Corrective Action Plans

Finding 499092 (2023-002)

Material Weakness 2023

Chisago County

MN

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.403

Finding Number: 2023-002 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Kristin Waddell Corrective Action Planned: Extensive rese...

Finding Number: 2023-002 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Kristin Waddell Corrective Action Planned: Extensive research was done on this topic and position of the County is that cities and townships are non-entitlement units (NEUs) who report to the Treasury directly. SLFRF Compliance and Reporting Guidance published by The Department of the Treasury states that NEUs are not subrecipients under the SLFRF program; they are SLFRF recipients that report directly to the Treasury. Recipients of the County’s ARPA Broadband grants: -provided the specific unserved or underserved areas located within the County where therequested ARPA funds would be used to deliver high-speed, reliable, and affordable internet(typically accompanied by the consultant report coordinating the construction) on their grantapplications to the County Board; and -have certified they are complying with “all federal, state, and local laws and all requirementsand published guidance set forth regarding the usage of any and all monies appropriated underthe ARPA” in their signed grant agreements with the County; However, beginning in 2024 the County will collect itemized support for the expenditures incurred related to the ARPA Broadband Grant Program. Anticipated Completion Date: Immediately

View Audit 321886 Questioned Costs: $1

Finding 499087 (2023-003)

Significant Deficiency 2023

Sound Generations

WA

Allowable Costs / Cost Principles § 200.303

Type of Finding: Significant Deficiency in Internal Control over Compliance – Activities Allowed or Unallowed, Allowable Costs / Cost Principles Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Aging Cluster Assistance Listing Number; 93.044 / 93.045 / 93.053 Feder...

Type of Finding: Significant Deficiency in Internal Control over Compliance – Activities Allowed or Unallowed, Allowable Costs / Cost Principles Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Aging Cluster Assistance Listing Number; 93.044 / 93.045 / 93.053 Federal Award Identification Number and Year: DA23-1109-2023, DA23-1176-2023 Pass-Through Agency: City of Seattle Pass-Through Number(s): DA23-1109, DA23-1176 Award Period: January 1, 2023 through December 31, 2023 Criteria or specific requirement: 2 CFR 200.303(a) states that 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 be in compliance 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 the Organization of the Treadway Commission (COSO).” Condition: During testing of payroll, it was noted that three employee’s wages had been misallocated between contracts. These misallocations occurred due to clerical errors and inadequate monitoring and review of the allocation process. Questioned Costs: None Context: A sample of 60 payroll samples were made from a population of over 260 individual employee paychecks. Of the 60 sampled, three samples had wages misallocated. The first was misallocated between the Community Dining and Meals on Wheels contracts. The second had misallocations between two funding sources under the Meals on Wheels contract. The third had misallocations between the Meals on Wheels contract and another funder. Cause: In one instance, a manual intervening calculation needed to be made to a normally automated process due to an illness at the executive level during time study updates. As a result of a clerical error, the allocations between the contracts were accidentally switched and the misallocation was not caught during review. In the remaining two instances, a formula error resulted in a misallocation of wages between funding sources. Effect: The misallocation of expenses could impact on the accuracy of financial reporting for the major program and could result in noncompliance with federal regulations. Repeat Finding: No. Recommendation: CLA recommends that Sound Generations emphasize the importance of its procedures for monitoring and reviewing the allocation of wages between contracts and provide training to the individuals responsible for the allocation of expenses. Views of responsible officials and planned corrective actions: Sound Generations Agrees with the finding. Sound Generations has reviewed and revised its procedures to include reviews at intermediary steps as well as streamlined its automation to allow for less opportunity for manual inputs and clerical errors. Responsible Official: Carlos Rojas, Chief Financial Officer; Christina Hannan, Controller Anticipated Completion Date: June 30, 2024

View Audit 321877

Finding 499086 (2023-002)

Significant Deficiency 2023

Sound Generations

WA

Cash Management Reporting Significant Deficiency § 200.303

Type of Finding: Significant Deficiency in Internal Control over Compliance - Reporting Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Aging Cluster Assistance Listing Number; 93.044 / 93.045 / 93.053 Federal Award Identification Number and Year: DA23-1109-2023 P...

Type of Finding: Significant Deficiency in Internal Control over Compliance - Reporting Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Aging Cluster Assistance Listing Number; 93.044 / 93.045 / 93.053 Federal Award Identification Number and Year: DA23-1109-2023 Pass-Through Agency: City of Seattle Pass-Through Number(s): DA23-1109 Award Period: January 1, 2023 through December 31, 2023 Criteria or specific requirement: 2 CFR 200.303(a) states that 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 be in compliance 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 the Organization of the Treadway Commission (COSO).” Condition: During testing of reporting, it was noted that, for one sample, documentation was not retained of approval of financial reporting. Questioned Costs: None Context: A sample of 9 financial reports was made from a population of 54 total reports. Of the 9 sampled, 1 was missing evidence of authorized personnel review and approval. Cause: In this one instance, verbal approval was given rather than emailed approval. Effect: Without adequate documentation and controls in place to ensure costs are reasonable and intended for the program charged, Sound Generations could incorrectly charge expenditures to the federal program, report fraudulent expenditures, or not request appropriate reimbursement that Sound Generations is entitled to under the terms of the grant. Repeat Finding: No. Recommendation: CLA recommends that documentation is retained as proof of authorized personnel review. Views of responsible officials and planned corrective actions: Sound Generations agrees with the finding. Sound Generations has revised its approval process to include digital signatures with time stamps by authorized personnel on all documentation rather than emailed approvals. Responsible Official: Carlos Rojas, Chief Financial Officer; Christina Hannan, Controller Anticipated Completion Date: March 31, 2024

View Audit 321877

Finding 499076 (2023-001)

Material Weakness 2023

Gary Public Transportation Corporation

IN

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303 § 200.403

CORRECTIVE ACTION PLAN Finding 2023-001 - Controls Over Payroll Expenditures (Material Weakness) Criteria: 2 CFR 200.403 establishes principles and standards for determining costs for federal awards carried out through grants, cost reimbursement contracts, and other agreements with state and loca...

CORRECTIVE ACTION PLAN Finding 2023-001 - Controls Over Payroll Expenditures (Material Weakness) Criteria: 2 CFR 200.403 establishes principles and standards for determining costs for federal awards carried out through grants, cost reimbursement contracts, and other agreements with state and local governments. To be allowable, under federal awards, cost must meet certain criteria: a) Be necessary and reasonable for the performance of the Federal award and be allocable thereto under these principles. b) Conform to any limitations or exclusions set forth in these principles or in the Federal award as to types or amount of cost items. c) Be consistent with policies and procedures that apply uniformly to both federally-financed and other activities of the non-Federal entity. d) Be accorded consistent treatment. A cost may not be assigned to a Federal award as a direct cost if any other cost incurred for the same purpose in like circumstances has been allocated to the Federal award as an indirect cost. e) Be determined in accordance with generally accepted accounting principles (GAAP), except, for state and local governments and Indian tribes only, as otherwise provided for in this part. f) Not be included as a cost or used to meet cost sharing or matching requirements of any other federally financed program in either the current or a prior period. g) Be adequately documented. h) Cost must be incurred during the approved budget period. Additionally, 2 CFR 200.303 indicates that non-Federal Entities receiving Federal awards 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 terms and conditions of the Federal award. The Corporation should have controls in place to document that salaries and overtime paid with federal funds were allowable. Timecards supporting hours worked should be approved and pay rates reviewed. Context: A summary of allowable charges for the grant was prepared for submission. Within a sample of 45, we noted that 25 timecards did not have a documented review. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. The Transportation Department provides a spreadsheet that details time operators work by route. This process is used to align FTA funding streams with routes driven. The spreadsheet is kept by the Transportation Manager and reviewed by the Director of Transportation. These two positions approve time prior to submitting it for processing. The Gary Public Transportation Corporation management had hoped to get its payroll provider to provide a solution to this particular timesheet approval matter. However, the complexity of these timesheets made a resolve too complicated for reasonable implementation. So, a simple solution has been devised. The Transportation Manager and Director shall sign off on a document to stating their review and approval of those timesheets.

View Audit 321864

Finding 499074 (2023-002)

Material Weakness 2023

City of West Lafayette

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Finding 2023-002 Finding Subject: • Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment. Summary of Finding: • Documentation was not created when vendor was verified that it was not suspended nor debarred. Contact Person: Peter Gray Contact Phone: 765-775-5150 Views of Respo...

Finding 2023-002 Finding Subject: • Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment. Summary of Finding: • Documentation was not created when vendor was verified that it was not suspended nor debarred. Contact Person: Peter Gray Contact Phone: 765-775-5150 Views of Responsible Official: • We concur with the finding. Explanation and Reasons for Disagreement: • N/A Description of Corrective Action: • The City did perform procedures to verify that the vendor was not suspended nor debarred. However, no documentation was created. The vendors in question were not, and are not currently, suspended nor debarred. • We will create an affidavit for vendors that receive Federal funds to sign that they are not suspended nor debarred from receiving Federal Funds. Any change in that status is to be reported to us. Anticipated Completion Date: 31 October 2024

View Audit 321859

Finding 499066 (2023-002)

Significant Deficiency 2023

Douglas County

MN

Eligibility Reporting Significant Deficiency § 200.303

Recommendation: It is recommended County management add an additional control review over the eligibility of casefile reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to designate a...

Recommendation: It is recommended County management add an additional control review over the eligibility of casefile reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to designate an internal reviewer to continually review the casefile eligibility determinations throughout the year. Name of the contact person responsible for corrective action plan: Jill Frisell, Finance Director Planned completion date for corrective action plan: December 31, 2024

View Audit 321840

Finding 499061 (2023-003)

Material Weakness 2023

Metropolitan School District of Lawrence Township

IN

Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

FINDING 2023-003 Finding Subject: COVID- 19 – Education Stabilization Fund – Wage Rate Requirements Summary of Finding: Three construction contracts were paid from the COVID-19 – Education Stabilization Fund grant funds, totaling $5,442,378, during the audit period. The provision that addresses the ...

FINDING 2023-003 Finding Subject: COVID- 19 – Education Stabilization Fund – Wage Rate Requirements Summary of Finding: Three construction contracts were paid from the COVID-19 – Education Stabilization Fund grant funds, totaling $5,442,378, during the audit period. The provision that addresses the Wage Rate requirements was included in all contracts; however, not all applicable contractors complied with the requirement to submit a copy of the payroll and statement of compliance to the entity for each week in which contract work was performed. Certified payrolls were not provided to the School Corporation throughout the course of the project for one of three applicable contractors. The school corporation did not have a control in place and operating effectively over the Wage Rate Requirements compliance requirement during the audit period. Contact Person Responsible for Corrective Action: Matt Miles Contact Phone Number and Email Address: 317-423-8380 mattmiles@msdlt.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The School District will obtain regular contractor certified payrolls for all renovation projects paid for by ESSER to ensure wage requirements are in place. Anticipated Completion Date: Corrective action steps have been implemented and will be refreshed.

View Audit 321827

Finding 499060 (2023-002)

Material Weakness 2023

Metropolitan School District of Lawrence Township

IN

Subrecipient Monitoring Material Weakness Reporting § 200.302 § 200.303 § 200.328 § 200.329

FINDING 2023-002 Finding Subject: COVID- 19 – Education Stabilization Fund - Reporting Summary of Finding: The School Corporation completed and submitted three annual Data Collection reports (Reports) for the ESSER grants. For one of the three reports tested, the report was not supported by the unit...

FINDING 2023-002 Finding Subject: COVID- 19 – Education Stabilization Fund - Reporting Summary of Finding: The School Corporation completed and submitted three annual Data Collection reports (Reports) for the ESSER grants. For one of the three reports tested, the report was not supported by the unit’s records. The financial information provided did not agree with the data submitted in the Reports, therefore we could not determine their accuracy. Contact Person Responsible for Corrective Action: Matt Miles Contact Phone Number and Email Address: 317-423-8380 mattmiles@msdlt.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The School District will work to ensure the ESSER report amounts tie to the accounting records and will improve record keeping of supporting documentation. If the amounts do not match, District will document support for all claims. Anticipated Completion Date: Corrective action steps have been implemented and will be refreshed.

View Audit 321827

Finding 499056 (2023-001)

Material Weakness 2023

Metropolitan School District of Lawrence Township

IN

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

FINDING 2023-001 Finding Subject: Special Education Cluster – Procurement, Suspension, and Debarment Summary of Finding: The School Corporation did not obtain price or rate quotes for the four vendors tested that was less than the simplified acquisition threshold of $150,000 but exceeded the $10,000...

FINDING 2023-001 Finding Subject: Special Education Cluster – Procurement, Suspension, and Debarment Summary of Finding: The School Corporation did not obtain price or rate quotes for the four vendors tested that was less than the simplified acquisition threshold of $150,000 but exceeded the $10,000 micro-purchase threshold. Documentation detailing the history of procurement, which must include the reason for the procurement method used, was not available for audit. There was no evidence of the School Corporation verifying two vendors tested for Suspension and Debarment that these vendors were not excluded or disqualified from participation in federal assistance programs or activities. Contact Person Responsible for Corrective Action: Matt Miles Contact Phone Number and Email Address: 317-423-8380 mattmiles@msdlt.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: This is a repeat finding due to the immediate timing of the prior audit and a lag for new controls to take effect. The School District will obtain 3 quotes or do a bid process in the future. If there is limited availability, we will document the reason 3 quotes are not possible. Additionally, the District will check for suspension and debarment, create a write-up of our findings, and obtain Board approval for the contract. Anticipated Completion Date: Corrective action steps have been implemented and will be refreshed.

View Audit 321827

Finding 499027 (2023-002)

Significant Deficiency 2023

Watonwan County

MN

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.303

Finding Number: 2023-002 Finding Title: Local Collaborative Time Study (LCTS) Annual Spending Report Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Erin Marks Corrective Action Planned: The 2023 report was revised and completed by the Fiscal Offi...

Finding Number: 2023-002 Finding Title: Local Collaborative Time Study (LCTS) Annual Spending Report Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Erin Marks Corrective Action Planned: The 2023 report was revised and completed by the Fiscal Officer. Effective immediately and on going, the spending report will be completed by the Fiscal Officer and reviewed by the Supervisor. Narrative detail and programmatic reporting will be completed by the Collaborative Coordinator and reviewed by the Director. Anticipated Completion Date: 12/31/2024

View Audit 321815

Finding 498968 (2023-003)

Material Weakness 2023

Southern Research Institute

AL

Procurement, Suspension & Debarment § 200.303 § 200.319 § 200.320 § 200.326

Finding 2023-003 – Procurement Non-Compliance (Material Weakness) Federal Program Title: U.S. Department of Treasury – ALN 21.027, Covid-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF), and Research and Development Cluster Assistance Listing Number: Various Action taken in response t...

Finding 2023-003 – Procurement Non-Compliance (Material Weakness) Federal Program Title: U.S. Department of Treasury – ALN 21.027, Covid-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF), and Research and Development Cluster Assistance Listing Number: Various Action taken in response to finding: We have taken steps to identify all active federal awards that are subject to Federal procurement requirements under 2 CFR Part 200; these actions will ensure that all purchase orders and other subcontract arrangements under existing federal awards are subject to our purchasing system policies and procedures for Federal awards. Southern Research’s existing purchasing policies and procedures for Federal awards were reviewed and deemed acceptable in 2017 by the Defense Contract Management Agency (DCMA) Huntsville, AL. Contracts appropriately classified as Federal awards will be subject to purchasing policies and procedures that are compliant with Federal regulations. As part of the business process review, we will implement processes to ensure that all new Federal awards are classified correctly, and that Southern Research’s Federal purchasing system policies and procedures are applied to all Federal awards. Name of Person Responsible for the Corrective Action Plan: David A. Rutledge, Sr. Advisor - Finance Planned Completion Date for Corrective Action Plan: We anticipate that new process recommendations from the business process review related to purchasing will be implemented no later than December 31, 2024.

View Audit 321789

Finding 498957 (2023-006)

Material Weakness 2023

City of Bluffton

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.303

FINDING 2023-006 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: Material Weakness Contact Person Responsible for Corrective Action: Bri Lautzenheiser Contact Phone Number and Email Address: bri@blufftonindiana.gov Views of Responsible Of...

FINDING 2023-006 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: Material Weakness Contact Person Responsible for Corrective Action: Bri Lautzenheiser Contact Phone Number and Email Address: bri@blufftonindiana.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: All persons involved in the internal control; preparer, reviewer, etc. will be documented on the P&E Report document or with a checklist to show that we actually completed the internal controls we have in our policy. Anticipated Completion Date: immediately

View Audit 321762

Finding 498956 (2023-005)

Material Weakness 2023

City of Bluffton

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2023-005 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Summary of Finding: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Bri Lautzenheiser Contact Phone Number and Email Address: bri@blufftonindia...

FINDING 2023-005 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Summary of Finding: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Bri Lautzenheiser Contact Phone Number and Email Address: bri@blufftonindiana.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: All bids going out will include a Suspension and Debarment declaration that all bidders will need to fill out and sign, and the bid packets, including completed declaration, will be reviewed and approved by governance and management. Anticipated Completion Date: immediately

View Audit 321762

Finding 498955 (2023-004)

Material Weakness 2023

City of Bluffton

IN

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

FINDING 2023-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Summary of Finding: Material Weakness, Other Matters. Contact Person Responsible for Corrective Action: Bri Lautzenheiser Contact Phone Number and Email Address: bri@blufftonindi...

FINDING 2023-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Summary of Finding: Material Weakness, Other Matters. Contact Person Responsible for Corrective Action: Bri Lautzenheiser Contact Phone Number and Email Address: bri@blufftonindiana.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: All bids going out will include a Suspension and Debarment declaration that all bidders will need to fill out and sign, and the bid packets, including completed declaration, will be reviewed and approved by governance and management. Anticipated Completion Date: immediately

View Audit 321762

Finding 498954 (2023-003)

Material Weakness 2023

City of Bluffton

IN

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.300 § 200.302 § 200.303 § 200.328 § 200.329

FINDING 2023-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs / Cost Principles, Period of Performance Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Bri Lau...

FINDING 2023-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs / Cost Principles, Period of Performance Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Bri Lautzenheiser Contact Phone Number and Email Address: bri@blufftonindiana.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Any transfers that happen, will be reviewed, and will have better documentation of what claims made the transfer happen and make sure supporting documentation is attached to the claim to prove the use of the transferred funds. Anticipated Completion Date: Immediately

View Audit 321762 Questioned Costs: $1

Finding 498921 (2023-001)

Significant Deficiency 2023

Adventist Health System Sunbelt Healthcare Corporation

FL

Procurement, Suspension & Debarment Subrecipient Monitoring Period of Performance § 200.303

Corrective Action Plan December 31, 2023 Federal Award Findings and Questioned Costs – For the Year Ended December 31, 2023 Finding 2023-001 Information on the federal program: Federal Grantor: United States Department of Health and Human Services and Department of Defense Assistance Listing No...

Corrective Action Plan December 31, 2023 Federal Award Findings and Questioned Costs – For the Year Ended December 31, 2023 Finding 2023-001 Information on the federal program: Federal Grantor: United States Department of Health and Human Services and Department of Defense Assistance Listing No.: Various; Research and Development Cluster Period of Performance: January 1, 2023 – December 31, 2023 Views of responsible officials and planned corrective actions: Management agrees with the finding. Management plans to add controls to validate the accuracy of the suspension and debarment search results performed by the third-party service provider when the search results in no match. In addition, management plans to implement a process over the reconciliation of the vendor and supplier list to the third-party service provider list to ensure completeness of the suspension and debarment checks performed. Responsible official: Stacey Wilson, Director Grants Management Anticipated completion date: December 31, 2024

View Audit 321761

Finding 498918 (2023-004)

Material Weakness 2023

Forth

OR

Allowable Costs / Cost Principles Material Weakness Matching / Level of Effort / Earmarking § 200.303

Conservation Research and Development Program – Assistance Listing #81.086 Recommendation: The Organization should establish written policies and procedures regarding allocation processes, including ensuring internal controls are in place. It would also be beneficial to eliminate or reduce the amoun...

Conservation Research and Development Program – Assistance Listing #81.086 Recommendation: The Organization should establish written policies and procedures regarding allocation processes, including ensuring internal controls are in place. It would also be beneficial to eliminate or reduce the amount of manual inputs into the allocation process. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action Plan: We agree with the auditor’s comments, and the following action will be taken to improve the situation. We will establish written policies and procedures regarding allocation processes, including ensuring internal controls are in place by November 30, 2024. Simultaneously, we will also consider options to eliminate or reduce the amount of manual inputs into the allocation process. Name(s) of the contact people responsible for correction action: Gina Avalos-Limardo, Director of Finance & Operations and Ronald Tran, Senior Finance Manager Plan completion date for corrective action plan: November 30, 2024

View Audit 321749

Finding 498917 (2023-003)

Material Weakness 2023

Forth

OR

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness § 200.303

Conservation Research and Development Program – Assistance Listing #81.086 Recommendation: The Organization should establish written policies and procedures regarding firsttier subawards including tracking and proper internal control procedures. Explanation of disagreement with audit findings: there...

Conservation Research and Development Program – Assistance Listing #81.086 Recommendation: The Organization should establish written policies and procedures regarding firsttier subawards including tracking and proper internal control procedures. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action Plan: We agree with the auditor’s comments and the following actions have been taken to improve the situation. We hired a Contracts & Compliance Manager in 2024 who is now responsible for reporting first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) by the reporting due date. Additionally, we established written policies and procedures regarding first-tier subawards including tracking and proper internal control procedures. Name(s) of the contact people responsible for correction action: Gina Avalos-Limardo, Director of Finance & Operations and Cho Heide, Contracts & Compliance Manager Plan completion date for corrective action plan: September 30, 2024

View Audit 321749

Finding 498916 (2023-002)

Material Weakness 2023

Forth

OR

Cash Management Internal Control / Segregation of Duties Material Weakness § 200.303

Conservation Research and Development Program – Assistance Listing #81.086 Plan completion date for corrective action plan: October 31, 2024 Recommendation: The Organization should establish written policies and procedures regarding invoicing for cost- reimbursement related to federal grants which i...

Conservation Research and Development Program – Assistance Listing #81.086 Plan completion date for corrective action plan: October 31, 2024 Recommendation: The Organization should establish written policies and procedures regarding invoicing for cost- reimbursement related to federal grants which include proper segregation of duties. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action Plan: We agree with the auditor’s comments, and the following actions have been or will be taken to improve the situation. We hired a Grants Accountant in 2024 to take over the responsibility of preparing invoices for cost-reimbursement. This allows for the additional control of the Senior Finance Manager reviewing the invoices. This review is now being documented in writing. Additionally, there are procedures in place to ensure if the Senior Finance Manager prepares the invoice, the Director of Finance & Operations reviews and documents approval of the invoice. We will establish written policies and procedures to document this process by October 31, 2024. Name(s) of the contact people responsible for correction action: Gina Avalos-Limardo, Director of Finance & Operations and Ronald Tran, Senior Finance Manager

View Audit 321749

Finding 498915 (2023-001)

Significant Deficiency 2023

Forth

OR

Subrecipient Monitoring § 200.303 § 200.332

2023-001 Conservation Research and Development Program – Assistance Listing #81.086 Recommendation: The Organization should establish written policies and procedures regarding the contracting and monitoring of subrecipients that are in line with Uniform Guidance requirements, as well as establish or...

2023-001 Conservation Research and Development Program – Assistance Listing #81.086 Recommendation: The Organization should establish written policies and procedures regarding the contracting and monitoring of subrecipients that are in line with Uniform Guidance requirements, as well as establish organizational controls to ensure that such policies and procedures are being followed. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action Plan: We agree with the auditor’s comments and will implement the following action steps to improve the situation. We will create and document a procedure which ensures we obtain audits on an annual basis from our subrecipients. This procedure will be implemented by October 31, 2024. Name(s) of the contact people responsible for correction action: Gina Avalos-Limardo, Director of Finance & Operations and Cho Heide, Contracts & Compliance Manager Plan completion date for corrective action plan: October 31, 2024

View Audit 321749

Finding 498902 (2023-001)

Significant Deficiency 2023

The Rogosin Institute, Inc.

NY

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Information on the federal program: Grantor: U.S Department of Defense, U.S. Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing No. / FAIN / Pass-Through Entity (if applicable) / Pass-Through Entity Identifying Number (if applicable): 12.420 ...

Information on the federal program: Grantor: U.S Department of Defense, U.S. Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing No. / FAIN / Pass-Through Entity (if applicable) / Pass-Through Entity Identifying Number (if applicable): 12.420 / W81XWH2110945 / Royal Institution for the Advancement of Learning / McGill University / PT89891 93.847 / RC2DK125960 93.847 / UC2DK126021 / MDI Biological Laboratory / UC2DK126021-04/ROGOSIN 93.847 / U01DK123786 / University of Washington / UWSC11731 Views of responsible officials and planned corrective actions: Management concurs with this audit finding and will further enhance the suspension and debarment process and controls to meet the requirements of 2 CFR part 200. Name of responsible official: Name – Lauren Everson Title – Director of Finance, NYP Phone: (212-297-3325) Email: jrh9009@nyp.org Projected completion date: December 31, 2024

View Audit 321719

Finding 498887 (2023-002)

Material Weakness 2023

Wayne County

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.303

FINDING 2023-002 Finding Subject: COVID 19 - Coronavirus State and Local Fiscal Recovery Funds Summary of Finding: The US Treasury Quarterly Project and Expenditure Reports did not have documentation of internal review and approval prior to submittal to the US Treasury. Corrective action will includ...

FINDING 2023-002 Finding Subject: COVID 19 - Coronavirus State and Local Fiscal Recovery Funds Summary of Finding: The US Treasury Quarterly Project and Expenditure Reports did not have documentation of internal review and approval prior to submittal to the US Treasury. Corrective action will include internal review and approval of the report, documented in writing, prior to submittal. Contact Person Responsible for Corrective Action: Jeff Plasterer, County Commissioner Contact Phone Number and Email Address: 765.973.9237 jeff.plasterer@co.wayne.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: A form has been created for the specific purpose to document the internal review procedure for the US Treasury Quarterly Project and Expenditure Report. The Commissioners' staff who is responsible for the accurate and timely completion of the US Quarterly Project and Expenditure Report will make the completed report available to the President of the Board of Commissioners (or their designee), who will review the report prior to submittal, thus providing the proper segregation of duties, as well as avoid potential misstatements to go undetected. Anticipated Completion Date: The form has been created and will become effective immediately, and will be utilized for all future Quarterly Project and Expenditure Reports of the Coronavirus State and Local Fiscal Recovery Funds.

View Audit 321681

Finding 498883 (2023-001)

Significant Deficiency 2023

Putting All Communities Together for Families Collaborative

MN

Procurement, Suspension & Debarment § 200.303 § 200.318

Finding Number: 2023-001 Finding Title: Procurement, Suspension and Debarment Program: 93.104 Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (SED) (Journey to Independence) Name of Contact Person Responsible for Corrective Action: Jolene Lambert, Fina...

Finding Number: 2023-001 Finding Title: Procurement, Suspension and Debarment Program: 93.104 Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (SED) (Journey to Independence) Name of Contact Person Responsible for Corrective Action: Jolene Lambert, Finance and Benefits Coordinator Corrective Action Planned: To ensure consistency in managing sponsored projects, PACT for Families Collaborative implemented a procurement policy effective June 25, 2024, per Uniform Guidance Procurement Standards. In October 2023, we transitioned to an updated expenditure authorization process that includes a revised Expenditure Authorization Form (EAF) that requires pricing from multiple suppliers to document and secure the most reasonable purchase. While suspensions and debarments have been checked through SAM.gov for several years, printouts of the verification process were not retained. As of August 29, 2023, printouts are now kept as official documentation. The one micro-purchase identified during the audit occurred before this date. Anticipated Completion Date: August 29, 2023

View Audit 321676

Finding 498881 (2023-001)

Significant Deficiency 2023

United Voices for Newcomer Rights

NM

Subrecipient Monitoring Cash Management Allowable Costs / Cost Principles § 200.1 § 200.303

Recommendation UVNR should implement procedures to ensure thorough monitoring and accurate accounting of all subrecipient expenditures. Subrecipients should be required to submit properly supported invoices with their reimbursement requests. It is also recommended that authorized gra...

Recommendation UVNR should implement procedures to ensure thorough monitoring and accurate accounting of all subrecipient expenditures. Subrecipients should be required to submit properly supported invoices with their reimbursement requests. It is also recommended that authorized grant personnel diligently review and approve these invoices to ensure that reimbursements are made only for actual expenditures. Management Response Corrective Action: 1. Meet with subrecipient to clarify compliance issues with 2023 disbursements and to discuss plans of action for 2024 through grant period end (occurred on 9/10/24). 2. Subrecipient will invoice monthly providing grant personnel with an invoice and general ledger of expenses. 3. Grant personnel will adopt a policy of reviewing subrecipient’s monthly invoices and supporting documents, including adding a requirement for grant personnel to approve and sign subrecipient invoices before drawing down from the federal award’s payment management system. 4. Signed and approved grant invoices and supporting documentation will also be shared with accounts for approval before drawing down from the federal award’s payment management system. 5. Grant personnel will meet regularly with accountants for thorough and continuous monitoring of the award, including accurate accounting of subrecipient funds Due Date of Completion: September 30, 2024 - ongoing Responsible Party(ies): Co-Executive Directors

View Audit 321664

Finding 498873 (2023-002)

Material Weakness 2023

Clay County

MN

Eligibility Material Weakness Internal Control / Segregation of Duties § 200.303

Finding Number: 2023-002 Finding Title: Eligibility Program: Medical Assistance Program (AL No. 93.778) Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Director and Karen Syverson, Supervisor Corrective Action Planned: To address the findings from the recent audit, Clay Count...

Finding Number: 2023-002 Finding Title: Eligibility Program: Medical Assistance Program (AL No. 93.778) Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Director and Karen Syverson, Supervisor Corrective Action Planned: To address the findings from the recent audit, Clay County Social Services will take both immediate and long-term corrective actions. First, the case files identified with discrepancies will be revie.wed in detail, and necessary corrections will be made to ensure that the documentation in both the case files and the MAXIS system aligns with program requirements. Requests for case file numbers have already been submitted to the MA team lead to identify the cases needing correction. This will include reverification of asset amounts, we will match MAXIS's citizenship status with the appropriate documentation within the case file. In addition, one-on-one reviews will be conducted with the staff responsible for administering the affected cases. During these reviews, case-specific feedback will be provided, detailing the nature of the errors and explaining corrective actions to prevent recurrence. For long-term preventative measures, Clay County will implement a more comprehensive and mandatory training program for all staff involved in eligibility determination. This training will focus on key areas such as proper documentation for citizenship, asset verification, and data entry protocols to reduce human errors in MAXIS. We will continue conducting periodic case file audits with increased frequency to detect errors early and provide timely feedback to staff. Audit results will be shared with the entire team to promote learning from errors and reinforce best practices in documentation and data entry. Anticipated Completion Date: The cases found in error will be corrected by November 15, 2024. Case file reviews will continue monthly.

View Audit 321655

Corrective Action Plans

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