Corrective Action Plans

Finding 61074 (2022-018)

Material Weakness 2022

NH

Subrecipient Monitoring § 200.332 § 200.501 § 200.521

View of Responsible Officials The Department will review its Sub-recipient Monitoring Policy and assess compliance across the Department. It is important to note that between April 2020 and June 2022 the Department was involved in the State?s strategic response to the COVID-19 pandemic. During th...

View of Responsible Officials The Department will review its Sub-recipient Monitoring Policy and assess compliance across the Department. It is important to note that between April 2020 and June 2022 the Department was involved in the State?s strategic response to the COVID-19 pandemic. During this time, New Hampshire was under a state of emergency (Executive Order 2020-04), processes were rapidly converted to fully digital overnight, the State?s standard approval processes were suspended and non-standard templates were utilized to respond to the COVID-19 pandemic. The Department worked with other State Departments and the National Guard to create a record number of amendments, contracts, and other agreements (approximately 200% more than standard). The Department is in the process of instituting a new contract life cycle management solution that will utilize conditional logic to include the required notifications for agreements involving federal funds in order to ensure compliance. Implementation is anticipated to be complete in July 2023. As the COVID-19 pandemic strategic response has wound down, the Department has not suspended its regular standard approval or subrecipient risk assessment and monitoring processes and has not used non-standard templates to award federal funding. The Financial Compliance Unit (FCU) will continue to work with the Business System Analyst of the Cost Allocation Unit in determining the amount of Federal payments made to the vendors. The FCU receives a vendor payment list on a quarterly basis that includes the total amount of Federal funds that were paid to all contracted agencies. We will continue to closely monitor the FAC to obtain all copies of the Single Audits pertaining to the DHHS agencies. In addition, we will devise a spreadsheet that will list all contracts that have been awarded Federal funds and cross check these agencies to vendor payment list. The DHHS updated the policy on risk assessment on November 16, 2020 to ensure that all contracts have a risk assessment performed regardless of funding source. We also have added verbiage in the contracts effective for contracts that begin after November 2021. It states any Contractor that receives an amount equal to or greater than $250,000 from the Department during a single fiscal year, regardless of the funding source, may be required, at a minimum, to submit annual financial audits performed by an independent CPA if the Department?s risk assessment determination indicates the Contractor is high-risk. Finally, effective for any new procurement subsequent to March 2022, all back-up documentation must accompany the invoices and be submitted on a monthly basis. Anticipated Completion Date: July 2023 Contact Person: Melissa Kelleher, Grants Administrator, Ann Driscoll, Financial Compliance Unit

View Audit 49723

Finding 61073 (2022-017)

Material Weakness 2022

State of New Hampshire

NH

Procurement, Suspension & Debarment Subrecipient Monitoring

View of Responsible Officials The Department will review existing internal controls to assess whether they are sufficient to provide management with reasonable assurance the Department complies with the 2 CFR section 180.300. It is important to note that between April 2020 and June 2022 the Depart...

View of Responsible Officials The Department will review existing internal controls to assess whether they are sufficient to provide management with reasonable assurance the Department complies with the 2 CFR section 180.300. It is important to note that between April 2020 and June 2022 the Department was involved in the State?s strategic response to the COVID-19 pandemic. During this time, New Hampshire was under a state of emergency (Executive Order 2020-04), processes were rapidly converted to fully digital overnight, the State?s standard approval processes were suspended and non-standard templates were utilized to respond to the COVID-19 pandemic. The Department worked with other State Departments and the National Guard to create a record number of amendments, contracts, and other agreements (approximately 200% more than standard). The Department is in the process of instituting a new contract life cycle management solution that will utilize conditional logic to include the required attestation for agreements involving federal funds in order to ensure compliance. Implementation is anticipated to be complete in July 2023. As the COVID-19 pandemic strategic response has wound down, the Department has not suspended its regular standard approval or subrecipient risk assessment and monitoring processes and has not used non-standard templates to award federal funding. All standard templates require vendors to sign a certification regarding suspension and debarment. Anticipated Completion Date: July 2023 Contact Person: Melissa Kelleher, Grants Administrator

View Audit 49723

Finding 60929 (2022-005)

Significant Deficiency 2022

Prince George's County, MD

MD

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Finding Number: 2022-005 Program: COVID-19 ? Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Award Number and Year: ELC08CHW (3/1/2021 ? 2/28/2022) Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Criteria...

Finding Number: 2022-005 Program: COVID-19 ? Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Award Number and Year: ELC08CHW (3/1/2021 ? 2/28/2022) Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Criteria or specific requirement: Compliance: Per Maryland Department of Health, subgrantees are required to submit Monthly Status Reports by the 10th of the month they are reporting on. Control: Per 2 CFR section 200.303(a), a non-Federal entity must: Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should comply with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: Prince George?s County (County) did not file Monthly Status Reports in a timely manner. Cause: The County?s procedures and controls were not sufficient to ensure that Monthly Status Reports were filed timely. Resolution: The Health Department will review and enhance internal controls and procedures to ensure that Monthly Status Reports are filed timely. Specifically, the Health Department will update the routing reporting deliverables matrix that documents all grant reporting requirements and frequency to ensure we are in compliance with the reporting requirements. In addition, we will update our internal grant guidance document to include all control requirements per 2 CFR section 200.303, by adding language to establish and maintain effective internal controls over the Federal award. We will hold a meeting with the fiscal team once the internal grant guidance document is updated to ensure compliance with guidance in standards for internal control in the Federal Government. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Responsible Party: Sezelle Gabriel Banwaree, Associate Director of Administration Anticipated corrective action plan completion date: The Health Department will continue to follow the established procedures and reporting requirements for a non-Federal entity to ensure we comply with the monthly status report requirements by the 10th of the month we are reporting on. We will have our reporting calendar and grant requirements document updated by no later than Friday, April 28, 2023.

View Audit 56502

Finding 60850 (2022-001)

Significant Deficiency 2022

Wesley at Millington, Inc.

TN

Subrecipient Monitoring HUD Housing Programs

Statement of condition #2022-001 (Assistance Listing #14.157): At June 30, 2022, deposits to the reserve for replacements account of $150 were not made. Recommendation: Management should transfer $150 from the operating account to the reserve for replacements account. Action(s) taken or planned on t...

Statement of condition #2022-001 (Assistance Listing #14.157): At June 30, 2022, deposits to the reserve for replacements account of $150 were not made. Recommendation: Management should transfer $150 from the operating account to the reserve for replacements account. Action(s) taken or planned on the finding: The Project transferred $150 on September 21, 2022 to the reserve for replacements account. Completion date: September 21, 2022

View Audit 54055

Finding 60848 (2022-001)

Material Weakness 2022

Alternatives to Hunger

WA

Subrecipient Monitoring Eligibility Material Weakness

Finding 2022-001 ? Eligibility ? Material Weakness in Internal Controls Over Compliance and Material Non-Compliance Condition and Context: As part of our testing of eligibility, using a random number generator, we selected 25 days the Organization was open for food distribution during the year ende...

Finding 2022-001 ? Eligibility ? Material Weakness in Internal Controls Over Compliance and Material Non-Compliance Condition and Context: As part of our testing of eligibility, using a random number generator, we selected 25 days the Organization was open for food distribution during the year ended December 31, 2022. Out of the 25 days tested, the Organization did not follow intake guidelines for required eligibility and data collection prescribed by the Washington State Department of Agriculture for 12 different days. Planned Corrective Action: The organization implemented procedures to collect client intake data for one of the programs identified in testing and expects to continue making progress on the remaining program during 2023 and 2024. Responsible Division/Office and Individual: Mike Cohen, Executive Director Estimated Completion Date: 12/31/2024

View Audit 50250

Finding 60716 (2022-002)

Material Weakness 2022

Metro Meals on Wheels, Inc.

MN

Subrecipient Monitoring

2022-002 - Aging Cluster - Material Weakness in Compliance, Recommendation: Our recommendations include a few steps. First, we recommend that management develop documentation regarding how risks of subrecipients are evaluated yearly. This documentation should include considerations of subrecipient w...

2022-002 - Aging Cluster - Material Weakness in Compliance, Recommendation: Our recommendations include a few steps. First, we recommend that management develop documentation regarding how risks of subrecipients are evaluated yearly. This documentation should include considerations of subrecipient weaknesses and any follow-up actions taken. It should also document resolution processes and whether resolution was made. (Not all subrecipients will need remedial action. This conclusion should be documented as well.) Second, we recommend that management develop paperwork to properly monitor subrecipients and follow-up on deficiencies according to ? 200.332. These processes have started in 2022. Site visit documentation can be modified to include useful documentation for these purposes. In addition, management can consider the MMOW funder's site visit documentation in monitoring procedures. If the funder's monitoring of Metro Meals on Wheels' subrecipients is used by management, the funder's documentation should be reviewed and stored as support by management. Third, we recommend recording any remedial action taken during the year related to subrecipient errors. Fourth, we recommend developing a year-end report that includes a reminder for subrecipients to perform a single audit, if required, and notify Metro Meals on Wheels of the audit results as it pertains to the passed-through funding.2022-002 - Aging Cluster - Material Weakness in Compliance, Recommendation: Our recommendations include a few steps. First, we recommend that management develop documentation regarding how risks of subrecipients are evaluated yearly. This documentation should include considerations of subrecipient weaknesses and any follow-up actions taken. It should also document resolution processes and whether resolution was made. (Not all subrecipients will need remedial action. This conclusion should be documented as well.) Second, we recommend that management develop paperwork to properly monitor subrecipients and follow-up on deficiencies according to ? 200.332. These processes have started in 2022. Site visit documentation can be modified to include useful documentation for these purposes. In addition, management can consider the MMOW funder's site visit documentation in monitoring procedures. If the funder's monitoring of Metro Meals on Wheels' subrecipients is used by management, the funder's documentation should be reviewed and stored as support by management. Third, we recommend recording any remedial action taken during the year related to subrecipient errors. Fourth, we recommend developing a year-end report that includes a reminder for subrecipients to perform a single audit, if required, and notify Metro Meals on Wheels of the audit results as it pertains to the passed-through funding. Planned Action Management will develop risk assessment and monitoring documentation for subrecipients' yearly evaluations. Subrecipients' weaknesses and follow-up recommendations will be included in the documentation and shared with the subrecipients along with subsequent corrective actions taken by the subrecipients. Included in the year-end report will be the recommendation that subrecipients perform a single audit, if required, and notify Metro Meals on Wheels of the audit results as it pertains to the passed-through funding.

View Audit 49331

Finding 60715 (2022-001)

Material Weakness 2022

Metro Meals on Wheels, Inc.

MN

Subrecipient Monitoring Reporting

CORRECTIVE ACTION PLAN November 7, 2022 U.S. Department of Health and Human Services Passed-through Metropolitan Area Agency on Aging dba Trellis Metro Meals on Wheels, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2022. Name and address of independent p...

CORRECTIVE ACTION PLAN November 7, 2022 U.S. Department of Health and Human Services Passed-through Metropolitan Area Agency on Aging dba Trellis Metro Meals on Wheels, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2022. Name and address of independent public accounting firm: Abdo 5201 Eden Avenue, Suite 250 Edina, MN 55436 Audit period: April 1, 2021 - March 31, 2022 The findings from the March 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings - Major Federal Award Programs Audit 2022-001 - Aging Cluster - Material Weakness in Compliance Recommendation: We recommend that the Executive Director and any other relevant staff review ? 200.332(a) and ensure that all requirements are met. Specifically, the expected Assistance Listing Numbers of Federal funding should be included in the subrecipient contracts. In addition, we recommend creating a year-end summary report for each subrecipient which should indicate the total funding given through each ALN (if more than one) or other funding sources. Planned Action The Executive Director and other relevant staff have reviewed ? 200.332(a) and will ensure that all requirements are met. The expected Assistance Listing Numbers of Federal funding will be included in the subrecipient contracts. In addition, staff will create a year-end summary report for each subrecipient which will indicate the total funding provided through each ALN.

View Audit 49331

Finding 60701 (2022-005)

Material Weakness 2022

Kankakee Valley School Corporation

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.303

FINDING 2022-0005 Contact Person Responsible for Corrective Action: Chris Richie Contact Phone Number: 219-987-4711 ext. 1113 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Before submissions, grant reports will be reviewed by someone other than the...

FINDING 2022-0005 Contact Person Responsible for Corrective Action: Chris Richie Contact Phone Number: 219-987-4711 ext. 1113 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Before submissions, grant reports will be reviewed by someone other than the preparer of the report to ensure the information submitted was accurate. Individuals will initial and date a hard copy of final the report acknowledging the accuracy and submission of the report. Anticipated Completion Date: March 31, 2023

View Audit 55733

Finding 60658 (2022-003)

Significant Deficiency 2022

Board of Education of the City of Chicago

IL

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2022-003 Corrective Action Plan: CPS will implement a policy to verify practitioner credential records twice a year with the IL HFS and Federal Healthcare and Human Services (HHS) OIG websites as outlined in the LEA handbook. The Medicaid team will document the verification and obtain review...

FINDING 2022-003 Corrective Action Plan: CPS will implement a policy to verify practitioner credential records twice a year with the IL HFS and Federal Healthcare and Human Services (HHS) OIG websites as outlined in the LEA handbook. The Medicaid team will document the verification and obtain review and approval from the Medicaid Director. CPS will start the verification process in April, 2023 after the policy and procedure are finalized. Contact person: Patrick T. Alforque, Controller

View Audit 56618

Finding 60649 (2022-002)

Material Weakness 2022

Covenant Healthcare System and Subsidiaries

MI

Subrecipient Monitoring Material Weakness Reporting

Finding Number: 2022-002 Condition: Covenant HealthCare's controls in place for reporting submissions did not identify that guidelines were not followed related to the reporting of expenses. Planned Corrective Action: Covenant Healthcare will implement additional layers of expense review prior to su...

Finding Number: 2022-002 Condition: Covenant HealthCare's controls in place for reporting submissions did not identify that guidelines were not followed related to the reporting of expenses. Planned Corrective Action: Covenant Healthcare will implement additional layers of expense review prior to submission to ensure that reports are submitted within the established guidelines. Contact person responsible for corrective action: Andrew Young, Corporate Controller Anticipated Completion Date: 3/31/2023

View Audit 56347

Finding 60648 (2022-001)

Material Weakness 2022

Covenant Healthcare System and Subsidiaries

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

Finding Number: 2022-001 Condition: Covenant HealthCare's controls in place for reporting submissions did not identify that guidelines were not followed related to the inclusion of expenses that had previously been reimbursed. Planned Corrective Action: Covenant Healthcare will implement additional ...

Finding Number: 2022-001 Condition: Covenant HealthCare's controls in place for reporting submissions did not identify that guidelines were not followed related to the inclusion of expenses that had previously been reimbursed. Planned Corrective Action: Covenant Healthcare will implement additional layers of expense review prior to submission to ensure that reports are submitted within the established guidelines. Contact person responsible for corrective action: Andrew Young, Corporate Controller Anticipated Completion Date: 3/31/2023

View Audit 56347

Finding 60630 (2022-001)

Significant Deficiency 2022

City of Irvine

CA

Subrecipient Monitoring

City of Irvine respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: CliftonLarsonAllen LLP 2875 Michelle Drive, Suite 300 Irvine, CA 92606 Audit Period: July 1, 2021 ? June 30, 2022 Significant Deficiency...

City of Irvine respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: CliftonLarsonAllen LLP 2875 Michelle Drive, Suite 300 Irvine, CA 92606 Audit Period: July 1, 2021 ? June 30, 2022 Significant Deficiency in Internal Control over Compliance and Other Matter: 2022 ? 001 Recommendation: We recommend that the City implement policies and procedures to ensure that FFATA reporting occurs for all subawards of $30,000 or more for all federal awards. Action Taken: The City works with a consultant that provides the FFATA reporting for all Department of Housing and Urban Development grants. The City is updating its grant procedures to include a new process to file the FFATA report for all federal grants that have subawards of $30,000 or greater. For any questions regarding this plan, please contact me at 949-724-6031 or email twashle@cityofirvine.org.

View Audit 52110

Finding 60561 (2022-001)

Significant Deficiency 2022

Haverhill Housing Authority

MA

HUD Housing Programs Special Tests & Provisions Subrecipient Monitoring

2022-001 ? SPECIAL TESTS AND PROVISIONS ? CARES ACT FUNDING Other Matter/Significant Deficiency Auditee?s Response and Planned Corrective Action HHA has completed the necessary training recommended by HUD and addressed the use of the ineligible expenses with HUD. This issue was considered closed as ...

2022-001 ? SPECIAL TESTS AND PROVISIONS ? CARES ACT FUNDING Other Matter/Significant Deficiency Auditee?s Response and Planned Corrective Action HHA has completed the necessary training recommended by HUD and addressed the use of the ineligible expenses with HUD. This issue was considered closed as of December 20, 2021. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Clara Ruiz-Vargas, Executive Director

View Audit 56439

Finding 60545 (2022-001)

Material Weakness 2022

Lake Michigan College

MI

Student Financial Aid Subrecipient Monitoring Material Weakness

Finding Number: 2022-001 ALN, Federal Agency, and Program Name - Student Financial Assistance Cluster-Federal Direct Student Loan Program ALN 84.268 Condition: The College was not sending notifications meeting the required criteria during the year. Planned Corrective Action: The College has updated...

Finding Number: 2022-001 ALN, Federal Agency, and Program Name - Student Financial Assistance Cluster-Federal Direct Student Loan Program ALN 84.268 Condition: The College was not sending notifications meeting the required criteria during the year. Planned Corrective Action: The College has updated notifications to include the required elements beginning in the Fall 2022 semester. Contact person responsible for corrective action: Nicole Hatter Anticipated Completion Date: 11/22/2022

View Audit 56183

Finding 60517 (2022-001)

Significant Deficiency 2022

City of Daly City

CA

Procurement, Suspension & Debarment Subrecipient Monitoring

Finding Reference Number: SA2022-001 Suspension and Debarment Documentation for Contracts and Subcontracts AL Number: 21.027 AL Title: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agency: Department of the Treasury Federal Award Identification Number: SLFRP2686 68-028...

Finding Reference Number: SA2022-001 Suspension and Debarment Documentation for Contracts and Subcontracts AL Number: 21.027 AL Title: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agency: Department of the Treasury Federal Award Identification Number: SLFRP2686 68-0281986 Name of Pass-Through Entity: California State Water Resources Control Board ? Fiscal Year of Initial Finding: 2022 ? Name(s) of the contact person: Abby Veeser, Deputy Director of Finance ? Corrective Action Plan: City staff will better comply with this rule going forward by either checking the exclusions list for suspensions or debarments for proposed contractors and subrecipients or by including suspension and debarment language in contracts. Finance staff will communicate this new procedure to the appropriate project managers. ? Anticipated Completion Date: 06/30/23

View Audit 61017

Finding 60478 (2022-001)

None 2022

College of the Ozarks

MO

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

View of Responsible Officials: Management concurred with the finding and has implemented procedures to review the information shared between College of the Ozarks and the NSLDS.

View Audit 56310

Finding 60414 (2022-001)

None 2022

Thornton Fractional Township High School District No. 215

IL

Reporting Subrecipient Monitoring

Condition: The School District did not comply with the requirements of filing quarterly and final reports by the due dates set by ISBE. Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. Anticipated Date of Completion...

Condition: The School District did not comply with the requirements of filing quarterly and final reports by the due dates set by ISBE. Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. Anticipated Date of Completion: 6/30/23. Name of Contact Person: Dr. Sophia Jones-Redmond. Management Response: The District will review the reporting deadlines and file reports moving forward on a timely manner by the due dates.

View Audit 55692

Finding 60408 (2022-001)

Material Weakness 2022

City of Marion

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303 § 200.328

FINDING 2022-001 Material Weakness - Reporting Contact Person Responsible for Corrective Action: Julie Flores Contact Phone Number: 765-382-3779 Views of Responsible Official: Agree with finding Description of Corrective Action Plan: The Controller?s Office will send the monthly appropriation report...

FINDING 2022-001 Material Weakness - Reporting Contact Person Responsible for Corrective Action: Julie Flores Contact Phone Number: 765-382-3779 Views of Responsible Official: Agree with finding Description of Corrective Action Plan: The Controller?s Office will send the monthly appropriation reports for transportation to the Administrative Assistant (AA) and to the Transportation Manager to review and reconcile. After the monthly report has been reconciled by the transportation Administrative Assistant, it will be initial and dated by the AA, the work will be forwarded to the grant administrator, transportation manager and controller?s office. The Controller?s Office will review to ensure accurate information was forwarded to the grant administrator. These changes will be reflected in the City of Marion?s Internal Control Policy. Anticipation Completion Date: 09/01/23

View Audit 50527

Finding 60395 (2022-001)

Material Weakness 2022

Tacoma School District No. 10

WA

Procurement, Suspension & Debarment School Nutrition Programs Subrecipient Monitoring

The District will include the SAM.gov check on all purchases made using Federal funds on a purchase order (PO). Supporting documentation will be retained. This verification will occur prior to any payment being made. The District will ensure that POs are signed by vendors/contractors indicating t...

The District will include the SAM.gov check on all purchases made using Federal funds on a purchase order (PO). Supporting documentation will be retained. This verification will occur prior to any payment being made. The District will ensure that POs are signed by vendors/contractors indicating their non-suspended and non-debarred status, affirming their eligibility to participate in the procurement process.

View Audit 55808

Finding 60393 (2022-003)

Significant Deficiency 2022

County of Orange, California

CA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.303

Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing Number: 21.027 Federal Grantor: U.S. Department of Treasury Award No. and Year: 2021 Compliance Requirements: Procurement and Suspension and Debarment Type of Finding: Significant Deficiency in...

Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing Number: 21.027 Federal Grantor: U.S. Department of Treasury Award No. and Year: 2021 Compliance Requirements: Procurement and Suspension and Debarment Type of Finding: Significant Deficiency in Internal Control Criteria: 2 CFR section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Title 2 CFR Section 200.214 of the Uniform Guidance states that the County must comply with 2 CFR part 180, which implements Executive Orders 12549 and 12689. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. The 2022 Compliance Supplement states: Non-Federal entities are prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. ?Covered transactions? include contracts for goods and services awarded under a non-procurement transaction (e.g., grant or cooperative agreement) that are expected to equal or exceed $25,000 or meet certain other criteria as specified in 2 CFR section 180.220. All non-procurement transactions entered into by a pass-through entity (i.e., subawards to subrecipients), irrespective of award amount, are considered covered transactions, unless they are exempt as provided in 2 CFR section 180.215. When a non-Federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration (GSA) and available at https://www.sam.gov/SAM/, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). Condition: During our testing of the Orange County Public Works (OCPW) and the County Executive Office?s (CEO) provisions for procurement requirements under the COVID-19 Coronavirus State and Local Fiscal Recovery Funds, we noted the following instances where there was no evidence that the OCPW or CEO departments verified the entity was not suspended or debarred or otherwise excluded from participating in the transaction, prior to entering the contract, in accordance with County policy ? Three (3) of three (3) contracts through the OCPW department selected for testing. ? Two (2) of six (6) contracts through the CEO department selected for testing. Cause: The OCPW and CEO departments did not follow their policy to verify the information described in the condition prior to entering the transactions. Effect: The County?s control and compliance were not consistently followed, which required verification of suspension or debarment prior to entering the contract. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A nonstatistical sample of three (3) out of eight (8) procurement contracts were sampled from OCPW and six (6) out of fourteen (14) procurement contracts were sampled from the CEO department for the COVID-19 Coronavirus State and Local Fiscal Recovery Funds. The condition above was identified during our testwork of the OCPW and CEO departments? internal controls over procurement and suspension and debarment. Repeat Finding from Prior Years: No. Recommendation: We recommend that the OCPW and CEO departments adhere to their procurement procedures requiring the suspension or debarment verification is performed prior to entering into a covered transaction. Management Response and Corrective Action: County Executive Office: 1. Person Responsible: Selina Chan-Wychgel, Fiscal Services Manager 2. Corrective Action Plan: The County Executive Office will adhere to the Contract Policy Manual (CPM) and internal policy and procedure of ensuring the suspension or debarment verification of a contractor is performed and documented prior to awarding a contract. The County Procurement Office will continue to provide trainings and reminders to County-wide procurement staff of this guideline to ensure compliance with Federal Award protocol. 3. Anticipated Implementation date: June 30, 2023 OC Public Works: 1. Person Responsible: Joseph Sly 2. Corrective Action Plan: On October 21, 2022, OCPW Procurement updated the Department?s policy and procedure to include an additional requirement for the submission of the Alternative Funding Procurement Acknowledgement Form when utilizing non-County funding sources. The contracts selected in this audit were awarded prior to October 21, 2022. 3. Anticipated Implementation date: October 21, 2022

View Audit 56545

Finding 60392 (2022-001)

Material Weakness 2022

County of Orange, California

CA

Reporting Subrecipient Monitoring Material Weakness

Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing Number: 21.027 Federal Grantor: U.S. Department of Treasury Award No. and Year: 2021 Compliance Requirements: Reporting Type of Finding: Material Weakness in Internal Control over Compliance an...

Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing Number: 21.027 Federal Grantor: U.S. Department of Treasury Award No. and Year: 2021 Compliance Requirements: Reporting Type of Finding: Material Weakness in Internal Control over Compliance and Material Noncompliance Criteria: The OMB Approved Award No. 1505-0271 requires that reports submitted to the federal awarding agency include all activity of the reporting period, and are supported by applicable accounting or performance records. The County of Orange (the County) must submit quarterly Project and Expenditure Reports that contain costs incurred during the covered period. Critical information includes: ? Obligations and Expenditures o Current period obligation o Cumulative obligation o Current period expenditure o Cumulative expenditure ? Subawards ? Detailed information on any loans issued; contracts and grants awarded; transfers made to other government entities; and direct payments made by the recipient that are greater than $50,000. For amounts less than $50,000, the recipient must report in the aggregate for these same categories of loans issued; contracts and grants awarded; transfers made to other government entities and direct payments made by the recipient. Condition: Expenditure information was materially different from expenditures reported on the SEFA. This was due to the County identifying additional expenditures after year-end, related to the June 30, 2022 fiscal year. Cause: The County prepared the Project and Expenditure Reports as of a point in time, but internal controls did not allow for consistent reporting or expenditure recognition, to avoid material variances. Effect: Expenditure information in the Project and Expenditure Reports for December 2021, March 2022, and June 2022 reflected modified cash basis expenditures at a point in time, but contained material differences from the amounts included in the SEFA. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A non-statistical sample of three (3) out of four (4) Project and Expenditure Reports submitted during the year were selected for reporting testing. The cumulative impact is as follows: ? Cumulative expenditure o Reported - $89,613,061 o Per audit/supporting records - $296,907,350, a difference of $207,294,289 Repeat Findings from Prior Years: No. Recommendation: We recommend the County enhance internal controls to ensure Project and Expenditure Reports are prepared in accordance with governing requirements, and updated timely if revisions are made by the County, to avoid material variances to the underlying expenditures reported on the SEFA. Management Response and Corrective Action: Auditor Controller: 1. Person Responsible: Bertalicia Tapia, Financial Reporting & Mandated Costs (FRMC) Manager 2. Corrective Action Plan: While the County reconciles the Project and Expenditure Reports filed with the US Treasury to the County?s accounting records, a temporary difference between the reported amounts on the SEFA and US Treasury reports was caused by a one-time permitted adjustment to reallocate expenditures for government services subsequent to filing the US Treasury reports. While currently in compliance with US Treasury reporting guidelines, the County will reflect the permitted adjustment on its subsequent quarterly Project and Expenditure Report due to the US Treasury on April 30, 2023. 3. Anticipated Implementation date: April 30, 2023

View Audit 56545

Finding 60381 (2022-004)

Significant Deficiency 2022

County of Orange, California

CA

Subrecipient Monitoring § 200.332

Program: Homeland Security Grant Program Federal Financial Assistance Listing Number: 97.067 Federal Grantor: U.S. Department of Homeland Security Passed-Through: California Office of Emergency Services Award No. and Year: 2019-0035 and 2020; 2020-0095 and 2021 Compliance Requirements: Subrecipient...

Program: Homeland Security Grant Program Federal Financial Assistance Listing Number: 97.067 Federal Grantor: U.S. Department of Homeland Security Passed-Through: California Office of Emergency Services Award No. and Year: 2019-0035 and 2020; 2020-0095 and 2021 Compliance Requirements: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control and Instance of Noncompliance Criteria: 2 CFR section 200.332(b), Requirements for Pass-Through Entities, states that all pass-through entities must evaluate each subrecipient?s risk of noncompliance with Federal statues, regulations and the terms and conditions of the subaward for purpose of determining the appropriate subrecipient monitoring. Condition: During our testing of Homeland Security Grant Program (HSGP) of the Sheriff-Coroner department?s provisions for evaluating subrecipient?s risk of noncompliance with Federal statutes, regulations and the terms and conditions of the subaward, we noted for two (2) of two (2) subrecipients selected, the required evaluation of the subrecipient?s risk of noncompliance was not documented. Further, onsite reviews were not performed. Cause: The Sheriff-Coroner department did not adhere to established policies and procedures relating to documentation of the risk assessment when a subrecipient contract is awarded. With respect to onsite reviews, these were not performed due to COVID restrictions. Effect: There is an increased risk that the monitoring procedures performed may not address the subrecipient?s risk of noncompliance. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: The entire population of two (2) subrecipients were selected for subrecipient monitoring testing from the Sheriff-Coroner department for the Homeland Security Grant Program. Repeat Finding from Prior Years: No. Recommendation: We recommend that the Sheriff-Coroner department follow the implemented policies and procedures to ensure that the required evaluation of the subrecipient?s risk of noncompliance be documented in accordance with 2 CFR section 200.332(b). Management Response and Corrective Action: Sheriff-Coroner?s Department: 1. Person Responsible: Yumi Leung, Supervising Grants Manager 2. Corrective action plan: The Sheriff-Coroner Department will complete a pre-award risk assessment form at the time the subrecipient is notified of a subaward. The Sheriff-Coroner Department resumed subrecipient monitoring visits starting January 2023. Going forward, if on-site visits are not possible, virtual meetings with subrecipients will be conducted. 3. Anticipated Implementation date: June 2023

View Audit 56545

Finding 60350 (2022-006)

Significant Deficiency 2022

County of Orange, California

CA

Subrecipient Monitoring Procurement, Suspension & Debarment Significant Deficiency

Program: Foster Care Federal Financial Assistance Listing Number: 93.658 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Social Services Award No. and Year: 2201CAFOST and 2022, 2101CAFOST and 2021 Compliance Requirements: Subrecipient Monitoring...

Program: Foster Care Federal Financial Assistance Listing Number: 93.658 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Social Services Award No. and Year: 2201CAFOST and 2022, 2101CAFOST and 2021 Compliance Requirements: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control Criteria: 2 CFR Section 180.300a, Responsibilities of Participants Regarding Doing Business with Other Persons (and repeated in the California Department of Social Services - County Fiscal Letter No. 21/22 ? 115) counties are required to verify that recipients or contracts have not been suspended or debarred by using the federal SAM (Systems for Award Management). Condition: During our testing from the Foster Care Program of the SSA, we noted for one (1) of the eight (8) subrecipients selected, the SSA did not have documentation that the SAM clearance was performed prior to entering the contract with the subrecipient. The County?s policy was to verify subrecipient was not suspended or debarred prior to entering the contract, but the County did not retain evidence of this check prior to entering the contract. Cause: The SSA department did not follow their policy to retain documentation of the verification of the information prior to entering the contract. Effect: The County?s control policies were not consistently followed, which required documentation of the verification prior to entering the contract. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A non-statistical sample of eight (8) of fifty-three (53) subrecipients were selected for subrecipient Monitoring testing from SSA for the Foster Care program. Repeat Findings from Prior Years: No. Recommendation: We recommend that SSA adhere to their procedures required documentation of the SAM check prior to entering the contract. Management Response and Corrective Action: Social Services Agency: 1. Person Responsible: Karen Vu, Administrative Manager II, Contract Services 2. Corrective action plan: A checklist will be developed listing all the required documentation to be completed, including the SAM clearance check, prior to entering into a contract with a vendor. Contracts staff will be required to complete the checklist prior to entering into a contract with a vendor and maintain documentation of the verification in the Contracts file. 3. Anticipated Implementation date: July 1, 2023

View Audit 56545

Finding 60349 (2022-005)

Significant Deficiency 2022

County of Orange, California

CA

Subrecipient Monitoring § 200.331

Program: Homeland Security Grant Program Federal Financial Assistance Listing Number: 97.067 Federal Grantor: U.S. Department of Homeland Security Passed-Through: California Office of Emergency Services Award No. and Year: 2019-0035 and 2020; 2020-0095 and 2021 Program: Foster Care Federal Financia...

Program: Homeland Security Grant Program Federal Financial Assistance Listing Number: 97.067 Federal Grantor: U.S. Department of Homeland Security Passed-Through: California Office of Emergency Services Award No. and Year: 2019-0035 and 2020; 2020-0095 and 2021 Program: Foster Care Federal Financial Assistance Listing Number: 93.658 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Social Services Award No. and Year: 2201CAFOST and 2022, 2101CAFOST and 2021 Compliance Requirements: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control and Instance of Noncompliance Criteria: 2 CFR Part 200.331(a), Requirements for Pass-Through Entities, states that all pass-through entities must ensure that every subaward is clearly identified to the subrecipient as a subaward and includes certain information as well as all the requirements imposed by the pass-through entity on the subrecipient so that the Federal award is used in accordance with Federal statutes, regulations, and the terms and conditions of the award. Condition: The following information was not provided at the time of the subaward for two (2) of two (2) subawards selected for testing from the Homeland Security Grant Program within the Sheriff-Coroner department: ? Federal award identification number ? Identification of whether the award is research and development ? Indirect cost rate for the federal award The following information was not provided at the time of the subaward for seven (7) of eight (8) subawards selected for testing from the SSA department for the Foster Care program: ? Subrecipient?s unique entity identifier ? Federal award identification number ? Federal award date of award to recipient by the Federal agency ? Subaward period of performance ? Amount of federal funds obligated to the subrecipient ? Amount of federal funds committed to the subrecipient ? Federal award project description ? Name of federal awarding agency ? CFDA number ? Identification of whether the award is research and development ? Indirect cost rate Cause: The Sheriff-Coroner and SSA departments procedures did not consistently ensure that the required award information and applicable requirements were communicated to subrecipients. Effect: The Sheriff-Coroner and SSA departments did not identify the required elements of the subaward to the subrecipients at the time of the subaward, increasing the risk of noncompliance. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: The entire population of two (2) subrecipients were selected for subrecipient monitoring testing for HSGP ? Sheriff-Coroner department. A non-statistical sample of eight (8) of fifty-three (53) subrecipients were selected for subrecipient monitoring testing for the Foster Care program ? SSA. Repeat Finding from Prior Years: No. Recommendation: We recommend that the Sheriff-Coroner and SSA departments modify and strengthen its current policies and procedures to ensure that all required award information and applicable requirements are communicated to subrecipients at the time of subaward in accordance with 2 CFR section 200.331(a). Management Response and Corrective Action: Sheriff-Coroner?s Department: 1. Person Responsible: Yumi Leung, Supervising Grants Manager 2. Corrective action plan: The Sheriff-Coroner Department will identify on future subaward letters whether the award is research and development, and whether there is an indirect cost rate for the federal award. 3. Anticipated Implementation date: June 2023 Social Services Agency: 1. Person Responsible: Karen Vu, Administrative Manager II, Contracts Services 2. Corrective action plan: SSA will revise the current Subrecipient Monitoring Policy and Procedures to ensure that all required award information and applicable requirements are communicated to subrecipients at the time of subaward in accordance with 2 CFR section 200.331(a). A check list will be developed to track activities and ensure that the required award information and applicable requirements were communicated to subrecipients. 3. Anticipated Implementation date: July 1, 2023

View Audit 56545

Finding 60348 (2022-002)

Material Weakness 2022

County of Orange, California

CA

Subrecipient Monitoring § 200.332 § 200.501

Program: Foster Care Federal Financial Assistance Listing Number: 93.658 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Social Services Award No. and Year: 2201CAFOST and 2022, 2101CAFOST and 2021 Compliance Requirements: Subrecipient Monitorin...

Program: Foster Care Federal Financial Assistance Listing Number: 93.658 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Social Services Award No. and Year: 2201CAFOST and 2022, 2101CAFOST and 2021 Compliance Requirements: Subrecipient Monitoring Type of Finding: Material Weakness in Internal Control over Compliance and Material Noncompliance Criteria: In accordance with Title 2 U.S. Code of Federal Regulations (CFR) 200.332, pass-through entities must comply with the following: ? 2 CFR 200.332(d) ? Monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward; and that subaward performance goals are achieved. Pass-through entity monitoring of the subrecipient must include the information at 2 CFR 200.332(d)(1) through (4). ? 2 CFR 200.332(f) ? Verify that every subrecipient is audited as required by Subpart F of this part when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in 200.501. The California Department of Social Services further clarifies in its County Fiscal Letter No. 21/22 ? 115 that Foster Family Agency (FFA), Group Home, and Short Term Residential Therapeutic Programs (STRTP) are ?considered subrecipients and subject to the same audit requirements and require the same degree of oversight as other subrecipients?. Further, while there are some licensing and oversight functions performed by the state over FFAs, group homes, and STRTPs, ?counties are still ultimately responsible for review of these audits and their findings, any follow- up to ensure compliance, and any other form of monitoring and oversight required by federal and state laws and regulations.? Condition: The County did not have any formal controls or procedures in place for subrecipient monitoring for the Foster Care program. Cause: The County did not maintain procedures to monitor the activities of each subrecipient, or verify that every subrecipient is audited, as required. Effect: The County did not maintain policies and procedures to align with the Subrecipient Monitoring requirements in 2 CFR 200.332 and did not comply with subrecipient monitoring requirements related to the program. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A nonstatistical sample of eight (8) out of 53 subrecipients were sampled, which included six (6) FFA, and two (2) STRTP types. The condition noted above was identified during our procedures related to subrecipient monitoring, and was pervasive to the program. Repeat Findings from Prior Years: No. Recommendation: We recommend that the County implement policies and procedures in accordance with 2 CFR 200.332 to ensure compliance with subrecipient monitoring requirements. Management Response and Corrective Action: Social Services Agency: 1. Person Responsible: Kristi Fiskum, Deputy Division Director, Family Assessment & Shelter Services and Karen Vu, Administrative Manager II, Contracts Services 2. Corrective action plan: SSA will revise its current Subrecipient Monitoring Policy in accordance with 2 CFR 200.332 to ensure compliance with subrecipient monitoring requirements. SSA will include procedures for verifying that every subrecipient is audited and a monitoring checklist will be developed to track activities. 3. Anticipated Implementation date: July 1, 2023

View Audit 56545

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