Corrective Action Plans

Finding 402908 (2023-005)

Significant Deficiency 2023

Mayo Clinic

MN

Questioned Costs Procurement, Suspension & Debarment § 200.214 § 200.303 § 200.319 § 200.320

Federal Program Information Federal Agencies: U.S. Department of Health and Human Services and U.S. Department of Defense Federal Cluster: Research and Development (R&D) Pass-Through Entity: The University of Texas Health (93.853, NS119834) Assistance Listing Nos.: 12.420, 93.310, 93.353, 93.393, an...

Federal Program Information Federal Agencies: U.S. Department of Health and Human Services and U.S. Department of Defense Federal Cluster: Research and Development (R&D) Pass-Through Entity: The University of Texas Health (93.853, NS119834) Assistance Listing Nos.: 12.420, 93.310, 93.353, 93.393, and 93.853 Award Numbers: W81XWH-15-1-0292 (12.420), OD23121 (93.310), CA246568 (93.353), CA259201 (93.393), NS119834 (93.853), NS122096 (93.853) Award Periods: Various Corrective Action Planned Management conducted an education and training session for procurement teams in June 2024 to reinforce procurement requirements and documentation standards. Management will implement an independent sanction and debarment check for suppliers as part of existing quarterly audits over Supplier AP vendor master tables and related changes to those tables. Persons Responsible for Corrective Action Daniel Schmitz, Division Chair - Supply Chain Management Scott Hammer, Director - Supply Chain Management Target Completion Date June 30, 2024

View Audit 310163 Questioned Costs: $1

Finding 402859 (2023-004)

Significant Deficiency 2023

National Fair Housing Alliance

DC

Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.319 § 200.320

Views of Responsible Officials: NFHA will review and update its current Procurement Policies to ensure that they meet all current Federal and Uniform Guidance requirements. This will include documentation of contractor selection and single source vendor criteria. NFHA will provide additional trainin...

Views of Responsible Officials: NFHA will review and update its current Procurement Policies to ensure that they meet all current Federal and Uniform Guidance requirements. This will include documentation of contractor selection and single source vendor criteria. NFHA will provide additional training to all staff on the revised policies and procedures.

View Audit 310063

Finding 402858 (2023-003)

Material Weakness 2023

National Fair Housing Alliance

DC

Procurement, Suspension & Debarment § 200.214 § 200.303

Views of Responsible Officials: NFHA previously had a process in place, but it was not implemented properly during this fiscal year by the person to whom the responsibility was transferred. NFHA has resumed the process to perform checks in SAM.gov as part of the onboarding process for all new vendor...

Views of Responsible Officials: NFHA previously had a process in place, but it was not implemented properly during this fiscal year by the person to whom the responsibility was transferred. NFHA has resumed the process to perform checks in SAM.gov as part of the onboarding process for all new vendors. NFHA will also perform reviews of existing vendors on an annual basis and maintain evidence of these checks with the appropriate vendor files.

View Audit 310063

Finding 402853 (2023-001)

Significant Deficiency 2023

New Jersey Turnpike Authority

NJ

Allowable Costs / Cost Principles Cash Management Eligibility § 200.303 § 200.403 § 200.406 § 200.430

Findings Related to the Financial Statements Reported in Accordance with Government Auditing Standards None Findings Related to Federal Awards 2023-001 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency: U.S. Department of Homeland Security: Passed through the Sta...

Findings Related to the Financial Statements Reported in Accordance with Government Auditing Standards None Findings Related to Federal Awards 2023-001 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency: U.S. Department of Homeland Security: Passed through the State of New Jersey, Department of Law and Public Safety Program Titles and Assistance Listing Numbers (ALN): Disaster Grants – Public Assistance (Presidentially Declared Disasters) – ALN 97.036 Federal Grant Numbers: State of New Jersey pass-through number: UH1WX, Project Worksheet #1822 – Award Year 2023 (Application 553330) Contact Person: Donna Wilser, Deputy Executive Director, 732-750-5300 Corrective Action: Management agrees with the finding. We are committed to strengthening our processes to ensure that all physical timesheets related to FEMA-declared disaster events are properly maintained and readily accessible. To achieve this, we will implement enhanced procedures and controls to ensure full compliance with the Uniform Guidance requirements. Anticipated Completion Date: December 1st, 2024

View Audit 310037

Finding 402552 (2023-031)

Significant Deficiency 2023

State of Michigan

MI

Reporting Internal Control / Segregation of Duties § 200.303

Finding 2023-031 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Workfront Change Management Process Management Views DTMB agrees with the finding. Planned Corrective Action DTMB has created an enhancement tracker to track key documentation throughout the change management process...

Finding 2023-031 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Workfront Change Management Process Management Views DTMB agrees with the finding. Planned Corrective Action DTMB has created an enhancement tracker to track key documentation throughout the change management process. This will ensure that DTMB maintains documentation of testing results at all stages and authorization and completion of all change order requests. DTMB has also enhanced documentation for meetings between program management and development teams. Anticipated Completion Date Completed Responsible Individual(s) Jennifer Edmonds, DTMB

View Audit 309982

Finding 402551 (2023-030)

Significant Deficiency 2023

State of Michigan

MI

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.303

Finding 2023-030 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Workfront Security Management and Access Controls Management Views DTMB agrees with the finding. Planned Corrective Action For part a., DTMB has implemented processes and documentation to track user access requests to...

Finding 2023-030 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Workfront Security Management and Access Controls Management Views DTMB agrees with the finding. Planned Corrective Action For part a., DTMB has implemented processes and documentation to track user access requests to support approval of the system role for all Workfront users. For part b., DTMB has updated processes to ensure it maintains documentation to support the review of all privileged Workfront accounts on a semiannual basis. Anticipated Completion Date Completed Responsible Individual(s) Jennifer Edmonds, DTMB

View Audit 309982

Finding 402548 (2023-027)

Significant Deficiency 2023

State of Michigan

MI

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

Finding 2023-027 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Insufficient Respite Payment Controls Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS began performing weekly reconciliations of the Medical Services Administration Manual Payment Syste...

Finding 2023-027 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Insufficient Respite Payment Controls Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS began performing weekly reconciliations of the Medical Services Administration Manual Payment System (MSAPay) payment details and Home Help beneficiary applications during February 2024, to ensure only approved outstanding applications are paid. In addition, MDHHS implemented additional steps in the MSAPay approval process during May 2024 to prevent duplicate payments, including a review process to verify the beneficiary did not receive previous payments related to the respite grant, prior to creating a new payment voucher. Anticipated Completion Date Completed Responsible Individual(s) Crystal Kline, MDHHS Jessica Bowen, MDHHS Elaina Brown, MDHHS

View Audit 309982

Finding 402547 (2023-026)

Significant Deficiency 2023

State of Michigan

MI

Allowable Costs / Cost Principles Cash Management Eligibility § 200.303

Finding 2023-026 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Grant Reimbursement Approval Procedures Management Views EGLE agrees with the finding. Planned Corrective Action EGLE’s Water Resources Division’s Administration staff reviewed the existing process with staff conducti...

Finding 2023-026 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Grant Reimbursement Approval Procedures Management Views EGLE agrees with the finding. Planned Corrective Action EGLE’s Water Resources Division’s Administration staff reviewed the existing process with staff conducting the administrative review to ensure the technical review will be completed in advance of making any payment. If Administration staff have received a request for payment without the technical review, Administration staff will forward all documents received to the project manager to obtain the technical review. Once the technical review has been completed, Administration staff will conduct the administrative review and process the payment request. Additionally, EGLE subsequently reviewed the reimbursement request noted in the finding to ensure that the cumulative totals requested have been for projects that are consistent with the grant award. Anticipated Completion Date Completed Responsible Individual(s) Phil Argiroff, EGLE Amy Hicks, EGLE

View Audit 309982

Finding 402528 (2023-024)

Significant Deficiency 2023

State of Michigan

MI

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.306

Finding 2023-024 Fish and Wildlife Cluster, ALN 15.605, 15.611, and 15.626 - Inappropriate Telecommunication Expenditures Management Views DNR agrees with the finding. Planned Corrective Action DNR sent an email communication on May 7, 2024, to the Department Budget Control Team as a reminder to u...

Finding 2023-024 Fish and Wildlife Cluster, ALN 15.605, 15.611, and 15.626 - Inappropriate Telecommunication Expenditures Management Views DNR agrees with the finding. Planned Corrective Action DNR sent an email communication on May 7, 2024, to the Department Budget Control Team as a reminder to use the monthly DTMB telecom billing detail to verify all employees coded to fish and wildlife activities are valid. The monitoring of these charges will continue to occur as part of the interim quarterly assessments. Anticipated Completion Date Completed Responsible Individual(s) Jennifer Houle, DNR

View Audit 309982

Finding 402493 (2023-007)

Significant Deficiency 2023

State of Michigan

MI

Internal Control / Segregation of Duties § 200.303

Finding 2023-007 MDE, Change Management Process Management Views MDE agrees with the finding. Planned Corrective Action MDE and DTMB will work to implement a regular review of DevOps tickets to ensure documentation is maintained at all stages of the process, that change order requests are closed, ...

Finding 2023-007 MDE, Change Management Process Management Views MDE agrees with the finding. Planned Corrective Action MDE and DTMB will work to implement a regular review of DevOps tickets to ensure documentation is maintained at all stages of the process, that change order requests are closed, and the completion is documented in a timely manner. Anticipated Completion Date October 1, 2024 Responsible Individual(s) Monica Butler, MDE Sean Strom, DTMB

View Audit 309982

Finding 402492 (2023-006)

Significant Deficiency 2023

State of Michigan

MI

Subrecipient Monitoring Cash Management Reporting § 200.303

Finding 2023-006 MDE, Security Management and Access Controls Management Views The Michigan Department of Education (MDE) agrees with the finding. Planned Corrective Action For part a., as part of the Michigan Nutrition Data (MiND) 2.0 Implementation Project, MDE will institute a mechanism to capt...

Finding 2023-006 MDE, Security Management and Access Controls Management Views The Michigan Department of Education (MDE) agrees with the finding. Planned Corrective Action For part a., as part of the Michigan Nutrition Data (MiND) 2.0 Implementation Project, MDE will institute a mechanism to capture the person to whom the access has been delegated. MDE will review the policies and procedures with department staff that is responsible for security access controls for the Next Generation Grant, Application and Cash Management System (NexSys) to ensure proper access control policies are followed. For part b., MDE will update policies and procedures to ensure review of all accounts on a semi-annual basis. For parts c. and d., MDE will continue to work with DTMB to find more efficient ways to ensure all non-privileged users are recertified and improve the technical solution to deactivate users after 18 months of inactivity. For part e., as part of the movement of the grants management unit at MDE to a different office, MDE is reviewing the policies around high-risk transactions and will update the policies to meet established standards. Anticipated Completion Date October 1, 2024 Responsible Individual(s) David Judd, MDE

View Audit 309982

Finding 402473 (2023-003)

Significant Deficiency 2023

State of Michigan

MI

Internal Control / Segregation of Duties § 200.303

Finding 2023-003 Bridges Change Management Process Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS updated change control processes on May 18, 2023, requiring documentation of an alternate validation approval following each Bridges Integrated Automated Eligibility D...

Finding 2023-003 Bridges Change Management Process Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS updated change control processes on May 18, 2023, requiring documentation of an alternate validation approval following each Bridges Integrated Automated Eligibility Determination System (Bridges) release that does not have field testers performing post implementation validation. For Bridges releases occurring after May 18, 2023, MDHHS sends a communication within three business days after each release that validates the changes to Bridges were applied as expected and this validation is documented and retained as part of the release close-out process. Each exception identified occurred prior to the implemented corrective action. Anticipated Completion Date Completed Responsible Individual(s) Holly Roderick, MDHHS

View Audit 309982

Finding 402472 (2023-002)

Material Weakness 2023

State of Michigan

MI

Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility § 200.303

Finding 2023-002 Bridges Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For parts a., c., and d., MDHHS implemented the Database Security Application (DSA) on October 2, 2023, which includes documenting incompatible role exception ...

Finding 2023-002 Bridges Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For parts a., c., and d., MDHHS implemented the Database Security Application (DSA) on October 2, 2023, which includes documenting incompatible role exception requests and user access request approvals. The DSA also includes semi-annual review of privileged users and annual review for all users. For parts b. and e., MDHHS will revise internal business processes to include an additional level of monitoring and review to ensure compliance with the existing directives related to monitoring and review requirements. Anticipated Completion Date a., c., and d. Completed b. and e. August 2024 Responsible Individual(s) a., c., and d. Deon Nelson, MDHHS b. and e. Veronica Maxson, MDHHS

View Audit 309982

Finding 402469 (2023-001)

Significant Deficiency 2023

Community Loan Fund of New Jersey, Inc.

NJ

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Finding Related to Federal Awards 2023-001 Procurement – Suspension and Debarment Federal Agency: U.S. Department of Treasury Program Titles and Assistance Listing Numbers (ALN): Community Development Financial Institutions Bond Guarantee Program - ALN 21.014 Federal Grant Numbers: 19-BGA-00003 ...

Finding Related to Federal Awards 2023-001 Procurement – Suspension and Debarment Federal Agency: U.S. Department of Treasury Program Titles and Assistance Listing Numbers (ALN): Community Development Financial Institutions Bond Guarantee Program - ALN 21.014 Federal Grant Numbers: 19-BGA-00003 Contact Person: Varun Agnihotri, Manager Director, Portfolio Management, 732-640-2061 Corrective Action: A process and checklist will be put in place to ensure the independent status search is performed on recipients when a payment is made. The process and checklist will include a verification by someone other than the person preparing the request. Anticipated Completion Date: September 30, 2024

View Audit 309975

Finding 402467 (2023-011)

Material Weakness 2023

City of Cambridge Massachusetts

MA

Period of Performance Internal Control / Segregation of Duties Material Weakness § 200.303

Cambridge Public Schools' CFO or Grants Coordinator will review and sign-off on all tuition requisitions that will be charged to grants to confirm the grant approval date and compliance with the period of performance.

View Audit 309973

Finding 402465 (2023-010)

Material Weakness 2023

City of Cambridge Massachusetts

MA

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

The Finance department will document the reconciliation of the City's GL ARPA expenditures and obligations to the Department of Treasury ARPA reporting portal report both quarterly and annually. All reconciling adjustments and GL report documentation will be properly retained.

View Audit 309973

Finding 402463 (2023-009)

Material Weakness 2023

City of Cambridge Massachusetts

MA

Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303 § 200.332

The City will use a subrecipient audit certification form and a subrecipient risk assessment questionnaire to evaluate a subrecipient's risk/experience with federal funds as well as assess their federal funding threshold for having a single audit.

View Audit 309973

Finding 402461 (2023-008)

Material Weakness 2023

City of Cambridge Massachusetts

MA

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

The City will ensure that subrecipient contracts will include language about suspension and debarment. The City will also download a PDF copy of the subrecipients registration on SAM.GOV showing the subrecipient's Exclusion Summary Status.

View Audit 309973

Finding 402459 (2023-007)

Material Weakness 2023

City of Cambridge Massachusetts

MA

Subrecipient Monitoring HUD Housing Programs Material Weakness § 200.303

The City will work with all HOPWA subrecipients to ensure that a complete and accurate CAPER is completed in the appropriate format as required by HUD. This will include a focus on inputting the correct (eg, actual expended vs. award amount) funding amount.

View Audit 309973

Finding 402457 (2023-006)

Material Weakness 2023

City of Cambridge Massachusetts

MA

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.1 § 200.303

The City will use the contract start date (7/1) as the Obligation date, and will submit the FFATA report accordingly.

View Audit 309973

Finding 402455 (2023-005)

Material Weakness 2023

City of Cambridge Massachusetts

MA

Subrecipient Monitoring § 200.303 § 200.332

The City will incorporate a more formal review of financial audits of subrecipients in conjunction with new contracts moving forward. These audits, and City staff's verification of assessment will be included in each subrecipient file.

View Audit 309973

Finding 402452 (2023-003)

Material Weakness 2023

City of Cambridge Massachusetts

MA

Subrecipient Monitoring § 200.303 § 200.332

The City has established an Audit Review Certification form that is completed by employees to formally document review of subrecipient agencies' audit reports.

View Audit 309973

Finding 402450 (2023-002)

Material Weakness 2023

City of Cambridge Massachusetts

MA

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management § 200.303

Based on prior year (FY22) findings, the City established the following procedures to ensure payment requests received from subrecipients are paid within 30 days of receipt of a complete request for reimbursement: 1. Department of Human Service Programs (DHSP) Contract Manager reviews invoices withi...

Based on prior year (FY22) findings, the City established the following procedures to ensure payment requests received from subrecipients are paid within 30 days of receipt of a complete request for reimbursement: 1. Department of Human Service Programs (DHSP) Contract Manager reviews invoices within 5 business days of receipt of request for reimbursement from subrecipient. a. If invoice is complete, original date of receipt is recorded. b. If invoice is incomplete, subrecipient is notified of items or documentation that is missing and receipt date is updated to reflect date of receipt of complete invoice. 2. Contract Manager approves payment request and submits to DHSP Fiscal staff for processing. 3. Fiscal staff processes and submits to Auditing Department as Priority payment. Four of the 19 sampled payment requests were received or processed after receipt of the FY22 audit findings, and all of those requests for reimbursement were paid within 30 days of receipt.

View Audit 309973

Finding 402448 (2023-001)

Significant Deficiency 2023

City of Cambridge Massachusetts

MA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Based on the finding in the prior year audit, the City updated the subrecipient contract template in spring 2023 prior to execution of contracts for the FY24 ESG program year and will continue to utilize the updated template to ensure required language certifying that the agency, its officers, and e...

Based on the finding in the prior year audit, the City updated the subrecipient contract template in spring 2023 prior to execution of contracts for the FY24 ESG program year and will continue to utilize the updated template to ensure required language certifying that the agency, its officers, and employees are not suspended or debarred from doing business with the federal government. Staff will continue to verify that subrecipients are not suspended or debarred by checking against the Sam.gov Exclusion List and registration pages prior to executing contracts, and will document those checks through grant management meeting minutes and Smartsheet tracking.

View Audit 309973

Finding 402423 (2023-006)

Material Weakness 2023

The Henry Francis Du Pont Winterthur Museum, Inc.

DE

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

Management commits to documenting processes and procedures - in this case specifically for the endowment spending policy; instituting regular reviews for effectiveness and compliance and better defining the responsibilities and accountabilities of employee and outsourced staff.

View Audit 309950

Corrective Action Plans

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