Corrective Action Plans

Finding 51240 (2022-023)

Significant Deficiency 2022

State of Delaware

DE

Subrecipient Monitoring § 200.303 § 200.332 § 200.425 § 200.521

Reference Number: 2022-023 Prior Year Finding: 2021-018 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Substance Abuse and Mental Health Federal Program: Opioid STR Assistance Listing Numbe...

Reference Number: 2022-023 Prior Year Finding: 2021-018 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Substance Abuse and Mental Health Federal Program: Opioid STR Assistance Listing Number: 93.788 Award Number and Year: H79TI083305 (9/30/2020 ? 9/29/2022) Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: The Division should review and enhance internal controls and procedures to ensure that proper subrecipient monitoring is conducted in accordance with Federal regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division has been working to implement corrective action. DSAMH continues to update and enhance policies and procedures to ensure that proper subrecipient monitoring is conducted in accordance with Federal regulations. Name(s) of the contact person(s) responsible for corrective action: Mequoria Bowden, Chief of Administration, Office of the Secretary Administration Planned completion date for corrective action plan: October 31, 2023

View Audit 43524

Finding 51239 (2022-022)

Material Weakness 2022

State of Delaware

DE

Subrecipient Monitoring Material Weakness Reporting § 200.303

Reference Number: 2022-022 Prior Year Finding: 2021-020 Federal Agency: U.S. Department of Health and Human Services State Agency: Department of Health and Social Services State Division: Division of Substance Abuse and Mental Health Federal Program: Opioid STR Assistance Listing Number: 93.788 Awar...

Reference Number: 2022-022 Prior Year Finding: 2021-020 Federal Agency: U.S. Department of Health and Human Services State Agency: Department of Health and Social Services State Division: Division of Substance Abuse and Mental Health Federal Program: Opioid STR Assistance Listing Number: 93.788 Award Number and Year: H79TI083305 (9/30/2020 ? 9/29/2022) Compliance Requirement: Reporting ? Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: We recommend that the Division develop internal controls and procedures to ensure that FFATA reporting requirements are met. We further recommend the Division develop controls and procedures to ensure that all required subawards are reported accurately and timely to FSRS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division will reevaluate its current process, implement proper controls for FFATA reporting standards, and ensure subawards are reviewed timely. In addition, staff will be assigned to verify information prior to being keyed into FSRS. Name(s) of the contact person(s) responsible for corrective action: Mequoria Bowden, Chief of Administration, Office of the Secretary Administration Planned completion date for corrective action plan: October 31, 2023

View Audit 43524

Finding 51229 (2022-021)

Material Weakness 2022

State of Delaware

DE

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring § 200.303

Reference Number: 2022-021 Prior Year Finding: 2021-015 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Children?s Health Insurance Program M...

Reference Number: 2022-021 Prior Year Finding: 2021-015 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Children?s Health Insurance Program Medicaid Cluster Assistance Listing Number: 93.767, 93.775, 93.777, 93.778 Award Number and Year: 2105DE5021 (10/1/2020 ? 9/30/2022), 2205DE5021 (10/1/2021 ? 9/30/2023) 2105DE5MAP (10/1/2020 ? 9/30/2021), 2205DE5MAP (10/1/2021 ? 9/30/2022) Compliance Requirement: Special Tests ? Provider Eligibility Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: The Division should reevaluate its current process and perform additional training for determining and monitoring provider eligibility. More thorough reviews and supervision should be placed around the provider eligibility processes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division is reevaluating the current process for validating non-Par provider eligibility. This includes developing additional training for determining and monitoring provider eligibility and researching best practices in this area. The Division will also complete more thorough reviews and exercise increased supervisory oversight around the provider eligibility processes. Name(s) of the contact person(s) responsible for corrective action: Kathleen Dougherty Planned completion date for corrective action plan: September 30, 2023

View Audit 43524

Finding 51226 (2022-018)

Material Weakness 2022

State of Delaware

DE

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.308 § 200.309 § 200.403

Reference Number: 2022-018 Prior Year Finding: 2021-014 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Children?s Health Insurance Program (...

Reference Number: 2022-018 Prior Year Finding: 2021-014 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Children?s Health Insurance Program (CHIP) Assistance Listing Number: 93.767 Award Number and Year: 2205DE5021 (10/1/2021 ? 9/30/2023) Compliance Requirement: Period of Performance Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: The Division should review and enhance internal controls and procedures to ensure that it charges expenditures to the program that are incurred within an award?s allowable period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DMMA will review reported expenditures based on the date of the federal draw to ensure that the expenditures occured within the period reported. Name(s) of the contact person(s) responsible for corrective action: Unkyong Goldie Planned completion date for corrective action plan: September 30, 2023

View Audit 43524 Questioned Costs: $1

Finding 51224 (2022-017)

Material Weakness 2022

State of Delaware

DE

Subrecipient Monitoring Material Weakness Reporting § 200.303

Reference Number: 2022-017 Prior Year Finding: 2021-013 Federal Agency: U.S. Department of Health and Human Services State Agency: Department of Health and Social Services State Division: Division of State Service Centers Federal Program: COVID-19 ? Low-Income Home Energy Assistance Assistance Listi...

Reference Number: 2022-017 Prior Year Finding: 2021-013 Federal Agency: U.S. Department of Health and Human Services State Agency: Department of Health and Social Services State Division: Division of State Service Centers Federal Program: COVID-19 ? Low-Income Home Energy Assistance Assistance Listing Number: 93.568 Award Number and Year: 2001DELIEA (10/1/2019 ? 9/30/2021), 2101DELIEA (10/102020 ? 9/30/2022), 2010DEE5C6 (3/11/2021 ? 9/30/2022), 2201DELIEA (10/1/2021 ? 9/30/2023) Compliance Requirement: Reporting ? Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: We recommend that the Division develop internal controls and procedures to ensure that FFATA reporting requirements are met. We further recommend the Division develop controls and procedures to ensure that all required subawards are reported accurately and timely to FSRS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division has developed internal controls and procedures to ensure that FFATA reporting requirments are met and subawards are reported accurately and timely to FSRS. Specifically, the Division and Fiscal staff will work together to collect required information from the contractors and enter the FFATA information into FSRS portal. All contracts will have additional pages (through appendices) to collect information for FFATA reporting. Name(s) of the contact person(s) responsible for corrective action: Christopher Antonio Haly Laasme-McQuilkin Planned completion date for corrective action plan: June 30, 2023

View Audit 43524

Finding 51218 (2022-013)

Significant Deficiency 2022

State of Delaware

DE

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Reference Number: 2022-013 Prior Year Finding: 2021-011 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Public Health Federal Program: COVID-19 ? Epidemiology and Laboratory Capacity for Inf...

Reference Number: 2022-013 Prior Year Finding: 2021-011 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Public Health Federal Program: COVID-19 ? Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Assistance Listing Number: 93.323 Award Number and Year: NU50CK000497 (8/1/2019 ? 7/31/2024) Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: The Division should review and enhance internal controls and procedures to ensure that quarterly Progress Monitoring reports are filed timely and that it maintains documentation supporting timely submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division of Public Health (DPH) filed its quarterly Progress Monitoring reports timely but failed to maintain supporting documentation. DPH is saving all reports as PDF documents as they are submitted to the Federal Program via REDCap to timestamp the submission dates. The Federal Program announced that they were switching from the REDCap system to the CAMP system for compliance reporting. We verified that the CAMP system will not have the function to pull timestamped records, therefore we will continue the process of saving PDF documents from the new system, to show timely submission. DPH will continue evaluate the current process for submission of the compliance reporting to check for gaps in the process. Name(s) of the contact person(s) responsible for corrective action: Wes Holleger, Laboratory Deputy Director, Division of Public Health Planned completion date for corrective action plan: June 30, 2023

View Audit 43524

Finding 51204 (2022-011)

Significant Deficiency 2022

State of Delaware

DE

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.303 § 200.317

Reference Number: 2022-011 Prior Year Finding: No Federal Agency: U.S. Department of the Treasury State Department Name: Department of Health and Social Services State Division Name: Division of Social Services Federal Program: COVID-19 ? Coronavirus State and Local Fiscal Recovery Funds Assistance ...

Reference Number: 2022-011 Prior Year Finding: No Federal Agency: U.S. Department of the Treasury State Department Name: Department of Health and Social Services State Division Name: Division of Social Services Federal Program: COVID-19 ? Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Award Number and Year: SLFRP0139 (3/3/2021 ? 12/31/2024) SLFRP2629 (3/3/2021 ? 12/31/2024) Compliance Requirement: Procurement, Suspension & Debarment Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: The Division should review and enhance controls and procedures to ensure that it follows the State?s procurement policy and Federal suspension and debarment regulations for all goods and services charged to the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We agree with the auditor?s recommendation. Ongoing meeting, training, and monitoring have helped and will continue to help DSS staff to achieve compliance. The following actions have been taken to improve the Procurement process. ? Program unit staff will receive Procurement Bootcamp training on contract rules. ? Program unit & Fiscal unit staff will monitor and track all contracts, MOU/MOA?s and agreement so they are in compliance with State Procurement policy. ? Fiscal unit will ensure they have an approval to pay for any invoices. ? Conduct monthly meetings with OSEC CMP Managers and DSS Fiscal unit. Name(s) of the contact person(s) responsible for corrective action: Thomas Hall, DSS Director Victor Ting, DSS Chief of Administration Janneen Boyce, DSS Policy, Social Service Chief Administrator Joanne Sunga, DSS Fiscal, Social Service Chief Administrator Planned completion date for corrective action plan: ? Procurement Bootcamp training was completed March 22, 2023. ? Procurement monitoring, ongoing. ? Fiscal approval workflow, ongoing. ? Monthly Procurement meeting, ongoing.

View Audit 43524

Finding 51203 (2022-010)

Material Weakness 2022

State of Delaware

DE

Subrecipient Monitoring § 200.303

Reference Number: 2022-010 Prior Year Finding: No Federal Agency: U.S. Department of the Treasury State Department Name: Office of the Governor Federal Program: COVID-19 ? Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Award Number and Year: SLFRP0139 (3/3/2021 ?...

Reference Number: 2022-010 Prior Year Finding: No Federal Agency: U.S. Department of the Treasury State Department Name: Office of the Governor Federal Program: COVID-19 ? Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Award Number and Year: SLFRP0139 (3/3/2021 ? 12/31/2024) SLFRP2629 (3/3/2021 ? 12/31/2024) Compliance Requirement: Reporting Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: The Office should enhance its procedures and internal controls regarding preparation of the Project and Expenditure Reports to ensure that information reported is accurate and agrees to supporting documentation. We further recommend that the Office work with State agencies which incur costs under the program to develop procedures and controls to ensure that they provide accurate information to the Office on a timely basis to facilitate timely and accurate project reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding but here is our explanation. The American Rescue Plan State and Local Fiscal Recovery Funds are awarded in advance to our subrecipients based on language in each subrecipient agreement. Within United States Treasury?s reporting portal, we are required to report subawards for each subrecipient and related expenditures and programmatic details. We made the decision to report subrecipient activity for each subaward based on the quarterly data provided to our team. For instance, a subrecipient awarded $50,000 with quarterly expenditures of $10,000 were reported as expending $10,000 on the quarterly UST Project and Expenditure report. This decision was made because it most accurately accounted for the status of a project and the utilization of the funding. This approach resulted in a discrepancy between the expenses in FSF and the UST reporting. Based on guidance from CLA, coming out of the single audit, our team will be reporting the subrecipient activity as the amount paid to each, not based on the expenses of their subaward. A subrecipient awarded and paid $50,000 will be reported as an expenditure of $50,000. We will continue to track and capture subrecipient utilization of the funding through compliance monitoring and quarterly updates. The previously reported amounts in U.S. Treasury?s system will be adjusted for the quarter ending March 31, 2023. This action will resolve CLA?s reporting finding. CLA will test the 3/31/23 and 6/30/23 reports during next year?s single audit to ensure the finding was corrected.

View Audit 43524

Finding 51185 (2022-003)

Significant Deficiency 2022

Wisconsin Association of Free and Charitable Clinics, Inc.

WI

Allowable Costs / Cost Principles Subrecipient Monitoring Significant Deficiency

WISCONSIN ASSOCIATION OF FREE AND CHARITABLE CLINICS, INC. CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2022 "See Corrective Action Plan for chart/table"

View Audit 42598

Finding 51177 (2022-003)

Significant Deficiency 2022

State of Delaware

DE

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.303

Reference Number: 2022-003 Prior Year Finding: No Federal Agency: U.S. Department of Agriculture State Department Name: Department of Education Federal Program: Child Nutrition Cluster Assistance Listing Number: 10.553, 10.555, 10.559, 10.582 Award Number and Year: 1DE303301 (10/1/2020 ? 9/30/2022) ...

Reference Number: 2022-003 Prior Year Finding: No Federal Agency: U.S. Department of Agriculture State Department Name: Department of Education Federal Program: Child Nutrition Cluster Assistance Listing Number: 10.553, 10.555, 10.559, 10.582 Award Number and Year: 1DE303301 (10/1/2020 ? 9/30/2022) Compliance Requirement: Suspension and Debarment Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: The Department should ensure policies and procedures include the three options for determining suspension and debarment status listed in 2 CFR 180.300 and that controls are sufficient to ensure that the suspension and debarment status is verified for all subrecipients prior to issuance of the subawards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Delaware Department of Education (DDOE) Nutrition Team will update the online School Nutrition application to include a certification statement similar to the statement below. Have any current principal staff been debarred, suspended, proposed for debarment, declared inelligible, or voluntarily excluded from participation in this transaction by any Federla department or agency. Yes/No The DDOE Nutrition Team will check SAM exclusions on sam.gov until the application is updated. Name(s) of the contact person(s) responsible for corrective action: ? Jeremy Coleman, Support Staff ? Marianne Bernardi, Support Staff Planned completion date for corrective action plan: April 28, 2023

View Audit 43524

Finding 51040 (2022-002)

Significant Deficiency 2022

Elderbridge Agency on Aging

IA

Subrecipient Monitoring Reporting

WE WILL REVIEW OUR CONTRACTS BEFORE ISSUANCE WITH FISCAL YEAR 2023 TO INSURE THEY HAVE PROPER DISCLOSURE OF FEDERAL FUNDING

View Audit 48061

Finding 50960 (2022-001)

Material Weakness 2022

City of New Albany

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2022-001 Contact Person Responsible for Corrective Action: Linda Moeller Contact Phone Number: 812-948-5333 Views of Responsible Official: Concur With Finding Description of Corrective Action Plan: The City does not dispute the finding regarding suspension and disbarment as stated in the aud...

FINDING 2022-001 Contact Person Responsible for Corrective Action: Linda Moeller Contact Phone Number: 812-948-5333 Views of Responsible Official: Concur With Finding Description of Corrective Action Plan: The City does not dispute the finding regarding suspension and disbarment as stated in the audit. This is, unfortunately, a carryover from the 2021 audit which was not finalized and published till November 22, 2022. The city was aware during the finalization of the 2021 audit and discussed with auditors that this would be a problem for 2022 due to the timing of notification of the issue and the City?s inability to implement a corrective action for matters that occurred prior to November 22, 2022. The process for verification of suspension and disbarment was completed in late 2022/early 2023. Staff verifies prior to any recipient receiving funds that they are not federally suspended or disbarred from doing business at the federal level. A review of all recipients for 2022 confirmed that none of them had any issues with the federal suspension and disbarment requirement verification. The City rejects the classification of ?systemic? issues with SLRF funding and application of processes, but acknowledged the previous issues regarding suspension/disbarment as the only audited issue. As stated previously, the City implemented a process upon awareness of the finding and continues to follow it. A designated staff person verifies that any recipient of funds is not subject to suspension and/or disbarment for business at the federal level prior to any funding. Anticipated Completion Date: Done

View Audit 42127

Finding 50927 (2022-003)

Material Weakness 2022

Flagler Hospital, Inc. and Subsidiaries

FL

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

Condition: The System?s controls in place for subrecipient payments did not ensure that subrecipients were paid within the required 30 day window. Planned Corrective Action: The System will review and enhance its grant agreement review process by implementing controls to grant agreements are thoroug...

Condition: The System?s controls in place for subrecipient payments did not ensure that subrecipients were paid within the required 30 day window. Planned Corrective Action: The System will review and enhance its grant agreement review process by implementing controls to grant agreements are thoroughly reviewed and are adhering to all the compliance requirements. Contact person responsible for corrective action: Paige Stanton Anticipated Completion Date: 6/30/24

View Audit 46814

Finding 50926 (2022-002)

Material Weakness 2022

Flagler Hospital, Inc. and Subsidiaries

FL

Subrecipient Monitoring Material Weakness Reporting

Condition: The System?s controls in place for reporting submissions did not identify that guidelines were not followed related to the lost revenue calculations or the required submission timeline. Planned Corrective Action: The System will review and enhance its PRF reporting process by implementing...

Condition: The System?s controls in place for reporting submissions did not identify that guidelines were not followed related to the lost revenue calculations or the required submission timeline. Planned Corrective Action: The System will review and enhance its PRF reporting process by implementing controls to ensure reports are completed and submitted in accordance with the guidelines established by HHS. Contact person responsible for corrective action: Tom Bailey Anticipated Completion Date: 6/30/24

View Audit 46814

Finding 50924 (2022-002)

Material Weakness 2022

Saint Michael's Clinics, Inc.

NJ

Internal Control / Segregation of Duties Eligibility Subrecipient Monitoring

FINDING 2022-002: Clinic management team acknowledges that from the audit selection made of 65 patients that 15 were not recertified during the six-month period and the supporting documentation was not retained related to income verification for 3 patients. A detail plan of correction has been deve...

FINDING 2022-002: Clinic management team acknowledges that from the audit selection made of 65 patients that 15 were not recertified during the six-month period and the supporting documentation was not retained related to income verification for 3 patients. A detail plan of correction has been developed and is listed below: ? Revamping the job titles and description to encourage better return on recruitment efforts of medical case managers position. ? A position of Certified Case Counselor (CCC) ? Supervisor, was created and filled to provide direct oversight over the medical case managers that perform the bi-annual certifications, and other daily tasks. ? Quality management process, where Clinic clients are called ahead of time to notify them of their recertification requirements. ? Data Analyst(s) will generate a report of patients due for recertification 60 days in advance of the due date. The CCC-Supervisor will be directly accountable to review the progress of the re-certification. This will be further monitored by the Assistant Manager of the clinic. The CCC-Supervisor and Assistant Manager will also monitor retention of income verification supporting documentation for patients. CONTACT PERSON: Raj Mehta, Chief Financial Officer, Peter Ho Memorial Clinic EXPECTED COMPLETION DATE: September 30, 2023

View Audit 43310

Finding 50912 (2022-004)

Significant Deficiency 2022

Tennessee Wildlife Resources Foundation, Inc.

TN

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

Finding 4: Policy for Indirect Costs and Monitoring of that Policy (2022- 04) 4.1 Action Plan To address the identified issues regarding the policy for indirect costs and monitoring of that policy, the organization will take the following steps: ? Formalization of Policy: Develop and formalize a ...

Finding 4: Policy for Indirect Costs and Monitoring of that Policy (2022- 04) 4.1 Action Plan To address the identified issues regarding the policy for indirect costs and monitoring of that policy, the organization will take the following steps: ? Formalization of Policy: Develop and formalize a policy to consistently charge a de minimis rate of 10% for indirect costs on all federal programs. This policy will replace the previous practice of determining indirect costs on a case-by-case or grant-by-grant basis. ? Documentation of Base Rate: Document the base rate for modi?ed total direct costs to establish a clear and consistent basis for calculating the 10% de minimis rate. ? Monitoring and Compliance: Implement procedures for monitoring compliance with the new policy, including regular reviews to ensure that the 10% rate is being applied consistently across all federal programs. 4.2 Responsible Personnel The newly hired Grants Manager, along with the executive management team, will be responsible for ensuring compliance with the new policy. Their responsibilities will include overseeing the implementation of the policy and monitoring its adherence across all relevant programs. 4.3 Resources and Tools Page 45 The organization will leverage its existing resources, including the custom-built grant management solution and QuickBooks Online, to facilitate the implementation and monitoring of the new policy. 4.4 Implementa3on Timeline The organization plans to implement the new policy immediately, applying the 10% de minimis rate to all new grants moving forward without delay. 4.5 Training and Support The organization will provide necessary training and support to the Grants Manager and other relevant personnel to ensure a smooth transition to the new policy protocols. This will include training on the calculation and application of the 10% de minimis rate. 4.6 Monitoring and Evalua3on A monitoring and evaluation mechanism will be established to assess the e?ectiveness of the new policy. This will involve regular reviews to ensure consistent application of the 10% rate and compliance with federal requirements, thereby preventing the charging of potentially unallowable costs to federal programs.

View Audit 44500

Finding 50905 (2022-001)

Material Weakness 2022

Kelso School District No. 458

WA

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

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Kelso School District No. 458 September 1, 2021 through August 31, 2022 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Fede...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Kelso School District No. 458 September 1, 2021 through August 31, 2022 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with wage rate requirements. Name, address, and telephone of District contact person: Scott Westlund, Chief Financial & Operations Officer 601 Crawford, Kelso WA, 98626 (360) 501-1903 Corrective action the auditee plans to take in response to the finding: The Kelso School District appreciates the State Auditor?s Office review of the Davis-Bacon Act requirements in our use of federal funding for the Huntington Middle School construction project. The Kelso School District agrees with the auditor?s finding that more frequent monitoring of wage and payroll certifications is necessary to conform to Davis-Bacon Act. We realize that our reliance on the State of Washington?s Labor and Industries prevailing wage and payroll certifications site (where wage and certification data is submitted and stored) will require weekly review of submitted contractor payrolls and certifications. As we move forward into two additional construction projects utilizing federal funds, we will ensure our project management team provides weekly oversight of contractor compliance, collects weekly certifications and payrolls, and provides Kelso School District with required documentation. Anticipated date to complete the corrective action: Currently in place

View Audit 44228

Finding 50881 (2022-012)

Material Weakness 2022

City of Baton Rouge - Parish of East Baton Rouge

LA

Subrecipient Monitoring Special Tests & Provisions Reporting

2022-012) Special Test and Provisions Management?s response and corrective action is as follows: The City Parish transitioned the administration of the OCD in late 2021 and began hiring new staff throughout 2022. As the Office of Community Development onboarded staff in 2022, monitoring of afford...

2022-012) Special Test and Provisions Management?s response and corrective action is as follows: The City Parish transitioned the administration of the OCD in late 2021 and began hiring new staff throughout 2022. As the Office of Community Development onboarded staff in 2022, monitoring of affordable housing projects, previously conducted by the East Baton Rouge Parish Redevelopment Authority, had resumed. Additionally, the new leadership self-identified the need for additional monitoring and procured a consultant to provide a comprehensive third-party monitoring and assessment of all active subrecipients and developers. That review is anticipated to be completed in July of 2023. Expected Implementation Date: December 2024 Contact person: Marlee Pittman, Interim Director, Office of Community Development

View Audit 53428

Finding 50875 (2022-008)

Significant Deficiency 2022

City of Baton Rouge - Parish of East Baton Rouge

LA

Subrecipient Monitoring Cash Management Reporting

2022-008) David Bacon Wage Requirements Management?s response and corrective action is as follows: All OCD contracts with developers include requirements to comply with Davis-Bacon. As part of the approved policies and procedures, the OCD requests evidence of Davis-Bacon compliance during the clo...

2022-008) David Bacon Wage Requirements Management?s response and corrective action is as follows: All OCD contracts with developers include requirements to comply with Davis-Bacon. As part of the approved policies and procedures, the OCD requests evidence of Davis-Bacon compliance during the closeout of the project in order to ensure complete records. The OCD withholds the retainage at the end of the project until those records are received and reviewed as part of project close-out. The project cited for a lack of Davis-Bacon monitoring began the close-out process just as the audit was being finalized in June 2023 and per the OCD policy, the final reimbursement to the developer is being held until complete Davis Bacon records are submitted, reviewed, and approved. To implement best practices moving forward, the OCD is reviewing the policies and procedures and identifying ways to improve the collection and review of Davis-Bacon compliance. The current staff is scheduled to participate in training and is developing new reporting requirements in alignment with that training. Expected Implementation Date: July 2023 Contact person: Marlee Pittman, Interim Director, Office of Community Development

View Audit 53428

Finding 50873 (2022-006)

Significant Deficiency 2022

City of Baton Rouge - Parish of East Baton Rouge

LA

Reporting Subrecipient Monitoring HUD Housing Programs

2022-006) Reporting Management?s response and corrective action is as follows: The City-Parish transitioned the administration of the Office of Community Development (OCD) in late 2021 throughout 2022. The staff requested access to the Department of Housing and Urban Development?s online reportin...

2022-006) Reporting Management?s response and corrective action is as follows: The City-Parish transitioned the administration of the Office of Community Development (OCD) in late 2021 throughout 2022. The staff requested access to the Department of Housing and Urban Development?s online reporting system, the Integrated Disbursement and Information System (IDIS) in order to complete the CAPER. The OCD staff did not receive access to IDIS until January 2023, at which time the OCD staff began working to complete the reports. The 2022 program year report was completed in June 2023. Moving forward, the new administration at the OCD is redesigning the reporting system for subrecipients and developers to increase the efficiency and accuracy of reporting. The new system should reduce staff burden and reduce the impact of staff transitions on reporting requirements in the future. Expected Implementation Date: August 2023 Contact person: Marlee Pittman, Interim Director, Office of Community Development

View Audit 53428

Finding 50869 (2022-005)

Material Weakness 2022

Union County/college Corner Joint School District

IN

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

FINDING 2022-005 Subject: COVID-19 ? Education Stabilization Fund ? Reporting Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425D Federal Award Numbers and Years (or Other Identifying Numbers): S425D200013...

FINDING 2022-005 Subject: COVID-19 ? Education Stabilization Fund ? Reporting Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425D Federal Award Numbers and Years (or Other Identifying Numbers): S425D200013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) to meet federal reporting requirements for ESSER grant awards. The first report was for the period of March 13, 2020 to September 30, 2020 and was due by January 21, 2021. The second report was for the period of October 1, 2020 to June 30, 2021 and was due by May 13, 2022. For the first report, the amounts reported as expended did not agree to underlying expenditure records of the School Corporation. Per discussion with the Treasurer, the amount in the report included expenditures from outside of the reporting period, resulting in an overstatement of expenditures of approximately $28,000. Additionally, for both reports that were submitted, there was no documented review by someone other than the preparer of the report to ensure the information submitted was complete and accurate. Description of Corrective Action Plan: The treasurer will prepare the grant reporting and have the deputy treasurer review and make any corrections to the information online prior to submission. Responsible Party and Timeline for Completion: Jennifer Blakely, Treasurer, and Debbie Blevins, Deputy Treasurer ? this corrective action will be implemented for all reporting requirements immediately following the audit in March 2023.

View Audit 53337

Finding 50847 (2022-001)

Significant Deficiency 2022

Newport-Mesa Unified School District

CA

Subrecipient Monitoring Reporting Significant Deficiency

The District reported what was believed to be transferred into the program by the close of the fiscal year. Unfortunately, those expenses were not moved as the books were closed long after the reporting deadline. The report was adjusted with the CDE at the following reporting period and now reflect ...

The District reported what was believed to be transferred into the program by the close of the fiscal year. Unfortunately, those expenses were not moved as the books were closed long after the reporting deadline. The report was adjusted with the CDE at the following reporting period and now reflect the correct expenditures. In the future, all related year-end transfers will be prioritized and completed prior to the reporting deadlines to ensure that they match.

View Audit 52386

Finding 50841 (2022-002)

Significant Deficiency 2022

Switzerland County School Corporation

IN

Subrecipient Monitoring Reporting Significant Deficiency § 200.302 § 200.303 § 200.328

FINDING 2022-002 Information on the federal program: Subject: Education Stabilization Fund ? Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Entity: Indiana Department...

FINDING 2022-002 Information on the federal program: Subject: Education Stabilization Fund ? Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) to meet federal reporting requirements for ESSER grant awards and the GEER grant award. The first report was for the period of March 13, 2020 to September 30, 2020 and was due by January 21, 2021. The second report was for the period of October 1, 2020 to June 30, 2021 and was due by May 13, 2022. We noted for both reports that were submitted, there was no documented review by someone other than the preparer of the report to ensure the information submitted was complete and accurate. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. The School Treasurer will complete the Annual ESSER data report. The Grant Director will verify the report(s) for accuracy and completion. The Grant director will sign off on each report and then confirm via email the report(s) is correct and ready for submission to the IDOE. Responsible party and timeline for completion: Contact person responsible for Corrective Action: Patti Kappes, Treasurer Contact phone number: (812)427-4215 Anticipated completion date: April 30, 2023

View Audit 50941

Finding 50839 (2022-002)

Material Weakness 2022

City of Fellsmere

FL

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.303

The responsible party is Putnam Moreman, Finance Director. The findings will be corrected by October, 2023. 2022-002 SUSPENSION AND DEBARMENT U.S. Department of Treasury ALN 21.027 ? COVID-19 Coronavirus State and Local Recovery Funds Contract No. Y5082 (2021) 2022 Funding U.S. Department of Environ...

The responsible party is Putnam Moreman, Finance Director. The findings will be corrected by October, 2023. 2022-002 SUSPENSION AND DEBARMENT U.S. Department of Treasury ALN 21.027 ? COVID-19 Coronavirus State and Local Recovery Funds Contract No. Y5082 (2021) 2022 Funding U.S. Department of Environmental Protection Passed through Florida Department of Economic Opportunity ALN 66.460 ? Nonpoint Source Implementation Grant Contract No. NF068 (2020) 2022 Funding Recommendation: We recommend the City establish a procedure that requires a search for suspension and debarment for vendors receiving grant funds in excess of $25,000. Management?s Response: Whenever the City has a State or Federal grant, we always ensure that the vendors we do business with are not debarred from receiving State or Federal money. In this instance, we were buying relatively small tracts of land from our local pizza shop owner, a private individual, and we did not realize that the same rules applied. We have since ascertained that this individual is in fact not debarred. Going forward, Finance will ensure all expenditures of this nature document that the vendors are not debarred individuals.

View Audit 50350

Finding 50835 (2022-001)

Significant Deficiency 2022

Sycamore-Anderson Senior Housing, Inc. II Dba Sycamore Hsg 046-Ee015

OH

Questioned Costs Subrecipient Monitoring

Name of auditee: Sycamore-Anderson Senior Housing, Inc. II HUD auditee identification number: 046-EE015 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2022 CAP prepared by Name: Julie Cox Position: Management agent representative Telephone numb...

Name of auditee: Sycamore-Anderson Senior Housing, Inc. II HUD auditee identification number: 046-EE015 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2022 CAP prepared by Name: Julie Cox Position: Management agent representative Telephone number: (513) 472-2008 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition #2022-001: As of December 31, 2022, the resident security deposit cash account did not have adequate funds to cover the security deposits collected from residents. At December 31, 2022, the security deposit account was underfunded by $262. Recommendation: Management should reconcile the security deposit listing on a monthly basis and should transfer the funds from the operating account into the resident security deposit account to ensure the account is fully funded. Action(s) taken or planned on the finding: On January 25, 2023, management transferred funds from the operating account to adequately fund the resident security deposit account.

View Audit 47585 Questioned Costs: $1

Corrective Action Plans

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