Corrective Action Plans

Finding 2170 (2023-001)

Significant Deficiency 2023

CT

Special Tests & Provisions Subrecipient Monitoring Eligibility

October 5, 2023 To: United States Department of Health and Human Services Generations Family Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: June 30, 2023 The findings f...

October 5, 2023 To: United States Department of Health and Human Services Generations Family Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: June 30, 2023 The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FINANCIAL STATEMENT FINDINGS: Finding 2023.001- Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Action Taken: Upon review of the finding, it was determined that the system calculated the slide correctly, but the procedure code was assigned to the incorrect procedure class, creating the error. Beginning July 1, 2023, Management has: • Reviewed the entire fee schedule, schedule of discounts and procedure groupings in the practice management system compared to the board approved fee schedule. Only one procedure group required correction of one procedure code. • In addition, the Director of Patient Revenue will work with the Electronic Health Record vendor to organize the system procedure classes for all procedure codes and financial classes to decrease any crosswalk issues or redundancies. In addition, the Director of Patient Revenue will work with the EHR vendor to upload fee schedules and sliding fee discount groups electronically. Previous internal controls adopted include: • Upon creating adding a new charge to the system, the Director of Patient Revenue posts the charge into a test patient account to confirm that the standard and slide rates match those entered on the fee schedule • At the annual review and/or revision of the Agency’s fee schedule, the Billing Manager assists the Director of Patient Revenue in reviewing every charge on the updated/approved year’s fee schedule to confirm the rates and slide assignment match the Fee Schedule. • A quarterly audit of insured and self-pay patients occur to review that adjustments are correct per agency policy. This action decreases chances of system issues that cause erroneous adjustments going unnoticed. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Debra Savoie, CFO at (860) 456-6271.

View Audit 3746

Finding 2143 (2023-003)

Significant Deficiency 2023

Ord Public Schools District No. 5

NE

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

ESTABLISH INTERNAL CONTROL OVER FINANCIAL STATEMENT PREPARATION AND REVIEW Recommendation: The District should review and approve the proposed auditor adjusting entries and the adequacy of schedule of the expenditures of federal awards disclosures prepared by the auditors and apply analytic proc...

ESTABLISH INTERNAL CONTROL OVER FINANCIAL STATEMENT PREPARATION AND REVIEW Recommendation: The District should review and approve the proposed auditor adjusting entries and the adequacy of schedule of the expenditures of federal awards disclosures prepared by the auditors and apply analytic procedures to the draft financial statements, among other procedures as considered necessary by management. Action Taken: The District will prepare of schedule of federal expenditures based on expenditure categories as found in the District's general ledger and value of commodities for lunch program. This will be prepared using an excel spreadsheet. The District will review the audit adjustments as presented by the external auditors including those related to the federal expenditures and the related worksheet. We will ensure the adjustments made to federal award expenditures are appropriate by examining the nature and amount of the adjustments. Questionable items will be discussed and agreed upon between the District and the auditors. After review and approval of the entries, they will be input into the District's general ledger and the SEFA spreadsheet will be updated. This will be compared to the SEFA that is included in the audit report and if they are in agreement, this will be approved by management. All variances will be addressed prior to finalization of the audit report and submission to the Nebraska. If the Nebraska Department of Education has questions regarding this plan, please call Dr. Heather Nebesniak at 308.728.5013. Department of Education as well as to the Federal Audit Clearinghouse.

View Audit 3717

Finding 2131 (2023-001)

Significant Deficiency 2023

Unified School District #349 Stafford, Ks

KS

Subrecipient Monitoring Internal Control / Segregation of Duties

Finding 2023-1 - Lack of Segregation of Duties The District understands that this is a significant deficiency but feels it is not cost-effective at this time to hire additional employees to properly segregate duties. We feel that the oversight performed by the Superintendent and Board of Educatio...

Finding 2023-1 - Lack of Segregation of Duties The District understands that this is a significant deficiency but feels it is not cost-effective at this time to hire additional employees to properly segregate duties. We feel that the oversight performed by the Superintendent and Board of Education over the financial statement activity and reports of the District is adequate to help mitigate the lack of segregation of duties. We believe it would be inefficient and cost prohibitive to hire the additional employees needed to properly segregate duties so at this time we do not plan on making any changes. However, we will continue to monitor this situation and periodically determine if it is cost-effective for us to properly segregate duties.

View Audit 3696

Finding 2129 (2023-001)

Significant Deficiency 2023

Streator Esd No. 44

IL

Subrecipient Monitoring Material Weakness Reporting

The District will improve segregation of grant expenditures to ensure the amounts claimed agree to the general ledger. The District will also increase review and oversight of grant reporting to ensure accuracy.

View Audit 3688

Finding 2122 (2023-004)

None 2023

Dallas Christian College

TX

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking

Common Origination and Disbursement (COD) Reporting Planned Corrective Action: We’ve created a new activity in Anthology SIS labeled “FA – Return to Title IV” to be assigned to both FA staff and Student Accounts staff when returns are needed. These activities will include detailed notes as to what r...

Common Origination and Disbursement (COD) Reporting Planned Corrective Action: We’ve created a new activity in Anthology SIS labeled “FA – Return to Title IV” to be assigned to both FA staff and Student Accounts staff when returns are needed. These activities will include detailed notes as to what returns need to be applied to posted funds on the student’s ledger. This will ensure that we apply returns as required and that the returns applied also match the applied returns in COD. FA Solutions and DCC are aligned on better communications for returns that need to be applied to ensure accuracy going forward. Person Responsible for Corrective Action Plan: Jean-Claude St Juste, Financial Aid Director, Student Accounts staff, and FA Solutions staff. Anticipated Date of Completion: Immediately

View Audit 3665

Finding 2077 (2023-002)

Material Weakness 2023

Clintondale Community Schools

MI

Questioned Costs Subrecipient Monitoring Material Weakness

See corrective action plan in audit report

View Audit 3625 Questioned Costs: $1

Finding 2025 (2023-002)

Significant Deficiency 2023

South Heartland District Health Department

NE

Matching / Level of Effort / Earmarking Subrecipient Monitoring

Program: AL 93.069 – Public Health Emergency Preparedness – Matching Corrective Action Planned: SHDHD monitors matching fund levels for Federal subawards on a quarterly basis to determine whether the match amount is on track toward meeting the percentage required in each grant agreement. Regarding t...

Program: AL 93.069 – Public Health Emergency Preparedness – Matching Corrective Action Planned: SHDHD monitors matching fund levels for Federal subawards on a quarterly basis to determine whether the match amount is on track toward meeting the percentage required in each grant agreement. Regarding the PHEP award, in particular, the Department will ensure that the new Emergency Response Coordinator (hired in the middle of the grant period last year) is aware of the match requirements. SHDHD will also ensure that no Federal funds are used to pay for matching funds required in Federal subawards. The Department was not aware that this was not allowable. Anticipated Completion Date: June 30, 2024 Responsible Party: Kelly Derby, Erik Meyer, Brooke Wolfe

View Audit 3537

Finding 2024 (2023-003)

Significant Deficiency 2023

South Heartland District Health Department

NE

Procurement, Suspension & Debarment Subrecipient Monitoring

Program: AL 21.027 – COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension & Debarment Corrective Action Planned: SHDHD will add a clause to each Agreement covered by Federal funds, certifying that the recipient of the funds is eligible to receive such funds. SHDHD will also clar...

Program: AL 21.027 – COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension & Debarment Corrective Action Planned: SHDHD will add a clause to each Agreement covered by Federal funds, certifying that the recipient of the funds is eligible to receive such funds. SHDHD will also clarify the certification process in our Procurement Policy. Anticipated Completion Date: Ongoing, re Agreements. January 31, 2024, re policy change. Responsible Party: Michele Bever, Kelly Derby, Brooke Wolfe

View Audit 3537

Finding 1937 (2023-001)

Significant Deficiency 2023

Klawock City School District

AK

Reporting Subrecipient Monitoring Significant Deficiency § 200.303

Finding 2023-001 Lack of Internal Control over Reporting Name of Contact: Jim Holien Corrective Action Plan: Corrective Action Plan: The district will develop FFATA reporting policies and procedures to submit subaward award information through FSRS to ensure compliance with FFATA requirements. ...

Finding 2023-001 Lack of Internal Control over Reporting Name of Contact: Jim Holien Corrective Action Plan: Corrective Action Plan: The district will develop FFATA reporting policies and procedures to submit subaward award information through FSRS to ensure compliance with FFATA requirements. Proposed Completion Date: June 30, 2024

View Audit 3360

Finding 1862 (2023-003)

Significant Deficiency 2023

Blair County Community Action Program

PA

Internal Control / Segregation of Duties Subrecipient Monitoring

Corrective Action A signed subrecipient agreement should be in place prior to the pass-through of grant process. In the future, if BCCAP has a subrecipient contract, any ofthose changes will be accurately updated and an amended contract will be provided for both parties to sign. Completion Date 11/1...

Corrective Action A signed subrecipient agreement should be in place prior to the pass-through of grant process. In the future, if BCCAP has a subrecipient contract, any ofthose changes will be accurately updated and an amended contract will be provided for both parties to sign. Completion Date 11/1/2023 Agency Response Does the agency agree with the finding? -x-Yes --No Additional Comments N/A Agency Contact Responsible for Correction Action Name: Lisa Hann - Board President Address: 2301 Beale Ave Altoona, PA 16601 Phone Number: (814) 944-3583 Email: Ihann@familyservicesinc.net -

View Audit 3240

Finding 1749 (2023-001)

Significant Deficiency 2023

San Joaquin Health Centers

CA

Subrecipient Monitoring Cash Management Eligibility

Views of Responsible Officials and Planned Corrective Actions The Organization will continue to implement the following measures to ensure compliance with the sliding fee discount program, and consistently assess patient income and family size. The Organization will continue to provide ongoing train...

Views of Responsible Officials and Planned Corrective Actions The Organization will continue to implement the following measures to ensure compliance with the sliding fee discount program, and consistently assess patient income and family size. The Organization will continue to provide ongoing training to clinic staff who evaluate the sliding fee application at its clinic locations. The training consists of reviewing sliding fee program policies and procedures along with all applicable patient forms, sliding fee scale, and patient eligibility. The following quality control measures to ensure compliance have been implemented effective April 30, 2023; 1. Front Desk Peer Review of sliding fee application and verification of patient income and family size. 2. Enhance training materials to support Front Desk Staff with assessing sliding fee applications. 3. Quarterly feedback to Front Desk Staff based on sliding fee applications reviewed. Person Responsible: Kristopher D. Zuniga Position of Responsible Party: Chief Financial Officer Completion Date: April 30, 2023

View Audit 3036

Finding 1742 (2023-001)

Material Weakness 2023

Pencil Foundation

TN

Subrecipient Monitoring

Management's Corrective Action Plan Year Ended June 30, 2023 Finding 2023-001 PENCIL Foundation did not produce evidence of subrecipient monitoring of the appropriate use of funds and program updates of the subrecipients. Per 0MB guidance, non-federal entities are required to monitor the use of fund...

Management's Corrective Action Plan Year Ended June 30, 2023 Finding 2023-001 PENCIL Foundation did not produce evidence of subrecipient monitoring of the appropriate use of funds and program updates of the subrecipients. Per 0MB guidance, non-federal entities are required to monitor the use of funds provided to subrecipients. Subrecipients are those non-federal entities that receive funds that are not the end users of the funds. Department's Response: We concur. Views of Responsible Officials and Corrective Action: PENCIL should communicate the compliance requires for staff involved in the distribution of funds to subrecipients. The staff should conduct the required procedures to monitor the use of funds, check status of programs and obtain regular updates sufficient to satisfy themselves regarding the appropriate use of funds in accordance with the requirements of the federal award and any related contracts. Anticipated Completion Date: The fund distribution documentation process is in place. Subrecipients of funds have been reviewed through the grant process in various ways but a full reconciliation and accounting will be completed and documented by January 31, 2024 for all grant activity through December 31, 2023. Name of Responsible Person: Angie Adams, CEO

View Audit 3018

Finding 1709 (2023-005)

Significant Deficiency 2023

Community Unit School District 100

IL

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles

Condition: Quarterly expenditure reports for the projects expenditures were not timely filed for ESSER II D2 (4 of 4 quarters required), ESSER I (1 of 1 quarters required), and ESSER II ST (1 of 1 quarters required). Plan: To avoid this reporting and internal control issue, the District should sche...

Condition: Quarterly expenditure reports for the projects expenditures were not timely filed for ESSER II D2 (4 of 4 quarters required), ESSER I (1 of 1 quarters required), and ESSER II ST (1 of 1 quarters required). Plan: To avoid this reporting and internal control issue, the District should schedule the due dates of all expenditure reports in order to avoid late filings. Anticipated Date of Completion: June 30, 2024 Name of Contact Person: Lisa Schuenke, Assistant Superintendent of Finance and Human Resources Management Response: This District is aware of the issue and has determined that the majority of the problem occurs when a grant is first approved, and the first reporting period is missed or if a grant continues into subsequent project years. Management has found a dashboard within IWAS that has a listing of all grants by project year and dates that the grants and budgets are approved that will help determine when the first expenditure reports are due. Additionally, management will work on a process to ensure that expenditure reports are no longer missed or filed late.

View Audit 2972

Finding 1707 (2023-008)

Significant Deficiency 2023

Community Unit School District 100

IL

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Condition: Expenditures claimed on the projects’ quarterly reports were not included in the detailed budget approved by ISBE resulting in questioned costs for the projects. Plan: To avoid this reporting and internal control issue, the District should compare expenditure reports to the program budge...

Condition: Expenditures claimed on the projects’ quarterly reports were not included in the detailed budget approved by ISBE resulting in questioned costs for the projects. Plan: To avoid this reporting and internal control issue, the District should compare expenditure reports to the program budget that has been submitted. Budget policies per the State and Federal Grant Administration Policy should be reviewed and followed accordingly. Anticipated Date of Completion: June 30, 2024 Name of Contact Person: Lisa Schuenke, Assistant Superintendent of Finance and Human Resources Management Response: The District will work to properly report transactions in the future and follow the guidelines set forth in the policy manual.

View Audit 2972 Questioned Costs: $1

Finding 1706 (2023-006)

Significant Deficiency 2023

Community Unit School District 100

IL

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles

Condition: Quarterly expenditure reports for the project’s expenditures were not timely filed for ESSER III (2 of 4 quarters required) and ESSER III C3 (1 of 1 quarters required). Plan: To avoid this reporting and internal control issue, the District should schedule the due dates of all expenditure...

Condition: Quarterly expenditure reports for the project’s expenditures were not timely filed for ESSER III (2 of 4 quarters required) and ESSER III C3 (1 of 1 quarters required). Plan: To avoid this reporting and internal control issue, the District should schedule the due dates of all expenditure reports in order to avoid late filings. Anticipated Date of Completion: June 30, 2024 Name of Contact Person: Lisa Schuenke, Assistant Superintendent of Finance and Human Resources Management Response: This District is aware of the issue and has determined that the majority of the problem occurs when a grant is first approved, and the first reporting period is missed or if a grant continues into subsequent project years. Management has found a dashboard within IWAS that has a listing of all grants by project year and dates that the grants and budgets are approved that will help determine when the first expenditure reports are due. Additionally, management will work on a process to ensure that expenditure reports are no longer missed or filed late.

View Audit 2972

Finding 1703 (2023-007)

Significant Deficiency 2023

Community Unit School District 100

IL

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Condition: Expenditures claimed on the projects’ quarterly reports were not included in the detailed budget approved by ISBE resulting in questioned costs for the projects. Plan: To avoid this reporting and internal control issue, the District should compare expenditure reports to the program budge...

Condition: Expenditures claimed on the projects’ quarterly reports were not included in the detailed budget approved by ISBE resulting in questioned costs for the projects. Plan: To avoid this reporting and internal control issue, the District should compare expenditure reports to the program budget that has been submitted. Budget policies per the State and Federal Grant Administration Policy should be reviewed and followed accordingly. Anticipated Date of Completion: June 30, 2024 Name of Contact Person: Lisa Schuenke, Assistant Superintendent of Finance and Human Resources Management Response: The District will work to properly report transactions in the future and follow the guidelines set forth in the policy manual.

View Audit 2972 Questioned Costs: $1

Finding 1673 (2023-003)

None 2023

Missouri Housing Development Commission

MO

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.400 § 200.401

Finding 2023-003 – Allowable Costs and Activities, Eligibility – Compliance Federal Award. No. 21.026 Homeowner Assistance Fund – COVID 19 Corrective Action Plan: The Commission was made aware of the sophisticated fraudulent entity through its contacts with the National Council of State Housing Agen...

Finding 2023-003 – Allowable Costs and Activities, Eligibility – Compliance Federal Award. No. 21.026 Homeowner Assistance Fund – COVID 19 Corrective Action Plan: The Commission was made aware of the sophisticated fraudulent entity through its contacts with the National Council of State Housing Agencies (NCSHA). Staff remains active in those groups, participating in weekly and monthly calls and will adopt further preventative measures that have been shown to be effective in other states. Staff has implemented a more rigorous servicer onboarding process, whereby questionable items or documentation deemed to be suspicious or potentially altered will be presented to the program director, finance staff, compliance staff, or other internal staff for further investigation. Staff does not anticipate further issues with falsified information with the enhanced onboarding procedures implemented. In addition, balances owed are verified by loan servicers, and funds are paid directly to the servicer and never to individual homeowners. Completion Date: The Commission implemented additional compliance review procedures during fiscal year 2023 and completed its investigation of the identified case. Contact Person: Steve Whitson, Director of Community Programs

View Audit 2908 Questioned Costs: $1

Finding 1672 (2023-002)

Material Weakness 2023

Missouri Housing Development Commission

MO

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.400 § 200.401

Finding 2023-002 – Allowable Costs and Activities, Eligibility – Compliance and Control Finding Federal Award No. 21.023 Emergency Rental Assistance Program – COVID 19 Corrective Action Plan: The Commission administered direct assistance according to the program rules and regulations. The Commission...

Finding 2023-002 – Allowable Costs and Activities, Eligibility – Compliance and Control Finding Federal Award No. 21.023 Emergency Rental Assistance Program – COVID 19 Corrective Action Plan: The Commission administered direct assistance according to the program rules and regulations. The Commission collected the required information and documentation to review and approve applications. Applicants submitted certified applications meeting the requirements of the program. However, the Commission staff discovered through its noncompliance review and identification processes that some program applicants provided false information and fraudulent documentation that continues to be investigated and reported to the proper authorities. Internal controls have been enhanced to mitigate and help prevent further exposure to noncompliance. Past and ongoing measures implemented to ensure eligibility of all funds disbursed include: the adoption of a formal fraud, waste, and abuse policy in July 2021 as well as providing additional training to employees and third parties that were responsible for reviewing and approving applications in order to better detect invalid applicants to prevent funding these applicants. In May 2021, the Commission hired an Internal Compliance Manager and created an Internal Compliance Department who has engaged a third party law firm and a consulting group to provide consultative assistance to improve processes and to assist in investigating applications deemed to be questionable. Further, internal staffing capacity was expanded with the creation of the Community Programs Processes Department in fall 2021 and the Data and Analytics Department in early 2022. Additional investigative techniques such as “mass denial metrics” and tiered level reviews were implemented into weekly application processing. Commission staff set regular internal coordination meetings to improve communication and aid in the identification of new indicators. Internal compliance staff actively participates in national groups administering similar programs, and explores and adopts new preventative or other review measures demonstrated to be effective in other states. As program funds for direct rental and utility assistance have been expended and direct assistance applications no longer accepted, additional internal metrics and compliance review processes are being developed to apply a consistent process for examining any outstanding questioned costs and to make a final determination regarding the eligibility of disbursed funds. Completion Date: The Commission implemented additional compliance review procedures during fiscal years 2021 and 2022 and expects to conclude its investigation of the fiscal year identified cases during calendar year 2024. Contact Person: Steve Whitson, Director of Community Programs

View Audit 2908 Questioned Costs: $1

Finding 1670 (2023-001)

Material Weakness 2023

Missouri Housing Development Commission

MO

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.400 § 200.401

Finding 2023-001 – Allowable Costs and Activities – Compliance and Control Finding Federal Award No. 14.231 Emergency Solutions Grant Program – COVID 19 Corrective Action Plan: The Commission administered direct assistance according to the program rules and regulations. The Commission collected the ...

Finding 2023-001 – Allowable Costs and Activities – Compliance and Control Finding Federal Award No. 14.231 Emergency Solutions Grant Program – COVID 19 Corrective Action Plan: The Commission administered direct assistance according to the program rules and regulations. The Commission collected the required information and documentation to review and approve applications. Applicants submitted certified applications meeting the requirements of the program. However, the Commission staff discovered through its noncompliance review and identification processes that some program applicants provided false information and fraudulent documentation that continues to be investigated and reported to the proper authorities. Internal controls have been enhanced to mitigate and identify instances of potential noncompliance. The use of program funds for direct rental assistance under this program was concluded and the final disbursements made in early May 2021. Past and ongoing measures implemented to ensure eligibility of all funds disbursed include: The Commission hiring an Internal Compliance Manager and establishing an internal compliance department in May 2021 who engaged a third party law firm and a consulting group to provide consultative assistance to improve processes and to assist in investigating applications deemed to be questionable. A formal fraud, waste and abuse policy was adopted in July 2021. During fiscal year 2022, the Commission undertook extensive efforts to detect instances of ineligible applicants and documentation irregularities, which resulted in identification of these instances of applicant noncompliance. As program funds for direct rental assistance have been expended, additional internal metrics and compliance review processes are being developed to apply a consistent process for examining any outstanding questioned costs and to make a final determination regarding the eligibility of disbursed funds. Completion Date: The Commission implemented additional compliance review procedures during fiscal years 2021 and 2022, reviewed applications to identify potentially fraudulent applications during fiscal years 2022 and 2023 and expects to conclude its investigation of identified cases during fiscal year 2024. Contact Person: Steve Whitson, Director of Community Programs

View Audit 2908 Questioned Costs: $1

Finding 1611 (2023-002)

Significant Deficiency 2023

Fremont Public Schools

MI

Subrecipient Monitoring Equipment & Real Property Management Procurement, Suspension & Debarment

Condition: While performing single audit procedures it was noticed that the ESSER funds were used to purchase the equipment for the building upgrades that were also split with the Sinking Fund. Per the Compliance Supplement, recipients and subrecipients that use Education Stabilization Funds for mi...

Condition: While performing single audit procedures it was noticed that the ESSER funds were used to purchase the equipment for the building upgrades that were also split with the Sinking Fund. Per the Compliance Supplement, recipients and subrecipients that use Education Stabilization Funds for minor use laborers and mechanics must meet Davis-Bacon prevailing wage requirements. Corrective Steps to be Taken: The School District will work with the attorney and the contractor to add the proper language to the contract. Monitoring: The plan for monitoring adherence is that the Superintendent and Director of Financial Services will work with contractors to guarantee that all Davis-Bacon required prevailing wage language will be in contracts with federal funding. Name of Responsible Person for Further Information: Brad Reyburn, Superintendent and Julie Reams, Director of Financial Services Questioned Costs Related to this Finding: None Anticipated Completion Date: Prior to the start of the July 1, 2024 fiscal year.

View Audit 2857

Finding 1368 (2023-004)

Material Weakness 2023

McMurry University

TX

Student Financial Aid Special Tests & Provisions Subrecipient Monitoring

Finding 2023-004 Federal Agency Name: U.S. Department of Education Program Name: Student Financial Assistance Cluster ALN: 84.007, 84.033, 84.063, 84.268 and 84.379 Finding Summary: Unauthorized credit balances: In the event that a Title IV aid disbursement results in a credit balance on a stud...

Finding 2023-004 Federal Agency Name: U.S. Department of Education Program Name: Student Financial Assistance Cluster ALN: 84.007, 84.033, 84.063, 84.268 and 84.379 Finding Summary: Unauthorized credit balances: In the event that a Title IV aid disbursement results in a credit balance on a student’s account, the University is required to disburse the funds to the student within 14 days of the disbursement, unless the student or parent has authorized the retention of a credit balance. Five students who received Title IV aid resulting in a credit balance on their accounts did not receive a disbursement of the funds within 14 days of the disbursement. The University did not have an authorization from the student or parent to retain the credit balance. Responsible Individuals: Shawnta Clark, Director of Student Accounts Corrective Action Plan: We agree with the auditors’ findings and recommendations. Credit balance reports will be pulled twice weekly (Monday and Wednesday) to ensure federal funds credits are timely disbursed on designated check run days. A management review procedure will be added for monitoring credit balance reports. Anticipated Completion Date: December 22, 2023

View Audit 2584

Finding 1338 (2023-002)

Material Weakness 2023

Life Pacific University

CA

Subrecipient Monitoring Material Weakness

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: • Management has reached out to the audit team for guidance on implementation. LPU’s IT Director has been assigned the oversight of this project and will be making recommendations for leadership to consider. Leadership will balance ...

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: • Management has reached out to the audit team for guidance on implementation. LPU’s IT Director has been assigned the oversight of this project and will be making recommendations for leadership to consider. Leadership will balance these recommendations with current budget and resource restrictions. Budget constraints over the past several years have equated to limited resources in the IT department, as we currently have only one employee for IT needs. Person Responsible for Corrective Action Plan: Rachel Au, CFO Anticipated Date of Completion: Unknown. LPU’s current state make it difficult to identify with any specificity when this item will be addressed.

View Audit 2492

Finding 1278 (2023-001)

Significant Deficiency 2023

Staywell Healthcare, Inc.

CT

Special Tests & Provisions Subrecipient Monitoring Eligibility

FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCY 2023.001 – Sliding Fee Scale Discount Recommendation The Center should implement a system of controls to ensure all sliding fee discounts are properly supported. Action Taken All the Practice Managers (PM) and Director of Practice M...

FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCY 2023.001 – Sliding Fee Scale Discount Recommendation The Center should implement a system of controls to ensure all sliding fee discounts are properly supported. Action Taken All the Practice Managers (PM) and Director of Practice Management have been and will continue to review and monitor the sliding fee discount (SFD) on a daily basis on all slides for internal control. StayWell’s Patent Intake solution, ‘Phreesia’ has a dashboard in which this tool is being utilized effective November 1st, 2022 to monitor internal controls at the front desk operations with regard to accuracy of registration, patient demographic, insurance verification and most importantly the application of the Sliding Fee Discount Program and ensuring there is proper documentation to support (POI). Monthly random audits on the sliding fee discount program will continue to be performed by the PM’s and the Director of Practice Management. Director of Practice Management will also continue to perform SFD program compliance education to all Patients Service Associates (PSA) and all Practice Managers (PM) on a as needs basis.

View Audit 2412

Finding 1229 (2023-001)

Significant Deficiency 2023

Southern States Energy Board

GA

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

The Southern States Energy Board respectfully submits the following corrective action plan to incorporate a revision to our FY2023 policies and procedures that would provide additional tracking for the FSRS reporting requirement for subawards. The single finding is identified and discussed below. ...

The Southern States Energy Board respectfully submits the following corrective action plan to incorporate a revision to our FY2023 policies and procedures that would provide additional tracking for the FSRS reporting requirement for subawards. The single finding is identified and discussed below. Finding-Federal Award Finding: 2023 – 001 Improve Controls over Transparency Act Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control over Compliance Other Matters Federal Agency: U.S. Department of Energy Federal Program Name: Transportation of Transuranic Wastes to the Waste Isolation Pilot Plant Assistance Listing Number: 81.106 Federal Award Identification Number and Year: DE-EM0005215 - 2020 Award Period: 7/01/2020 – 6/30/2025 Budget Period: 07/01/2022-06/30/2023 Explanation of disagreement with audit finding: There is no disagreement with the isolated audit finding. Action taken in response to finding: Management developed a checklist for subaward amendments, prior to the receipt of the finding and upon identification that this report had been overlooked for Budget Period 3 for award DE-EM0005215-2020. Effective immediately, funds obligated to subawardees through subaward agreements, will be reported per the grant requirement to the FSRS and recognized in the FFATA Financial Reporting system. The project identified is a five-year project and the first two Budget Periods were submitted in a timely manner as per the project’s reporting requirements. Due to the nature of this award being incrementally funded, obligations to subawards are continuous throughout each budget period as funds are designated by the prime award. Therefore, the typical quarterly reporting system controls did not trigger management to complete this along with all the other financial and technical quarterly and annual submissions. Therefore, the FY2023 FSRS reporting requirement for this project was overlooked due to unusual timeliness of sub modifications and the workload of the accounting department. With the revised tracking/checklist for each subaward that includes modifications for incremental funding, this will no longer be an issue. Management would also like to note that all other reporting requirements were submitted on time and consistent with financial reporting requirements and that this was an isolated issue within Budget Period 3 for award DE-EM0005215-2020. Name of the contact person responsible for corrective action: Leigh Hawkins, Assistant Director of Business Operations, and Kathy Sammons, Director of Business Operations. Current Status: The planned completion date for corrective action plan is September 30, 2023. All submissions were completed prior to the final audit report completion. Therefore, management considers this issue fully corrected.

View Audit 2296

Finding 1176 (2023-001)

Significant Deficiency 2023

City of Scottsdale, Arizona

AZ

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Complete all PR26 and PR29 for CDBG and CV by November 17, 2023. The Community Assistance Office met with Housing and Urban Development on a weekly basis to reconcile grant funds within the 2020‐2025 Five‐Year Consolidated Action Plan beginning June 9, 2023. Training was provided to Community Assist...

Complete all PR26 and PR29 for CDBG and CV by November 17, 2023. The Community Assistance Office met with Housing and Urban Development on a weekly basis to reconcile grant funds within the 2020‐2025 Five‐Year Consolidated Action Plan beginning June 9, 2023. Training was provided to Community Assistance Office staff through Housing and Urban Development and through Cloudburst Consulting to ensure key staff positions responsible for the completion of these reports is full trained. Develop a Master Calendar for the Community Assistance Office with re‐occurring reports to include the PR26, PR29 and including FFATA to ensure they are completed accurately and timely. PR26 for CDBG and PR29 for CDBG and CDBG‐CV have been submitted as of October 25, 2023, and the HUD concluded weekly meetings with the Scottsdale Community Assistance Office on October 20, 2023. PR26 for CDBG‐CV will be completed and submitted by November 17, 2023. Policies will be updated to reflect 2 CFR 170 requiring the City to submit subaward information through the Federal Funding Accountability and Transparency Act by the end of the month subsequent to an award.

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