establish internal controls to ensure compliance and comply with the grant agreement and the Reporting compliance requirement. Contact Person Responsible for Corrective Action: Andrea Miller Contact Phone Number and Email Address: 765-564-2100, millera@delphi.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The treasurer will prepare all required reports, and the grant administrator will verify the information on the reports. Reports will be signed and dated by both parties. Anticipated Completion Date: July 2024

View Audit 293921

Finding 374280 (2023-005)

Material Weakness 2023

Delphi Community School Corporation

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.1 § 200.303 § 200.317 § 200.318 § 200.319

FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Procurement and Suspension and Debarment Summary of Finding: Management had not developed a system of internal controls that would have ensured compliance with the grant agreement and the Procurement and Suspension and Debarment compliance ...

FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Procurement and Suspension and Debarment Summary of Finding: Management had not developed a system of internal controls that would have ensured compliance with the grant agreement and the Procurement and Suspension and Debarment compliance requirement. The failure to establish an effective internal controls system enabled material noncompliance to go undetected. Noncompliance with the grant agreement and the Procurement and Suspension and Debarment compliance requirement could result in the loss of future federal funds to the School Corporation. We recommended that the School Corporation's management establish a system of internal controls to ensure compliance with the Procurement and Suspension and Debarment compliance requirement. Contact Person Responsible for Corrective Action: Andrea Miller Contact Phone Number and Email Address: 765-564-2100, millera@delphi.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director will obtain 3 quotes for any purchase over $10,000 from different vendors, in addition if the purchase is over $50,000 a contract will be awarded. Vendors will be verified by SAM.gov for suspension and disbarment, a record of these searches will be printed and kept in the vendor file. In addition, a vendor list will be provided annually to the school board for approval. Anticipated Completion Date: July 2024

View Audit 293921

Finding 374269 (2023-001)

Significant Deficiency 2023

Kalihi-Palama Health Center (hale Ho'ola Hou)

HI

Special Tests & Provisions Subrecipient Monitoring Eligibility

Finding 2023-001 Special Tests and Provisions - Sliding Fee Scale Recommendation Kalihi-Palama Health should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated, and patients receive the correct sliding fee discount. Action Taken: We implemented...

Finding 2023-001 Special Tests and Provisions - Sliding Fee Scale Recommendation Kalihi-Palama Health should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated, and patients receive the correct sliding fee discount. Action Taken: We implemented a new EHR system AthenaOne and it includes a sliding fee scale calculation tool. By March 18, 2024 we will have completed doing all of the testing and training of all current Patient Services/Front Desk staff. Effective April 1 2024, we will implement the following changes to ensure clients are appropriately charged according to the sliding fee scale: • Update recurring sliding fee scale employee training sessions to quarterly. • Update training process documentation and reference materials for sliding fee scale. • Implement monthly review and spot check procedures to ensure compliance with the sliding fee scale requirements and guidelines. Based on the results of the reviews and spot checks, individualized training will be provided staff. • Onboarding new Patient Services/Front Desk staff will be based on the updated training and reference materials. Should you need additional information or have questions, you can reach me at ekintu@kphc.org or (808) 791-6315. Emmuel Kintu, D. Mgt, MBA Chief Executive Office & Executive Director

View Audit 293873

Finding 372673 (2023-003)

Significant Deficiency 2023

Move United

MD

Reporting Subrecipient Monitoring

Recommendation: We recommend that the Organization review its monitoring process for the annual reporting of SF-425 reports, and ensure reports are filed timely within the requirements of the reporting deadlines. If an extension is necessary for any instances of reporting, a request for extension sh...

Recommendation: We recommend that the Organization review its monitoring process for the annual reporting of SF-425 reports, and ensure reports are filed timely within the requirements of the reporting deadlines. If an extension is necessary for any instances of reporting, a request for extension should be filed with the federal agency, along with a justified explanation for the additional time needed. Otherwise, all annual reports should be filed timely no later than 60 days after the end of each fiscal year.Views of Responsible Officials and Planned Corrective Action: Move United will put in place a three tier redundancy plan for ensuring that filings, both within the VA Salesforce system and within the Payment Management System, are filed prior to or on time each quarter. The Chief Financial Officer, Programs Director and Grants Administrator will work collaboratively to complete the necessary data compilation at least one week prior to the filing deadline. All three individuals will be trained on and have access to the two systems. In the event one individual is incapacitated at the time of filing, one of the other two will complete the filing on time. Person Responsible: Chief Financial & Operating Officer, Programs Director. Planned Completion Date: Immediately.

View Audit 293787

Finding 372643 (2023-002)

Material Weakness 2023

Martinsville Msd

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.302 § 200.303 § 200.328 § 200.329 § 200.334

Finding 2023‐002 Finding Subject: COVID‐19 ‐ Education Stabilization Fund ‐ Reporting Summary of Finding: The School Corporation was required to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not l...

Finding 2023‐002 Finding Subject: COVID‐19 ‐ Education Stabilization Fund ‐ Reporting Summary of Finding: The School Corporation was required to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not limited to, current period expenditures, prior period expenditures, and expenditures per activity. The School Corporation submitted two reports during the audit period; however, a single employee prepared and submitted the reports without evidence of a review or oversight process in place to prevent or detect and correct errors for the first report submission. Additionally, for the ESSER I Year 2 reporting, the ‘Total Mandatory Subgrant Amount Expended in Current Reporting Period’ was not supported by the School Corporation's records. Actual expenditures from a provided report did not agree to the amount submitted for the Annual Performance Reporting. The key line item ‘Total Mandatory Subgrant Amount Expended in Current Reporting Period’ for the ESSER I Year 2 report was determined to be overstated by $80,342. Contact Person Responsible for Corrective Action: Whitney Kuszmaul, District Treasurer & Tiffany Grant, Grant Coordinator Contact Phone Number and Email Address: (765) 342‐6641 Whitney.Kuszmaul@msdmartinsville.org & Tiffany.Grant@msdmartinsville.org Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Grant Coordinator works to collect the data from a couple different sources. The staff report information comes from our Payroll/HR department, the CE information comes from our Reporting Specialist and the financial data comes from District Treasurer. The Grant Coordinator requests a detailed report for the appropriate period and break down the detailed report by project/report categories. All of this information is then recorded in the DOE data sheet and is reviewed and tied back to the detailed reports provided by the District Treasurer. After review, the Grant Coordinator and the District Treasurer initial/sign off on the DOE data sheets. The Jot Form confirmation is retained with the DOE data sheets and supporting reports/documentation. Anticipated Completion Date: February 2024

View Audit 293718

Finding 372641 (2023-001)

Material Weakness 2023

Martinsville Msd

IN

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

Finding 2023‐001 Finding Subject: COVID‐19 ‐ Education Stabilization Fund ‐ Allowable Costs/Cost Principles Summary of Finding: The School Corporation paid security contractors without an invoice. Costs charged to grant funds must be adequately documented. The School Corporation had an accounts paya...

Finding 2023‐001 Finding Subject: COVID‐19 ‐ Education Stabilization Fund ‐ Allowable Costs/Cost Principles Summary of Finding: The School Corporation paid security contractors without an invoice. Costs charged to grant funds must be adequately documented. The School Corporation had an accounts payable voucher signed by the contractor, but there was no invoice supporting the accounts payable voucher. Costs charged to grant funds must be adequately supported with documentation. Contact Person Responsible for Corrective Action: Tiffany Grant, Grant Coordinator Contact Phone Number and Email Address: 765‐342‐6641 ‐ Tiffany.Grant@msdmartinsville.org Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: A contract is on file with the Martinsville City Police Department for the contracted police officers that work for the MSD of Martinsville. Going forward, contracted police officers will submit their timesheets directly to the MSD of Martinsville Assistant Police Chief. The Assistant Police Chief will verify hours worked and submitted to the schedule. The Assistant Police Chief will review and initial/sign the vouchers before submitting those to the Grant Coordinator for review and signature. Anticipated Completion Date: February 2024

View Audit 293718

Corrective Action Plans

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