Corrective Action Plans

Finding 504292 (2024-004)

Significant Deficiency 2024

ID

Questioned Costs Student Financial Aid Eligibility § 200.303

Student Financial Assistance Cluster – Assistance Listing No. 84.007. Recommendation: We recommend the University review their FSEOG awarding policy and procedures to ensure FSEOG is awarded to students with the lowest expected family contributions. Explanation of disagreement with audit finding: T...

Student Financial Assistance Cluster – Assistance Listing No. 84.007. Recommendation: We recommend the University review their FSEOG awarding policy and procedures to ensure FSEOG is awarded to students with the lowest expected family contributions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Student Financial Aid updated our auto packaging policy. Name(s) of the contact person(s) responsible for corrective action: This was a part of our aid year rollover process and planning. Planned completion date for corrective action plan: April 2024

View Audit 326827 Questioned Costs: $1

Finding 504291 (2024-002)

Significant Deficiency 2024

University of Idaho

ID

Student Financial Aid Matching / Level of Effort / Earmarking Reporting § 200.303

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007,84.033. Recommendation: We recommend that the University work with their third-party servicer and implement procedures to ensure that enrollment data, changes in status and effective dates within NSLDS are reported...

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007,84.033. Recommendation: We recommend that the University work with their third-party servicer and implement procedures to ensure that enrollment data, changes in status and effective dates within NSLDS are reported timely and accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We are adjusting our corrective action. Last year we tested several out of cycle enrollment adjustments each term to ensure our processes were working. We didn’t find any issues. This year we will be comparing all the students were not reported to the Clearinghouse with the list reported to the Clearinghouse to ensure all students who need to be reported are properly reported. Name(s) of the contact person(s) responsible for corrective action: Randi Croyle, Director of Financial Aid. Planned completion date for corrective action plan: We ran our first comparison on 9/19/2024 and we will be running every month we do the Clearinghouse reporting.

View Audit 326827

Finding 504290 (2024-001)

Significant Deficiency 2024

University of Idaho

ID

Student Financial Aid Matching / Level of Effort / Earmarking Significant Deficiency § 200.303

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007. Recommendation: CLA recommends the University review the requirement and implement an internal process and control to specifically monitor the outstanding Title IV funded checks throughout the year. Explanation ...

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007. Recommendation: CLA recommends the University review the requirement and implement an internal process and control to specifically monitor the outstanding Title IV funded checks throughout the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University agrees with the auditors’ recommendations of corrective action needed to ensure unclaimed Title IV federal funds are resolved within 240 days of disbursement date. The University has reviewed existing processes and identified improvements that will be made to internal procedures to ensure proper compliance is met. Name(s) of the contact person(s) responsible for corrective action: Delora Shoop & Amanda Bauer. Planned completion date for corrective action plan: December 2024

View Audit 326827

Finding 504266 (2024-002)

Significant Deficiency 2024

Lewis-Clark State College

ID

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

Student Financial Aid Cluster: Federal Pell Grant Program – Assistance Listing 84.038 Recommendation: We recommend the College review its current procedures for awarding Title IV funds and implement any changes necessary to ensure federal funds are awarded and disbursed in accordance with federal re...

Student Financial Aid Cluster: Federal Pell Grant Program – Assistance Listing 84.038 Recommendation: We recommend the College review its current procedures for awarding Title IV funds and implement any changes necessary to ensure federal funds are awarded and disbursed 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 finding was isolated to less-than-half-time Pell recipients. These recipients will be processed through the auto-packing process and then will undergo a secondary manual review prior to disbursement. Name(s) of the contact person(s) responsible for corrective action: Laura Hughes and John Bender Planned completion date for corrective action plan: Immediate Implementation

View Audit 326792

Finding 503947 (2024-002)

Significant Deficiency 2024

Clemson University

SC

Subrecipient Monitoring § 200.303 § 200.332

Action taken in response to finding: We have 26 active awards that would be non-R&D. Grants and Contracts Accounting (GCA) is currently reviewing each to verify if all had check boxes checked as R&D on Attachment 2 of the Federal Awards Terms and Conditions template of the FDP Cost Reimbursement Sub...

Action taken in response to finding: We have 26 active awards that would be non-R&D. Grants and Contracts Accounting (GCA) is currently reviewing each to verify if all had check boxes checked as R&D on Attachment 2 of the Federal Awards Terms and Conditions template of the FDP Cost Reimbursement Subaward. Once we have the impacted population, GCA will issue a modification for those to draw attention to the error. In addition, GCA will ensure internal procedures are updated to review this field and verify proper identification prior to subaward execution. Anticipated Completion Date: September 30, 2024 Person Responsible: Tracy Walters, Director of Grants and Contracts Contact/Responsible Party: Tracy Walters, Director of Grants and Contracts Contact Information: trwalte@clemson.edu

View Audit 326225

Finding 503946 (2024-001)

Significant Deficiency 2024

Clemson University

SC

Questioned Costs Matching / Level of Effort / Earmarking § 200.303 § 200.403

The Payroll Department has taken immediate action to develop additional safeguards to avoid duplicate pay. When Central Payroll adds to a payline, we will notify the requestor to inform them of this action and ask that they review their payline for accuracy. This should trigger a response from the r...

The Payroll Department has taken immediate action to develop additional safeguards to avoid duplicate pay. When Central Payroll adds to a payline, we will notify the requestor to inform them of this action and ask that they review their payline for accuracy. This should trigger a response from the requestor if they had also added the missing hours via a CU Special Pay. Additionally, as of 06/21/2024, the Late Timesheet option was turned off on CU Special Pay to strengthen controls. Individuals now contact payroll@clemson.edu for assistance. Once contacted the payroll/timekeeping team will update the timecard and ensure the missed pay is added to the next payroll cycle, assuming an emergency/off-cycle check is not needed. The College of Engineering and Applied Sciences (CECAS) will take action to strengthen internal controls to ensure accuracy and compliance. We will establish clear procedures to verify employee payroll data via paylines, as well as cross checking with CU Payroll to ensure changes are properly documented and authorized. We will provide ongoing training for departmental payroll staff on best practices and compliance requirements. Anticipated Completion Date: September 17, 2024 Person Responsible: Central Payroll – Ami Hood, Payroll Director; CECAS – Keri Cortese, Director of Procurement and Payroll Operations Contact/Responsible Party: Ami Hood, Payroll Director Contact Information: hooda@clemson.edu

View Audit 326225 Questioned Costs: $1

Finding 503764 (2024-002)

Significant Deficiency 2024

Southwest Montana Community Health Center

MT

Procurement, Suspension & Debarment § 200.303

Finding 2024 -002 Federal Agency Name: U.S. Department of Health and Human Services Assistance Listing Number: 93.526 Program Name: Grants for Capital Development in Health Centers Finding Summary: There was no evidence retained that the Community Health Center reviewed vendors to determine their st...

Finding 2024 -002 Federal Agency Name: U.S. Department of Health and Human Services Assistance Listing Number: 93.526 Program Name: Grants for Capital Development in Health Centers Finding Summary: There was no evidence retained that the Community Health Center reviewed vendors to determine their status in regards to the suspension and debarment requirement. Furthermore, the Community Health Center did not have written suspension and debarment policies. Responsible Individuals: Shelly Davis, CFO Corrective Action Plan: Management has reviewed and updated their procurement, suspension and debarment policy to include specific documentation regarding the documentation of suspension and debarment practices. Anticipated Completion Date: Procurement Policy 432 was updated and approved by the Board of Directors on June 27, 2024. Additionally, a procurement procedure was developed and implemented at the same time. This corrective action will be ongoing.

View Audit 326032

Finding 503610 (2024-001)

None 2024

Hubbs-Seaworld Research Institute

CA

Procurement, Suspension & Debarment § 200.303 § 200.319 § 200.320

Management Response: The management staff of Hubbs-SeaWorld Research Institute take very seriously the federal compliance related to the procurement of goods and services. Hubbs-SeaWorld Research Institute acknowledges the finding and has subsequently updated their procurement policy and procedures...

Management Response: The management staff of Hubbs-SeaWorld Research Institute take very seriously the federal compliance related to the procurement of goods and services. Hubbs-SeaWorld Research Institute acknowledges the finding and has subsequently updated their procurement policy and procedures to be in compliance with 2 CFR 200.303. Management has adopted a plan of action to prevent future instances of non-compliance. Action Taken: Hubbs-SeaWorld Research Institute plans to modify its procurement procedures for federal grants to comply with 2CFR section 200.319 by continuing to require at least three bids (or a sole source statement, if applicable) for any purchases over the micro-purchase threshold, currently $10,000. In addition, we will monitor cumulative vendor purchases on a monthly basis to ensure that price or rate quotations are obtained from an adequate number of qualified sources, that is, at least three bids (or a sole source statement, if applicable.)

View Audit 325801

Finding 503360 (2024-002)

Significant Deficiency 2024

Dawson County

NE

Procurement, Suspension & Debarment § 200.214 § 200.303

Program: AL 21.027 - COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Corrective Action Planned: The County has procedures in place; when a contractor is hired, sam.gov will be utilized to verify the entity has not been suspended or debarred. Anticipated Compl...

Program: AL 21.027 - COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Corrective Action Planned: The County has procedures in place; when a contractor is hired, sam.gov will be utilized to verify the entity has not been suspended or debarred. Anticipated Completion Date: September 30, 2024 Responsible Party: Michaela Arndt, County Clerk

View Audit 325523

Finding 503152 (2024-003)

Significant Deficiency 2024

Hill Top Home of Comfort, Inc.

ND

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

Finding 2024-003 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans andGrants CFDA #10.766 Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the USDA program reserve fund. Responsible Individuals: Gerry Le...

Finding 2024-003 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans andGrants CFDA #10.766 Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the USDA program reserve fund. Responsible Individuals: Gerry Leadbetter, Administrator Corrective Action Plan: Management will ensure a review separate from the preparer of the reconciliation for the program's reserve fund is completed with formal documentation noting the review. The Business Office Manager will reconcile the bank statement and will sign off on the bank statement, along with the Administrator for the USDA Loan Reserve Bank Account. Anticipated Completion Date: Ongoing

View Audit 325174

Finding 503146 (2024-001)

Material Weakness 2024

Amridge University, Inc.

AL

Student Financial Aid Reporting Matching / Level of Effort / Earmarking § 200.303

Correction action University personnel corrected the records in NSLDS and Clearinghouse on July 26, 2024 that were identified in Finding 2024-001. Additionally, university personnel conducted a thorough review of all students to ensure the records in NSLDS properly reflected an accurate enrollment s...

Correction action University personnel corrected the records in NSLDS and Clearinghouse on July 26, 2024 that were identified in Finding 2024-001. Additionally, university personnel conducted a thorough review of all students to ensure the records in NSLDS properly reflected an accurate enrollment status. The university immediately (August 2024) implemented training for the newly appointed Interim Registrar on the importance of timely and accurate reporting of enrollment status changes and graduation status. This training was conducted in coordination with the Vice President of Student Services, the Director of Financial Aid, the Controller, and the Director of Information Technology. In addition to hands-on training provided by university personnel, online resources were utilized from NSLDS, Clearinghouse, and the United States Department of Education. The policies and procedures for enrollment reporting has been strengthened, and includes the following reporting schedule: a student roster schedule will be submitted every 30 days. The exceptions report will be reviewed immediately and will be corrected within 10 days. Within 15 days of the end of each semester, a list of graduated students will be submitted to NSLDS. Exceptions will be corrected immediately to ensure all records in NSLDS match the student’s record. The university is confident that the finding related to enrollment reporting has been resolved. Enrollment files are being submitted every 30 days. Summer 2024 completers graduated on August 9, 2024. These students were reported through Clearinghouse, exceptions were addressed, and enrollment statuses of “Graduated” show on NSLDS as certified on September 13, 2024. The schedule of enrollment and reporting and graduation reporting will ensure that the statuses will be accurate in NSLDS. Responsible Person Rose Mulkey, Interim Registrar Anticipated completion date Completed as of July 26, 2024.

View Audit 325158

Finding 501986 (2024-002)

Significant Deficiency 2024

Dixon County

NE

Procurement, Suspension & Debarment § 200.214 § 200.303

Program: AL 21.027 - COVID-19- Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Corrective Action Planned: The County will implement procedures to ensure when a contractor is paid with federal funds, sam.gov will be utilized to verify the entity has not been suspended o...

Program: AL 21.027 - COVID-19- Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Corrective Action Planned: The County will implement procedures to ensure when a contractor is paid with federal funds, sam.gov will be utilized to verify the entity has not been suspended or debarred and such procedure will be adequately documented. Anticipated Completion Date: August 16,2024 Responsible Party: Dixon County Board of Supervisors: Don Andersen, Deric Anderson, Roger Peterson, Neil Blolun, Lisa Lunz, Terry Nicholson, and Steve Hassler.

View Audit 324145

Finding 499522 (2024-003)

Significant Deficiency 2024

Richardton Health Center

ND

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

Finding 2024-003 Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Assistance Listing #10.766 Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliation for the...

Finding 2024-003 Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Assistance Listing #10.766 Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliation for the federal program and there was no formal review of the balance in comparison to the required minimum reserve balance. Responsible Individual: Mandy Robinson, Administrator Corrective Action Plan: We will implement additional control processes to ensure a formal review over the reserve fund reconciliation and a formal review of the balance in comparison to the required minimum reserve balance is completed by staff separate from the preparer. Anticipated Completion Date: 12/31/2024

View Audit 322385

Finding 497911 (2024-001)

None 2024

Kansas City Care Clinic D/b/a Kc Care Health Center

MO

Procurement, Suspension & Debarment § 200.214 § 200.303

Management's Response: KC CARE Agrees Views of Responsible Officials and Corrective Action: This appears to be an isolated incident where the vendor was not entered at the correct time in our contract management database. But, in response to this incident, management created a clearer policy and ou...

Management's Response: KC CARE Agrees Views of Responsible Officials and Corrective Action: This appears to be an isolated incident where the vendor was not entered at the correct time in our contract management database. But, in response to this incident, management created a clearer policy and outlined the timing of entering new vendors into the database and then making sure to do initial exclusion check during procurement process. Responsible Official: Dennis Dunmeyer, COO Anticipated Completion Date: Already implemented.

View Audit 320498

Finding 1206519 (2023-011)

Material Weakness 2023

MacOmb County

MI

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

The County acknowledges delays in the preparation and submission of certain required federal reports, including Statements of Expenditures. These delays were attributable to data availability, process inefficiencies during the ERP transition period, and the timing in which the Statement of Expenditu...

The County acknowledges delays in the preparation and submission of certain required federal reports, including Statements of Expenditures. These delays were attributable to data availability, process inefficiencies during the ERP transition period, and the timing in which the Statement of Expenditures template was provided by the grantor. In response, the County is improving internal workflows by enhancing coordination between program and finance staff, strengthening review procedures, and standardizing reporting processes. These actions are intended to improve both the accuracy and timeliness of reporting as processes continue to be refined within the system environment.

View Audit 398574

Finding 1206515 (2023-010)

Material Weakness 2023

MacOmb County

MI

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

The County acknowledges deficiencies related to the timeliness of federal reporting, including delays in the submission of required financial reports. Certain reports were not submitted within required timeframes due to challenges in obtaining timely and complete data, delays in completing reconcili...

The County acknowledges deficiencies related to the timeliness of federal reporting, including delays in the submission of required financial reports. Certain reports were not submitted within required timeframes due to challenges in obtaining timely and complete data, delays in completing reconciliations during and following the ERP transition, and the timing of required reporting templates provided by the grantor. The County is strengthening reporting procedures by improving coordination between departments, enhancing reconciliation processes, and reinforcing internal timelines for report preparation and review. As system functionality and staff familiarity continue to improve, reporting timeliness is expected to stabilize, with full resolution anticipated in the 2025 audit cycle.

View Audit 398574

Finding 1206511 (2023-009)

Material Weakness 2023

MacOmb County

MI

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

The County acknowledges the deficiency related to ensuring expenditures charged to federal programs comply with allowable cost principles under Uniform Guidance. The transition to the Workday ERP system impacted established review processes and data availability. The County is strengthening internal...

The County acknowledges the deficiency related to ensuring expenditures charged to federal programs comply with allowable cost principles under Uniform Guidance. The transition to the Workday ERP system impacted established review processes and data availability. The County is strengthening internal controls by enhancing review and approval procedures and improving staff training. As system processes continue to be refined, compliance and documentation are expected to improve.

View Audit 398574

Finding 1206363 (2023-005)

Material Weakness 2023

Town of Livermore Falls

ME

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

CORRECTIVE ACTION PLAN (Concerning Finding 2023-005) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2023-005 The current Town Manager was appointed by...

CORRECTIVE ACTION PLAN (Concerning Finding 2023-005) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2023-005 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted, had approved and us using the new Procurement Policy that addresses this deficiency. Additionally, Department Heads are required to turn in no later than Thursday by 9 am, invoices to be paid on that week’s warrant. The Treasurer has been given authority by the Town Manager to contact Department Heads and request that they come to the office weekly to turn in invoices. All invoices must have the appropriate expense code and be signed by the Department Head. Anticipated Completion Date: This was completed January 23, 2024.

View Audit 398382

Finding 1206359 (2023-003)

Material Weakness 2023

Town of Livermore Falls

ME

Allowable Costs / Cost Principles § 200.303

CORRECTIVE ACTION PLAN (Concerning Finding 2023-003) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2023-003 The current Town Manager was appointed by...

CORRECTIVE ACTION PLAN (Concerning Finding 2023-003) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2023-003 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager that has implemented training for the Treasurer and the Select Board. She has implemented a process of having the Treasurer complete a warrant each week. The Select Board meets bi-monthly and the Town Manager has the Select Board review and approve all warrants as a regular action item in their meeting. Additionally, Department Heads are required to turn in no later than Thursday by 9 am, invoices to be paid on that week’s warrant. The Treasurer has been given authority by the Town Manager to contact Department Heads and request that they come to the office weekly to turn in invoices. All invoices must have the appropriate expense code and be signed by the Department Head. Anticipated Completion Date: This corrective action has been implemented as of October 2023.

View Audit 398382

Finding 1206102 (2023-004)

Material Weakness 2023

Future Ready Five

OH

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Reference Number: 2023-04 Finding Type: Significant Deficiency in Internal Control Over Compliance Description of Finding: During the audit, it was noted that the Organization was unable to provide formal support for the internal review of required reports under the major program before they were su...

Reference Number: 2023-04 Finding Type: Significant Deficiency in Internal Control Over Compliance Description of Finding: During the audit, it was noted that the Organization was unable to provide formal support for the internal review of required reports under the major program before they were submitted to the pass-through grantor. The Organization lacks established procedures which provide formal evidence that the accuracy and completeness of required reports was verified before submission. Without formal review controls in place, the Organization is more susceptible to reporting errors and/or noncompliance with federal requirements. Statement of Concurrence: Management agrees with the finding. Corrective Action: The Chief Financial Officer prepares the required reports, and the Chief Executive has informally approved the reports prior to submission. A formal review by the Chief Executive Officer has been implemented to document in writing the review by the Chief Executive Office prior to submission. Completion Date: January 31, 2026 Name of Contact Person: Maureen Thomas Chief Financial Officer 917-405-7185 maureen@frfive.org

View Audit 398055

Finding 1206100 (2023-002)

Material Weakness 2023

Future Ready Five

OH

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Reference Number: 2023-02 Finding Type: Significant Deficiency in Internal Control Over Compliance Description of Finding: During the audit, it was noted that the Organization was unable to provide formal support for the internal review of costs submitted to the pass-through grantor under the major ...

Reference Number: 2023-02 Finding Type: Significant Deficiency in Internal Control Over Compliance Description of Finding: During the audit, it was noted that the Organization was unable to provide formal support for the internal review of costs submitted to the pass-through grantor under the major program. The Organization lacks established procedures which provide formal evidence that the allowability, accuracy and completeness of transactions were verified before submission. Without adequate internal controls in place to ensure that all charges to the federal program are properly reviewed for allowability, the Organization faces increased risk of noncompliance with the allowability requirement and could request funds for unallowed costs. Statement of Concurrence: Management agrees with the finding. Corrective Action: Beginning July 2025, management implemented a formal review process in Blackbaud Financial Edge NXT for the Director of RISE and the Chief Operating Officer to review and approve all invoices prior to submission to the Chief Financial Officer to ensure all charges are allowed. All invoices $25,000 and over are also reviewed and approved by the Chief Executive Officer prior to submission to the Chief Financial Officer for payment. Prior to July 2025, written approvals were obtained through either email or initial sign-off on invoices. Completion Date: July 2025 Name of Contact Person: Maureen Thomas Chief Financial Officer 917-405-7185 maureen@frfive.org

View Audit 398055

Finding 1205935 (2023-002)

Material Weakness 2023

Gascosage Electric Cooperative

MO

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

The Organization concurs with the finding and management will implement procedures to ensure appropriate internal control procedures are in place for reporting. Management will implement additional internal controls to ensure appropriate segregation of duties between report preparation and review.

View Audit 397805

Finding 1205675 (2023-005)

Material Weakness 2023

Colorado West, INC and Affiliates

CO

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

CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2023 AUDITOR FINDING: 2023-005 According to 2 CFR Part 200.403 factors affecting allowability of costs - costs must meet the following general criteria in order to be allowable under Federal awards: (a) be necessary and reasonable for the perfo...

CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2023 AUDITOR FINDING: 2023-005 According to 2 CFR Part 200.403 factors affecting allowability of costs - costs must meet the following general criteria in order to be allowable under Federal awards: (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, (e) be determined in accordance with generally accepted accounting principles, (f) to 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 and (g) be adequately documented. In addition, according to 2 CFR Part 200.303, the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. The Organization did not maintain documentation to support that costs and reimbursement invoices had been approved in accordance with their internal control design. CLIENT PLANNED ACTION: To address the audit finding, we affirm that all reimbursement invoices and cost-related documentation are submitted to a Director-level staff member for review and approval prior to sending. All approved invoices and associated documentation are now stored in a centralized shared drive and onsite file cabinets accessible to relevant finance staff to ensure consistent retention and accessibility for audit and review purposes. These documents will also be accessible within the accounting information system, when organization switches to Sage, which is accessible to all parties that have approval responsibilities. CLIENT RESPONSIBLE PARTY: Cassie Kenney, Director of Accounting COMPLETION DATE: This process started as of June 30, 2024. Documents will be stored within Sage as soon as the switch to this software is effective (tentative July 1st, 2025).

View Audit 397388

Finding 1191619 (2023-006)

Material Weakness 2023

Rutgers, the State University of New Jersey

NJ

Reporting Internal Control / Segregation of Duties § 200.303 § 200.502 § 200.510

2023 006 Other – Inaccurate Reporting of the Schedule of Expenditures of Federal Awards Federal Agency: U.S. Department of Homeland Security - Pass Through – SNJ Office of Emergency Management Program Titles and ALN: Disaster Grants - Public Assistance (Presidentially Declared Disasters) (ALN 97.036...

2023 006 Other – Inaccurate Reporting of the Schedule of Expenditures of Federal Awards Federal Agency: U.S. Department of Homeland Security - Pass Through – SNJ Office of Emergency Management Program Titles and ALN: Disaster Grants - Public Assistance (Presidentially Declared Disasters) (ALN 97.036) Grant Number: Grant #4488 Proj F#2105 and Grant #4614 Proj F#690 Contact Person: Erin Cuomo, Interim Vice President IP&O Business Services; 848-932-4981 Corrective Action: The Office for Research, through its Research Administration leadership in collaboration with Institutional Planning & Operations and University Finance will develop and implement a formal Standard Operating Procedure (SOP) to establish a consistent institutional framework for the administration and oversight of federally funded capital projects, emergency recovery programs, and other non-traditional sponsored funding mechanisms. The SOP will define roles and responsibilities, establish compliance requirements, and standardize processes to ensure alignment with applicable federal regulations and institutional policies The Senior Vice President for Research, the Interim Senior Vice President & Chief Operating Officer, and the University Controller will serve as the responsible executives for oversight, approval and implementation of this SOP. Anticipated Completion Date: Completed

View Audit 395479

Finding 1179879 (2023-004)

Material Weakness 2023

North Homes, Inc.

MN

Cash Management Significant Deficiency Internal Control / Segregation of Duties § 200.303

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.829 Program Name: Section 223 Demonstration Programs to Improve Community Mental Health Services Finding Summary: There was no evidence retained that the Organization's cash management requests were reviewed a...

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.829 Program Name: Section 223 Demonstration Programs to Improve Community Mental Health Services Finding Summary: There was no evidence retained that the Organization's cash management requests were reviewed and approved prior to submission. Corrective Action Plan: The Organization has implemented a process to ensure that formal documentation of review and approval is obtained and retained (i.e. hard copies or email). Responsible Individual: Ashli Glorvigen, CFO Anticipated Completion Date: 12/31/2026

View Audit 392245

Corrective Action Plans

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