Corrective Action Plans

Finding 553654 (2024-002)

Material Weakness 2024

PR

Cash Management Subrecipient Monitoring Matching / Level of Effort / Earmarking

Federal Programs: Student Financial Assistance (SFA) Cluster - Various ALN COVID-19 Higher Education Emergency Relief Fund (HEERF) - 84.425 Compliance Requirement – Cash Management Management’s Response The UPR concurs with this finding. In two instances, UPR requested funds to G5 with too much ...

Federal Programs: Student Financial Assistance (SFA) Cluster - Various ALN COVID-19 Higher Education Emergency Relief Fund (HEERF) - 84.425 Compliance Requirement – Cash Management Management’s Response The UPR concurs with this finding. In two instances, UPR requested funds to G5 with too much time in advance. The central administration finance office asked for all units' payment schedules. We will review them and, if necessary, request that schedules include the date to request funds to G5 and the payment date. Schedules must be approved and signed by a finance director’s representative. Staff from the financial aid, fiscal affairs, finance, and disbursement offices will be trained on the FSA Handbook, specifically about requesting and managing FSA funds. We will discuss potential errors that may occur during the process and how, as a group, they can monitor and prevent missed payment deadlines. For example, if the finance office receives G5 funds before the scheduled date, the payment date to students must be brought forward. This type of monitoring and awareness of potential non-compliance should result in compliance with the regulations. Responsible Person or Office: Finance office at the central administration and finance offices at the eleven (11) institutional units. Timeline: 2025-2026

View Audit 352239

Finding 553636 (2024-002)

Significant Deficiency 2024

Anna Marie's Alliance

MN

Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency § 200.318 § 200.326

SIGNIFICANT DEFICIENCY 2024-002 Crime Victim Assistance -Assistance Listing No. 16.575 Recommendation: The Organization should continue to apply its current procurement policy to new and existing vendors to ensure proper documentation is retained in accordance with said procurement policy and SA UG...

SIGNIFICANT DEFICIENCY 2024-002 Crime Victim Assistance -Assistance Listing No. 16.575 Recommendation: The Organization should continue to apply its current procurement policy to new and existing vendors to ensure proper documentation is retained in accordance with said procurement policy and SA UG. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will apply its current procurement policy to new and existing vendors in order to comply with applicable procurement requirements. Name(s) of the contact person(s) responsible for corrective action: Tracy Johnson, Director of Finance Planned completion date for corrective action plan: June 30, 2025

View Audit 352209

Finding 553628 (2024-001)

None 2024

Nashoba Regional School District

MA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.309

Finding 2024-001 Condition: Costs were recorded for service periods prior to grant approval date. Corrective Action Planned: The district will implement controls to prevent the recording of costs for service periods prior to grant approval date by written guidance to all staff involved in federal ...

Finding 2024-001 Condition: Costs were recorded for service periods prior to grant approval date. Corrective Action Planned: The district will implement controls to prevent the recording of costs for service periods prior to grant approval date by written guidance to all staff involved in federal grant funds. Please note, that the practice at question is not in violation of school committee policy as we have not made any expenditures outside that entity’s approval date. Anticipated Completion Date: By July 1, 2025 Contact: Ross Mulkerin, Director of Finance and Operations

View Audit 352205 Questioned Costs: $1

Finding 553590 (2024-002)

Significant Deficiency 2024

City of Dowagiac

MI

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

Finding 2024-002 Significant Deficiency and Noncompliance - Lack of Required Uniform Guidance Policies and Procedures Condition: The City did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Anticipated Completion Date: September 30, 2025 Corrective Ac...

Finding 2024-002 Significant Deficiency and Noncompliance - Lack of Required Uniform Guidance Policies and Procedures Condition: The City did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Anticipated Completion Date: September 30, 2025 Corrective Action: The City will implement a new policy document specifically for Uniform Grant Compliance to have one document to ensure compliance.

View Audit 352186

Finding 553486 (2024-004)

None 2024

University of Southern California

CA

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.403

Management’s Views and Corrective Action Plan Management response to finding 2024-004: Review over cost transfers of subrecipient expenditures Cluster Name: Research and Development Federal Awarding Agency: Various Award Name: Various Award Number: Various Award Years: Various Assistance Listing T...

Management’s Views and Corrective Action Plan Management response to finding 2024-004: Review over cost transfers of subrecipient expenditures Cluster Name: Research and Development Federal Awarding Agency: Various Award Name: Various Award Number: Various Award Years: Various Assistance Listing Title: Various Assistance Listing Number: Various Pass-through entities: Various As described in Finding 2024-004, and as a result of improper training related to the implementation of the university’s new financial system in FY22, the university lacked adequate controls to identify the proper application of indirect costs as it relates to subrecipient expenses when using the cost transfer process to make corrections. Additionally, the university failed to properly apply its policy for the classification of subawards versus direct expenditures. As such, while cost transfers are a small percentage of overall transfer activity, an update to training materials will be made by June 2025 to educate cost transfer initiators on the proper method to use for this subset of subrecipient expenditures. Since February 2025, the Sponsor Projects Accounting (SPA) representative responsible for central office review of cost transfers now reviews to ensure that all intended grant related attributes are in effect before approving any subrecipient cost transfers. Additionally, as of February 2025, the university reinforced its policy regarding the classification of subawards versus direct expenditures with both the Procurement department and the SPA staff to ensure the proper expenditure classification is set up during the onboarding process of a contractor. The SPA team has completed its analysis and review of all previous subrecipient cost transfers to verify and correct the improper application of indirect cost limits and expenditure classifications. As of March 2025, all subrecipient cost transfer errors have been identified and corrected, resulting in questioned costs of approximately $587,000. Separately, this resulted in an under-recovery of $306,000 of indirect costs that were not charged to the original award. As all awards impacted are still open and active, the correcting expenditure adjustments were applied to the awards impacted that will affect future draw downs. Contact Person: Cindy Lee, Director, Sponsored Projects Accounting, cmlee@usc.edu

View Audit 352166

Finding 553469 (2024-002)

Material Weakness 2024

The Howard University

DC

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Name of Responsible Individual: Rawle Howard, Assistant Vice President, Procurement Corrective Action: Accounts Payable (AP) will create a Corrective Action plan to include the following. 1. The process to review Payment Request Forms (“PRFs”), used for payment to vendors that do not require the u...

Name of Responsible Individual: Rawle Howard, Assistant Vice President, Procurement Corrective Action: Accounts Payable (AP) will create a Corrective Action plan to include the following. 1. The process to review Payment Request Forms (“PRFs”), used for payment to vendors that do not require the use of a purchase order, will be improved by requiring the review of supporting documents to ensure expenses are allowable by the newly established Sponsored Program Office (SPO) post award team. This team will thoroughly review supporting documents to ensure expenses are allowable, allocable, and reasonable according to University policies and grant terms. PRFs will be reviewed by SPO and Grants and Contracts Accounting (GCA) and will serve as the key control point before transactions are forwarded to accounting to post to sponsored awards. 2. AP is working with Enterprise Technology Services (ETS) to modify the Workday Ad Hoc Business process to require additional review by PI, SPO, and GCA before payments can be issued. Each approval role will receive guidance regarding 3. AP will collaborate with SPO and GCA to issue communications and provide training to all PIs, SPO, GCA, and AP personnel. Anticipated Completion Date: December 31, 2025

View Audit 352153 Questioned Costs: $1

Finding 553086 (2024-013)

Significant Deficiency 2024

The Howard University

DC

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.305

Name of Responsible Individual: Marchon Jackson, Associate Vice President of Research; Jaquion Gholston, Assistant Vice President for Post-Award and UARC Operations; Rawle Howard, Assistant Vice President, Procurement Corrective Action: The process to review subrecipient invoices will be improved b...

Name of Responsible Individual: Marchon Jackson, Associate Vice President of Research; Jaquion Gholston, Assistant Vice President for Post-Award and UARC Operations; Rawle Howard, Assistant Vice President, Procurement Corrective Action: The process to review subrecipient invoices will be improved by requiring the review of supporting documents to ensure expenses are allowable by the Sponsored Program Office (SPO) post award team. This team will thoroughly review supporting documents to ensure expenses are allowable, allocable, reasonable and recorded in the proper period according to university policies and grant terms. Invoices will be reviewed by SPO and will serve as the key control point before transactions are forwarded to accounting to post to sponsored awards. Subrecipient invoices will be paid by Accounts Payable only after approval by SPO and GCA. The Director of Compliance will conduct spot checks on all sponsored transactional activity, especially for high-risk grants to provide an additional layer of oversight. The new review process and training for these responsibilities will be implemented by spring 2025 as part of the broader campus-wide workflow training and staffing up of the new SPO Post-Award office. Anticipated Completion Date: June 30, 2025

View Audit 352153

Finding 552703 (2024-012)

Significant Deficiency 2024

The Howard University

DC

Allowable Costs / Cost Principles Subrecipient Monitoring Reporting § 200.430

Name of Responsible Individual: Marchon Jackson, Associate Vice President for Research, Brenda Willis, Senior Executive Director of Financial Grants & Contracts, Jaquion Gholston, Assistant Vice President for Post-Award and UARC Operations Corrective Action: A new office is being developed to addres...

Name of Responsible Individual: Marchon Jackson, Associate Vice President for Research, Brenda Willis, Senior Executive Director of Financial Grants & Contracts, Jaquion Gholston, Assistant Vice President for Post-Award and UARC Operations Corrective Action: A new office is being developed to address the timeliness of the personnel payment request forms. In Phase I, CRAs will be assigned to high-volume research colleges to provide support for costing allocations. Phase 2 will encompass existing departmental administrators who will gradually transition into more centralized research workflows supported by CRAs. A shared services model for the remaining colleges is planned for FY26. Quarterly checklist and updates outlining cost allocation statuses will be completed with Deans and Associate Deans to determine the process needed to complete cost allocations timely. Anticipated Completion Date: July 1, 2025

View Audit 352153

Finding 551536 (2024-001)

Significant Deficiency 2024

Bay Area Air Quality Management District

CA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.435 § 200.459

View of Responsible Officials and Corrective Action Plan Air District Management concurs with the recommendation under Finding Reference Number F-2024-001. Upon review of the supporting travel expense documentation, management has found no discrepancies. Moving forward, the Air District will contin...

View of Responsible Officials and Corrective Action Plan Air District Management concurs with the recommendation under Finding Reference Number F-2024-001. Upon review of the supporting travel expense documentation, management has found no discrepancies. Moving forward, the Air District will continue to ensure that all supporting travel documentation agrees with the corresponding invoices to maintain compliance and accuracy. Regarding the overstatement of program expenditures, the Air District will initiate the recovery of the identified overcharges by deducting the amount from future reimbursement requests submitted to the Department of Homeland Security (DHS). Specifically, the Air District plans on recovering the $9,316 in overcharges from the contractor for fiscal year ending June 30, 2024. Additionally, the Air District is in the process of reviewing Fiscal Year 2025 invoices to identify any potential overcharges and will request reimbursement from the contractor, as necessary. To strengthen oversight and compliance, the Air District has begun implementing process changes as of February 2025. These changes ensure that consultant invoices align with the terms of the Air District’s contract prior to approval and payment processing. Name: Daniel Meer Title: Manager, Government Outreach & Special Projects Email: dmeer@baaqmd.gov

View Audit 352146 Questioned Costs: $1

Finding 551505 (2024-002)

Material Weakness 2024

Clarkson University

NY

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Management accepts this finding and notes there were issues with the disbursement records that prevented them from being sent to COD. Unexpected turnover in the workforce resulted in 25% normal processing capacity during the timeframe in question. Staffing levels in that area have been fully restore...

Management accepts this finding and notes there were issues with the disbursement records that prevented them from being sent to COD. Unexpected turnover in the workforce resulted in 25% normal processing capacity during the timeframe in question. Staffing levels in that area have been fully restored with appropriate training to the employees. A formal schedule has been developed whereby records are reconciled and sent to COD on a weekly basis to reduce the risk of late filings. In addition, the University is considering methods of improved redundancy and backup to prevent systemic issues going forward. Anticipated Completion Date December 2024 - completed Responsible Person Nicole Adner, Director of Financial Aid

View Audit 352112

Finding 551503 (2024-005)

Significant Deficiency 2024

South Carolina State University

SC

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Student Financial Aid § 200.303

Corrective Action Plan The University acknowledges this finding and is committed to immediate corrective measures to ensure compliance with federal regulations. The following actions will be undertaken: 1. Enhance Procedures and Internal Controls: The University will strengthen its procedures and ...

Corrective Action Plan The University acknowledges this finding and is committed to immediate corrective measures to ensure compliance with federal regulations. The following actions will be undertaken: 1. Enhance Procedures and Internal Controls: The University will strengthen its procedures and internal controls related to the submission of origination and disbursement records to the COD system. This includes implementing stricter monitoring mechanisms to ensure all records are submitted within the required timeframes. 2. Implement Advanced Technology Solutions: To improve the efficiency and accuracy of financial reporting, the University will adopt advanced technology solutions. These tools will facilitate timely and accurate submission of required data to the COD system. The newly established internal audit team will oversee the implementation and management of these corrective actions until the issue is fully resolved. The University is dedicated to enhancing its procedures and internal controls to ensure full compliance with federal origination and disbursement requirements. By taking these steps, the University aims to rectify the identified deficiency and prevent future occurrences, thereby maintaining the integrity of its financial reporting processes. Anticipated Completion Date: September 1, 2025

View Audit 352110

Finding 551493 (2024-001)

Significant Deficiency 2024

South Carolina State University

SC

Student Financial Aid Special Tests & Provisions Subrecipient Monitoring § 200.303

Corrective Action Plan The University acknowledges this finding and is committed to implementing immediate measures to ensure compliance with federal enrollment reporting requirements. The following steps will be undertaken: 1. Establish an Internal Audit Function: The University is actively seeki...

Corrective Action Plan The University acknowledges this finding and is committed to implementing immediate measures to ensure compliance with federal enrollment reporting requirements. The following steps will be undertaken: 1. Establish an Internal Audit Function: The University is actively seeking to fill a newly approved internal auditor position, with a dedicated budget line item to support this function. This role will provide leadership on all corrective action plans and serve as the primary contact for audit-related matters, ensuring onsite management for compliance issues within the University and its affiliated agencies. 2. Engage External Expertise: The Office of the Registrar will engage with the internal auditor and the National Student Loan Clearinghouse to review critical processes. This ongoing collaboration aims to assess the department’s strengths, weaknesses, opportunities, and threats, facilitating continuous improvement and compliance. 3. Enhance Staffing and Technological Resources: The University has made necessary staffing changes and will continue to evaluate the efficiency of the enrollment reporting process. This includes hiring additional staff as needed and incorporating advanced technology solutions to address this recurring issue. The implementation of enhanced technology will assist the Registrar in receiving alerts and status reports, ensuring timely and accurate processing. 4. Implement Robust Monitoring Systems: The University aims to generate necessary information and update systems to improve its capability to monitor student enrollment statuses, thereby enhancing compliance. This initiative will address challenges associated with certifying these enrollment status changes in a timely manner. 5. Strengthen Reporting Processes: Given the recurrence of this finding, the University will implement an enhanced reporting process, requiring the filing of transfer student status reports on a semester basis until the issue is resolved. The internal audit team will lead this reporting cycle, ensuring accountability and compliance. The internal audit unit will oversee and manage these corrective actions until the matter is fully resolved. The University is dedicated to enhancing its procedures and internal controls to ensure full compliance with enrollment reporting requirements. By implementing these measures, the University aims to rectify the identified deficiencies and prevent similar occurrences in the future, thereby upholding the integrity of its financial aid programs and maintaining compliance with federal regulations. Anticipated Completion Date: September 1, 2025

View Audit 352110

Finding 551444 (2024-006)

Significant Deficiency 2024

Volunteers of America Western Washington and Subsidiary

WA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303 § 200.430

We acknowledge BDO’s recommendation to ensure consistent approval and retention of timesheets by both employees and supervisors for each pay period requested for reimbursement. However, VOAWW asserts that we have established controls in place to obtain and retain timesheet approvals, and the two ins...

We acknowledge BDO’s recommendation to ensure consistent approval and retention of timesheets by both employees and supervisors for each pay period requested for reimbursement. However, VOAWW asserts that we have established controls in place to obtain and retain timesheet approvals, and the two instances of missing approvals identified in the audit were due to human error rather than a lack of controls. To prevent such occurrences in the future and reinforce our existing procedures, we will continue implementing and strengthening the following controls: • Proactive Timesheet Approval Monitoring – Reports are regularly run to identify missing timesheet approvals before payroll is processed. Employees and supervisors with outstanding approvals receive reminders to ensure further action as needed, including notifying program directors about missing timesheet submissions or approvals resulting in out-of-compliance with federal awards and Uniform Guidance. • Real-Time Payroll Processing Checks – During payroll processing, additional reminders are sent to employees and supervisors who have not yet approved their timesheets, further reducing the likelihood of omissions. • Additional Approval Outside the System – In response to BDO’s recommendation, we will require managers to email Payroll at the end of every pay period affirming that they have reviewed and approved all timecards. This additional layer of approval ensures that even if a manager forgets to approve a timesheet in the system, there is still documented confirmation of their review. • Post-Payroll Compensating Control Implemented in FY24 – To mitigate any risk of over/undercharging grants due to miscoded time from unapproved timesheets, a compensating control was introduced in FY24. This process requires Program Management to review and approve a post-payroll report identifying any discrepancies in time allocations, ensuring that all time charged to grants is accurate and properly approved. • Documentation and Continuous Improvement – VOAWW provided attestations to BDO where available and acknowledges that the compensating control was not fully implemented during FY23 but was in place for most of FY24. Moving forward, we will ensure that this control is consistently applied across all programs. By maintaining and strengthening these controls, including the additional email approval process, we are confident in our ability to ensure proper timesheet approvals while mitigating any risk of inaccurate grant charging. Responsible Individual: Claire Danielson, Controller Estimated time of completion: June 2025

View Audit 352105

Finding 551422 (2024-005)

Significant Deficiency 2024

Volunteers of America Western Washington and Subsidiary

WA

Matching / Level of Effort / Earmarking Subrecipient Monitoring Equipment & Real Property Management § 200.303 § 200.430 § 200.465

We acknowledge the auditors’ recommendation regarding the need for a more arm’s-length approach in determining rent charges between entities. To address this finding, we are making adjustments to our rent allocation methodology to enhance transparency and ensure compliance with best practices. As ...

We acknowledge the auditors’ recommendation regarding the need for a more arm’s-length approach in determining rent charges between entities. To address this finding, we are making adjustments to our rent allocation methodology to enhance transparency and ensure compliance with best practices. As part of our corrective action plan, we will implement the following measures: • Transition to an Actual Expense Allocation Methodology – VOAWW will modify the rent allocation process to allocate actual expenses incurred, ensuring that charges between entities reflect true costs. This approach eliminates the need for a year-end true-up process while maintaining fairness and accuracy. • Implementation of a True-Up Process for FY25 – While transitioning to the new methodology, we will conduct a true-up process for FY25 to reconcile any discrepancies and ensure that rent allocations align with actual expenses. These actions will help strengthen our internal controls and ensure that inter-entity rent allocations are handled in a compliant and equitable manner. Responsible Individual: Claire Danielson, Controller Estimated time of completion: June 2025

View Audit 352105

Finding 551396 (2024-004)

Significant Deficiency 2024

Volunteers of America Western Washington and Subsidiary

WA

Subrecipient Monitoring

We acknowledge the repeated finding regarding the lack of documentation around the review, approval, and submission of required performance reports. To address this issue, we remain committed to the continued implementation and strengthening of the controls we began putting in place last year. ...

We acknowledge the repeated finding regarding the lack of documentation around the review, approval, and submission of required performance reports. To address this issue, we remain committed to the continued implementation and strengthening of the controls we began putting in place last year. As part of our ongoing efforts, we are enhancing our processes through the following actions: • Strengthened Implementation of CC-001 – We will reinforce the policies and procedures established in CC-001 to ensure consistent adherence across all reporting functions. This includes analyzing resources allocated to perform this control, enhancing internal review protocols and ensuring clear documentation of approvals. • Implementation of ContractSafe Reporting Management – VOAWW is in the process of implementing ContractSafe, a Contract database with a reporting management system designed to send automated reporting reminders and track report submissions. This system will improve compliance by ensuring reports are submitted accurately and on time while maintaining a clear audit trail of approvals. • Improved Monitoring and Accountability – We will regularly assess the effectiveness of these controls, making necessary adjustments to further strengthen oversight and prevent future occurrences of this finding. By taking these steps, we aim to fully resolve this issue and establish a more robust and transparent process for managing required reports. Responsible Individual: Claire Danielson, Controller Estimated time of completion: June 2025

View Audit 352105

Finding 551220 (2024-020)

None 2024

Upshur County Board of Education

WV

Questioned Costs School Nutrition Programs Matching / Level of Effort / Earmarking § 200.334 § 200.403

The Board has developed procedures to ensure that all purchase orders are approved before orders are placed, all expenditures are properly authorized by the respective program director and supporting documentation is adequately maintained. The Board is using a requisition form in Droplet to achieve ...

The Board has developed procedures to ensure that all purchase orders are approved before orders are placed, all expenditures are properly authorized by the respective program director and supporting documentation is adequately maintained. The Board is using a requisition form in Droplet to achieve this goal. All employees authorized to make or approve purchases have been trained on purchasing procedures outlined in the Purchasing Policies and Procedures Manual for Local Educational Agencies in the State of West Virginia by the WVDE Office of School Finance on 2/23/2024.

View Audit 352084 Questioned Costs: $1

Finding 551208 (2024-019)

Material Weakness 2024

Upshur County Board of Education

WV

Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.334

The Board will establish procedures that will ensure compliance with guidance set forth in Title 2 U.S. Code of Federal Regulations (CFR) Part 200 for Special Education.

View Audit 352084 Questioned Costs: $1

Finding 551134 (2024-001)

Significant Deficiency 2024

Young at Heart Resources

MO

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

Agency Response: Currently, Young at Heart follows policies and procedures for holidays, week hours, etc. CEO and CFO are aware we must follow our policies. We have changed the work week policy and the holiday listings in our policies. Creating new policies was part of the corrective action plan wit...

Agency Response: Currently, Young at Heart follows policies and procedures for holidays, week hours, etc. CEO and CFO are aware we must follow our policies. We have changed the work week policy and the holiday listings in our policies. Creating new policies was part of the corrective action plan with the DHSS. The policies were created and approved by Young at Heart Board in July 2024. Employees work a 36 hour week and receive 13 paid holidays. The credit card procedure now is being followed as it should. This was also on the Correctve Action Plan with DHSS. Both the previous CEO (Michael Stopka) and CFO (Shari Harris) are no longer employed with the agency. When I started as CFO, the current interim CEO Freda Miller and I called the board chair regarding the personal charges by Michael Stopka on the corporate credit card. The board chair was unaware of this and would address the issue and make sure he not only didn’t use the card for personal charges but would not pay it online and bypass the internal control function of accounts payable and cash disbursements. The current procedure of all purchases must be approved by the CEO and CFO prior to purchase. Once the item is purchased, the receipt and the requisition is sent to the fiscal assistant who matches the receipts to the credit card bill. Once all items are accounted for, the fiscal assistant will cut a check. The check will then be signed by CEO and a board member. The credit card bill is no longer being paid on-line. I believe the internal control problems have been addressed both on the corrective action plan with MO DHSS and by current management. These items were corrected in July 2024 after M. Stopka & S. Harris had left the agency.

View Audit 352061

Finding 551125 (2024-003)

Material Weakness 2024

County of Solano

CA

Subrecipient Monitoring Reporting Material Weakness § 200.303

Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Housing Voucher Cluster Federal Assistance Listing Number: 14.871, 14.879 Pass‐through: n/a – direct award Award No. and Year: CA131, 2023/2024 Compliance Requirement: Reporting Type of Finding: Material Weakness in In...

Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Housing Voucher Cluster Federal Assistance Listing Number: 14.871, 14.879 Pass‐through: n/a – direct award Award No. and Year: CA131, 2023/2024 Compliance Requirement: Reporting Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Views of Responsible Officials and Corrective Action Plan: Since May 2022, the County has contacted multiple agencies trying to report through the FSRS system on the multiple Housing Voucher awards, with no success. The County’s assigned Housing and Urban Development (HUD) office is the San Francisco regional office. Per their director, “These are systems that we don’t work with in HUD PIH so I won’t be able to be of assistance relative to this.” The County is unable to complete FFATA reporting for reasons outside of the County’s control. Responsible Individual(s): James Bezek, Director of Resources Management Anticipated Completion Date: Because the corrective action is outside of the County’s control, we cannot determine an anticipated completion date.

View Audit 352056

Finding 551124 (2024-002)

Material Weakness 2024

County of Solano

CA

Subrecipient Monitoring § 200.331 § 200.521

Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Housing Voucher Cluster Federal Assistance Listing Number: 14.871, 14.879 Pass‐through: n/a – direct award Award No. and Year: CA131, 2023/2024 Compliance Requirement: Subrecipient Monitoring Type of Finding: Material ...

Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Housing Voucher Cluster Federal Assistance Listing Number: 14.871, 14.879 Pass‐through: n/a – direct award Award No. and Year: CA131, 2023/2024 Compliance Requirement: Subrecipient Monitoring Type of Finding: Material Weakness in Internal Control over Compliance, Instance of Noncompliance Views of Responsible Officials and Corrective Action Plan: Due to the subrecipient’s low-risk status, another site visit is not due until FY2025/26. When that visit takes place, the County will formally document and communicate the results of the site visit. The department has created a subrecipient monitoring checklist to be completed quarterly which includes review of quarterly reports and will serve as documentation. Additionally, the department has a standing quarterly meeting with the subrecipient and will add an agenda item for quarterly report review discussion. The department will begin taking meeting minutes for documentation. Responsible Individual(s): James Bezek, Director of Resources Management Anticipated Completion Date: June 30, 2025

View Audit 352056

Finding 551117 (2024-001)

Material Weakness 2024

Trinity College of Florida, Inc.

FL

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Trinity College of Florida will develop, implement and maintain a written information security program in accordance with GLBA compliance

View Audit 352041

Finding 551114 (2024-003)

Material Weakness 2024

Community Health Centers of Arkansas, Inc.

AR

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.318

Views of Responsible Officials and Planned Corrective Actions – Management acknowledges the audit finding related to procurement and suspension and debarment compliance under Federal Programs: Technical and Non-Financial Assistance to Health Centers, Grants for New and Expanded Services under the He...

Views of Responsible Officials and Planned Corrective Actions – Management acknowledges the audit finding related to procurement and suspension and debarment compliance under Federal Programs: Technical and Non-Financial Assistance to Health Centers, Grants for New and Expanded Services under the Health Center Program (Federal Assistance Listing Numbers 93.129, 93.527; Federal Award Year 2023-2024). We are committed to implementing corrective measures to address the identified deficiencies and ensure full compliance with 2 CFR 200.318 and 2 CFR 180 regulations. Corrective Actions Taken: 1. Established & Implemented Detailed Record-Keeping for Procurement Transactions: - A new accounting system with a centralized procurement tracking system has been implemented and is currently being used. Bill.com is used to record vendor invoices and procurement transactions in real time and syncs with Sage Intacct, the new accounting software implemented in January 2024. - Detailed records of all federal grant expenditures are maintained in Bill.com and monthly reconciliations are conducted in the general ledger to ensure all procurement transactions are properly classified to their specific grant by their grant ID. 2. Established & Implemented Suspension & Debarment Verification Procedures: - A new accounting system with a centralized procurement tracking system has been implemented and is currently being used. Bill.com is used to record vendor information including Sam.gov vendor eligibility documentation. - All vendors are verified using Sam.gov. and documentation is kept in the electronic vendor file in Bill.com. This process was implemented in March 2024 and is ongoing. 3. Monitoring - The Finance team conducts annual self-assessments to ensure vendor eligibility documentation is current and up to date. Any vendors that are suspended, debarred, or otherwise excluded from federal assistance programs are reported to the Executive team to ensure compliance. We believe that these actions will significantly mitigate the risks associated with the identified conditions and strengthen our internal control environment and align our procurement practices with federal regulations.

View Audit 352037

Finding 551112 (2024-001)

None 2024

Conservatorio De Musica De Puerto Rico

PR

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.510

Management is implementing enhanced controls and formal procedures to ensure that all funding sources, particularly those received through intermediary or passthroughentities, are correctly identified and appropriately classified for reporting. These measures include: - Expanding documentation reque...

Management is implementing enhanced controls and formal procedures to ensure that all funding sources, particularly those received through intermediary or passthroughentities, are correctly identified and appropriately classified for reporting. These measures include: - Expanding documentation requests to verify funding sources. - Maintaining ongoing dialogue with pass-through entities to confirm federal assistance classifications.

View Audit 352031

Finding 551094 (2024-008)

Significant Deficiency 2024

William Peace Universirty

NC

Subrecipient Monitoring Student Financial Aid Significant Deficiency

Student Financial Assistance Cluster - Assistance Listing No. No. 84.063, 84.268, 84.007, 84.033 Recommendation: We recommend the University ensure its written information security program addresses the required minimum elements as outlined in 16 CFR 314.4. Explanation of disagreement with audit fin...

Student Financial Assistance Cluster - Assistance Listing No. No. 84.063, 84.268, 84.007, 84.033 Recommendation: We recommend the University ensure its written information security program addresses the required minimum elements as outlined in 16 CFR 314.4. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Information Technology Department will ensure its written information security program addresses the required minimum elements outlined in 16 CFR 314.4. Name(s) of the contact person(s) responsible for corrective action: Belinda Burke, VP for Finance and Administration, CFO Planned completion date for corrective action plan: April 2025

View Audit 352022

Finding 549905 (2024-018)

Significant Deficiency 2024

State of Utah

UT

Subrecipient Monitoring Allowable Costs / Cost Principles Significant Deficiency § 200.302 § 200.430

2024-018. USU Extension Extra Services Compensation Program Non-Compliance with Uniform Guidance State Agency: Utah State University Research & Development Federal Agency: Various 1) Potential Financial Impact USU retained Huron Higher Education Consulting to conduct a Uniform Guidance compliance r...

2024-018. USU Extension Extra Services Compensation Program Non-Compliance with Uniform Guidance State Agency: Utah State University Research & Development Federal Agency: Various 1) Potential Financial Impact USU retained Huron Higher Education Consulting to conduct a Uniform Guidance compliance review of compensation costs charged to federal sponsors. Huron Consulting routinely works with Carnegie R1 institutions to review research compliance issues. Huron conducted a detailed review of an extensive data set for ESC payments made to USU employees, focusing on employees who had salary charged to federal grants or designated as a grant cost share. This review identified limited instances (1) when salaries directly charged to sponsored projects included extra service compensation in the institutional base salary and (2) when extra service compensation was charged to federal sponsors. Overall, the review found that the vast majority of USU ESC payments (referred to as secondary payments in the internal audit) were not charged to federal sponsored awards. Out of a total population of $5.8 million ESC payments reviewed, the unallowed compensation costs related to ESC is approximately $140,000. USU is in the process of addressing the unallowable compensation costs by removing unallowable charges on open awards and refunding unallowable charges on closed awards. 2) Policies and required documentation for ESC. ESC Policies: USU is reviewing its policies associated with ESC and institutional base salary (IBS) (both currently defined in USU Policy 376: Extra Service Compensation). A working group has been established that includes the Provost’s Office, the President’s Office, the Office of Research and Human Resources to develop updated procedures for requesting ESC. Once in place, a new Extra Service Compensation website will be rolled out that will provide guidance on the policy, acceptable uses of extra-service Compensation, and training materials. In conjunction with the website development, a communication plan to inform stakeholders, especially approving department heads and administrators, will be developed. Institutional Base Salary Policy and Procedures: USU will create and implement an Institutional Base Salary policy that aligns with federal requirements and industry best practices and specifically defines salary components and the associated pay codes that are included and excluded from an employee’s institutional base salary. USU will also update its time and effort certification system with correct institutional base salary mapping. 3) Internal controls for sponsored program compensation USU will implement the following improvements in its internal controls: Revised ESC Form. USU has revised its ESC Form to include documentation / calculation demonstrating payment is commensurate with institutional base salary. Revised ESC Application and Approval Process: USU has already updated the internal ESC review process to include appropriate controls to ensure that all ESC requests are reviewed for Uniform Guidance and USU policy requirements. In this regard, all ESC requests at USU are now reviewed by the Office of Sponsored Programs in the context of all funding sources associated with the applicant (including cost share indexes). This change directly addresses prior routing based on the source of funding which resulted in the Office of Research/Sponsored Programs being bypassed for state-funded ESC requests. Certification language has been inserted at appropriate approval levels to ensure that employees are not receiving ESC related to their primary position/workload. Improved Definitions of Primary Work Statement: USU has initiated a collaborative effort between Human Resources, the Provost’s Office, and the Office of Research to clearly define the primary work assignment for faculty via the role statement or annual work plans to clarify the full workload associated with the IBS. Increased Compliance Monitoring: After-the-fact monthly review of ESC payments is being collaboratively performed between the Office of Research and Provost’s Office. Additionally, USU has reorganized its operations to house post-award research administrators within the Office of Research and added an additional supervisory position to manage post award compliance and management. USU will charge central-post award research administrators with monitoring salary charges to sponsored awards and cost share accounts as a secondary internal control. Research Incentive Programs: The Office of Research will establish permissible conditions and components for research incentive programs and any and all proposed programs will be reviewed and approved by the Office of Research before implementation. 4) Adequate training to university personnel regarding sponsored programs compensation compliance. Uniform Guidance training for faculty and staff: USU is building and incorporating new training modules for those managing federal awards which will include guidance on allowable compensation costs and determining institutional base salary. ESC Training: USU has developed a new required annual training for anyone requesting or approving ESC from all types of funding sources at USU (delivered via USU’s Learn Blue system). This training addresses requirements for ESC and employees’ role and responsibilities for compliance requirements. Additional training regarding time and effort certification will be developed. Pay Code Training: USU will provide additional training and education for departmental and payroll staff responsible for coding and processing salary across the institution. Responsible Person: Lisa M. Berreau Vice President for Research Utah State University 435-797-3509 Anticipated completion date of corrective action plan: Actively in progress and full completion by Jan. 1, 2026.

View Audit 352012

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