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2023-008 – Reporting Federal Agency: U.S. Department of the Treasury Federal Program Name: Emergency Rental Assistance Program (ERAP) Assistance Listing Number: 23.023 Federal Award Identification Number and Year: Various Pass-Through Agency: Pennsylvania Department of Health and Human Services Pass...
2023-008 – Reporting Federal Agency: U.S. Department of the Treasury Federal Program Name: Emergency Rental Assistance Program (ERAP) Assistance Listing Number: 23.023 Federal Award Identification Number and Year: Various Pass-Through Agency: Pennsylvania Department of Health and Human Services Pass-Through Number(s): Not Available Award Period: 1/1/2023 – 12/31/23 Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: Policies and controls in place regarding the completeness of the SEFA were not properly functioning. Within the supporting listing of expenses relating to ERAP expenditures, six transactions were identified as prior fiscal-year expenditures that were included in the unadjusted 2023 expenditure total. The County revised the 2023 SEFA to exclude the 2022 expenditures. Recommendation: We recommend management should review the process of recording federal expenditures to determine expenditures are being included in the appropriate fiscal year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned and taken in response to finding: The reason for the finding’s recurrence is in part a result of the timing of when the finding was issued. For example, the 2022 Single Audit was issued in August 2024. At this point, the 2023 fiscal year was already complete. Additionally, the implementation of corrective actions are in progress, including providing training, oversight and guidance to departments administering the grants, but these efforts take time to complete and/or are ongoing. A Deputy Controller of Grant Accounting was hired in February 2023, and a Manager-Grant Accounting was hired in July 2024, after working in this capacity as a temporary staff member since mid-2023. The County approved an additional full-time grant accounting position in May 2025 and will begin recruiting for this position in June 2025. These positions are responsible for establishing accounting policies based on best practices for grant-related activities, developing and providing training and resources to grant- funded departments, reviewing grant-related accounting in the Infor system, preparation of the annual SEFA, and assisting in the facilitation and preparation of documents needed for the Single Audit. The work performed by these positions had been vacant since the departure of Internal Audit Staff who helped General Accounting prior to the 2021 audit as well as the SEFA. Several changes have been made since the grant accounting team was created including the following: The grant accounting team is developing streamlined and standardized SEFA templates for each department for SEFA preparation. The expenditures reported on each SEFA are being compared to the financial information in the GL where possible to ensure all appropriate expenditures are included. Additionally, we are incorporating tracking of lifetime grant expenditures into the SEFA process to ensure no expenditures are missed due to cut off or timing issues. In 2023, the grant accounting team created a Montgomery County Grant Repository. This repository is used to store all grant agreements awarded to the County. Departments submit grant information to the repository upon notification of grant award. The grant accounting team reviews the Grant Repository when preparing the SEFA to ensure no grant programs are inadvertently left off of the SEFA. Additionally, the availability of the Grant Repository enables members of the accounting, finance and grant departments to quickly access grant award information when needed for audits, reporting, or other requirements. The grant accounting team is continuing to review and update the County’s Grant Accounting policies and is working closely with departments to understand their utilization of Infor to account for grant- related activities. As these policies are formalized, we will continue to provide training and resources; in late 2023, the County hired an outside trainer to provide an in-depth training on the accrual method of accounting, grant accruals, and the treatment of grant revenue. The Grant Accountant provided training in April 2024 to explain and outline the SEFA and Single Audit processes. Grant-funded departments received a two-day training on utilization of the Grant Management components of Infor in February 2024. We are also providing guidance and education to departments on the differences in timing of various grant fiscal years and how these impact the financial audit, SEFA and Single Audit. For example, departments must understand how to report expenditures and receipts in the correct period regardless of the fiscal year associated to the contract (State: July-June; Federal: October-September; County: January-December) and understand how these amounts reconcile to the amounts reported to the funding agencies. The accounting department continues to work with departments to emphasize the importance of submitting financial documentation timely and reviewing what is in the General Ledger promptly at the end of each month. The Finance department is performing quarterly reviews with departments to go over financial status, including grant financials. Departments are continuing to utilize Project Codes and other components of Infor’s Grant Management System to ensure the proper accounting of grant-related expenses, receipts, and revenues in the GL. Name(s) of the contact person(s) responsible for corrective action: Thomas Landauer and Fonta Reilly Planned completion date for corrective action plan: September 2025
View Audit 370214 Questioned Costs: $1
To: FY2023 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding 2023-003 Federal Agency: U.S. Department of Treasury U.S. Department of Homeland Security ALN: 21.027 / 97.036 Grady...
To: FY2023 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding 2023-003 Federal Agency: U.S. Department of Treasury U.S. Department of Homeland Security ALN: 21.027 / 97.036 Grady Memorial Hospital Corporation’s CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will update our controls and processes to include additional review of expenses incurred during the relevant audit period. Grady’s corrective action plan: We have restated 2023 SEFA totals based on updates to the project funded within ALN 21.027 and for the project funded within 97.036. Going forward the SEFA will be reviewed to ensure that all related expenses for the audit period are incorporated. Contact person/s responsible for the corrective action: David Noble, Director, Grant Administration Anticipated Completion Date: Consistent with 2024 Financial Audit Reporting
FINDING 2023-005 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Disbarment: Summary of Finding: Material Weakness, Modified Opinion An effective internal control system, which would include segregation of duties, was not in place at the County in order...
FINDING 2023-005 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Disbarment: Summary of Finding: Material Weakness, Modified Opinion An effective internal control system, which would include segregation of duties, was not in place at the County in order to ensure compliance with requirements related to the grant agreement and the procurement and suspension and debarment compliance. Prior to entering into subawards and covered transactions with Coronavirus State and Local Fiscal Recovery Funds (CSLFRF), SLFRF funds, recipients are required to verify that contractors and subrecipients are not suspended, debarred, or otherwise excluded. Upon inquiring of the County to determine its policies and procedures related to suspension and debarment requirements for the CSLFRF, SLFRF funds, the County stated procedures were not in place to ensure vendors were not suspended or debarred prior to entering into covered transactions. The County had not performed procedures to ensure the vendors were not suspended or debarred or otherwise excluded or disqualified from participation in federal assistance programs or activities during the audit period on all of the 13 vendors determined to have covered transactions totaling $4,440,497, that were paid with SLFRF funds. The lack of internal controls and compliance under the previous Auditor Timothy J. Stabosz were systemic issues throughout the audit period. Contact Person Responsible for Corrective Action: Michael Rosenbaum Contact Phone Number and Email Address: 219-326-6808 Ext. 2226; mrosenbaum@laporteco.in.gov INDIANA STATE BOARD OF ACCOUNTS 44 Views of Responsible Official: We concur with the finding under the prior Auditor Timothy J. Stabosz. Description of Corrective Action Plan: Policies and procedures will be put in place to search on sam.gov to determine if a vendor has been suspended or disbarred. Anticipated Completion Date: August 2025
FINDING 2023-004 Finding Subject: Drinking Water State Revolving Fund (DWSRF) Cluster - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Tyler Pearson, Clerk Treasurer Contact Phone Number and Email Address: 574-739-1416 clerktreasurer@cityoflogansport.org V...
FINDING 2023-004 Finding Subject: Drinking Water State Revolving Fund (DWSRF) Cluster - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Tyler Pearson, Clerk Treasurer Contact Phone Number and Email Address: 574-739-1416 clerktreasurer@cityoflogansport.org Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will develop and implement a formal process for verifying that vendors are not suspended, debarred, or otherwise excluded from receiving federal funds before entering into contracts or transactions that meet or exceed the $25,000 threshold. The City will develop a purchasing policy that reflects the applicable state laws and regulations related to procurement. The City will also maintain proper documentation to support the appropriate procurement method. Anticipated Completion Date: December 31, 2025
FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Tyler Pearson, Clerk Treasurer Contact Phone Number and Email Address: 574-739-1416 cler...
FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Tyler Pearson, Clerk Treasurer Contact Phone Number and Email Address: 574-739-1416 clerktreasurer@cityoflogansport.org Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: As a measure of corrective action, I will be implementing a check sheet that will be attached to every claim sheet. This new procedure requires that you go through the check sheet and initial each item to ensure that all procedures have been followed correctly before submission. Additionally, I will also maintain a check sheet in my office since I am the last person to review each claim. This will help to ensure thoroughness and accuracy in our claims processing. Furthermore, moving forward, any grant funds will be placed into their own individual funds and distributed through an individual account. This approach will allow us to track payments for any expenses associated with these funds more effectively. Additionally, the BOT expenditure is done and in the future we will do a better job. Anticipated Completion Date: October 31,2025
View Audit 368938 Questioned Costs: $1
Views of Responsible Officials: The cause is related to the digital nature of the drawdown process and staff turnover. ICFJ will institute a procedure to capture drawdown information and/or create a documentation at the time of drawdown. Storage of the documentation will be incorporated into ICFJ’s ...
Views of Responsible Officials: The cause is related to the digital nature of the drawdown process and staff turnover. ICFJ will institute a procedure to capture drawdown information and/or create a documentation at the time of drawdown. Storage of the documentation will be incorporated into ICFJ’s digital records storage.
The grant accounting and SEFA preparation process will be refined, improved and documented. Internal resources will be reallocated to ensure sufficient coverage of these processes, and the primary accountability and oversight will shift to System Accounting. Management will ensure that in preparatio...
The grant accounting and SEFA preparation process will be refined, improved and documented. Internal resources will be reallocated to ensure sufficient coverage of these processes, and the primary accountability and oversight will shift to System Accounting. Management will ensure that in preparation of the SEFA, (1) a team member will assemble the initial reconciliation, (2) management will review the initial reconciliation and review the consolidation from all BayCare entities to the combined SEFA, (3) A final review will be conducted by the Director of Accounting. Sign-off from each preparer/reviewer shall be required. Meetings will be conducted as needed with departments outside of Hospital Finance to ensure completeness and accuracy of data. Start September 2025, Finalized Q1 2026
As PRF ended in 2023, no corrective action deemed appropriate for this specific program going forward. However, Management will ensure that in preparation of the SEFA, (1) a team member will assemble the initial reconciliation, (2) management will review the initial reconciliation and review the con...
As PRF ended in 2023, no corrective action deemed appropriate for this specific program going forward. However, Management will ensure that in preparation of the SEFA, (1) a team member will assemble the initial reconciliation, (2) management will review the initial reconciliation and review the consolidation from all BayCare entities to the combined SEFA, (3) A final review will be conducted by the Director of Accounting. Sign-off from each preparer/reviewer shall be required. Meetings will be conducted as needed with departments outside of Hospital Finance to ensure completeness and accuracy of data. Complete. AL No. 93.498 ended in 2023.
The grant accounting and SEFA preparation process will be refined, improved and documented. Internal resources will be reallocated to ensure sufficient coverage of these processes, and the primary accountability and oversight will shift to System Accounting. Management will ensure that in preparatio...
The grant accounting and SEFA preparation process will be refined, improved and documented. Internal resources will be reallocated to ensure sufficient coverage of these processes, and the primary accountability and oversight will shift to System Accounting. Management will ensure that in preparation of the SEFA, (1) a team member will assemble the initial reconciliation, (2) management will review the initial reconciliation and review the consolidation from all BayCare entities to the combined SEFA, (3) A final review will be conducted by the Director of Accounting. Sign-off from each preparer/reviewer shall be required. Meetings will be conducted as needed with departments outside of Hospital Finance to ensure completeness and accuracy of data. Start September 2025, Finalized Q1 2026
FINDING 2023-004 Finding Subject: COVID-19-Education Stabilization Fund - Special Tests and Provisions – Wage Rate Requirements Summary of Finding: Construction contracts in excess of $2,000 financed by federal assistance funds must pay wages not less than those established for the locality of the p...
FINDING 2023-004 Finding Subject: COVID-19-Education Stabilization Fund - Special Tests and Provisions – Wage Rate Requirements Summary of Finding: Construction contracts in excess of $2,000 financed by federal assistance funds must pay wages not less than those established for the locality of the project (prevailing wage rates) by the Department of Labor (DOL) to their laborers and mechanics. Nonfederal entities are to include in their construction contracts subject to the Wage Rate Requirements a provision that the contractor or subcontractor comply with these requirements and the DOL regulations. This would include a requirement to submit a copy of the payroll and statement of compliance to the entity for each week in which contract work was performed. The School Corporation had not designed nor implemented a system of internal controls to ensure that construction contracts in excess of $2,000 paid from federal grant funds included a prevailing wage rate clause. One construction contract, totaling$149,995, was paid for with COVID-19 – Education Stabilization Fund grant funds during the audit period. The contract did not include the required prevailing wage rate clause, nor were the certified payrolls submitted by the contractor. Contact Person Responsible for Corrective Action: Leslie Rittenhouse Contact Phone Number and Email Address: 765-395-3341 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The district has no plans nor approved budget for any remaining ESSER funds to be used a manner which would relate to the prevailing wage rate clause. Should the district amend the use of ESSER funding to include such activity the prevailing wage clause requirements will be completed in full. Anticipated Completion Date: Immediately.
FINDING 2023-003 Finding Subject: COVID-19-Education Stabilization Fund - Reporting Summary of Finding: The School Corporation was required to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not lim...
FINDING 2023-003 Finding Subject: COVID-19-Education Stabilization Fund - Reporting Summary of Finding: The School Corporation was required to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not limited to, current period expenditures, prior period expenditures, and expenditures per activity. During the audit period the School Corporation submitted two ESSER I reports, two ESSER II reports and two ESSER III reports, for a total of six reports. The annual data reports were prepared by the Treasurer. Due to the lack of effective internal controls one of the six annual data reports was not supported by the School Corporation’s records. For the ESSER III, Year 2 report, which covered the period of July 1, 2021 to June 30, 2022, total expenses per the report were $688,778. However, the School Corporation’s ledger had total expenses for the award, for that time period, of $784,638. The lack of controls and noncompliance were isolated to the ESSER III, Year 2 report. Contact Person Responsible for Corrective Action: Leslie Rittenhouse Contact Phone Number and Email Address: 765-395-3341 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: As the finding and error occurred in one entry of one report the district will continue the practice of having a second party review financial system data against report entries. The error in this instance was a misunderstanding of the entry. A secondary review of reporting guidelines and entries will take place prior to submission of any ESSER Data Reporting. Anticipated Completion Date: Upon the next submission of ESSER Data reporting.
FINDING 2023-002 Finding Subject: Child Nutrition Cluster – Eligibility Summary of Finding: For one of 40 students receiving free or reduced priced lunches, the eligibility determination was incorrect. The student was classified as reduced; however, the student should have been a regular paying stud...
FINDING 2023-002 Finding Subject: Child Nutrition Cluster – Eligibility Summary of Finding: For one of 40 students receiving free or reduced priced lunches, the eligibility determination was incorrect. The student was classified as reduced; however, the student should have been a regular paying student. The error was due to an incorrect family size being reported, which caused the classification to be incorrect. The lack of controls and noncompliance was isolated to the one student. Contact Person Responsible for Corrective Action: Leslie Rittenhouse Contact Phone Number and Email Address: 765-395-3341 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director will continue to review eligibility of students for the free and reduced meal program through the state level system. The district will have a secondary individual from the food service department review the eligibility determination following the initial review by the director. Both the director and the secondary individual will sign off on the determination paperwork. Entry into the state system for eligibility calculations will be reviewed for any entry errors. Anticipated Completion Date: All new determinations in the 2024-2025 school year.
Finding 2023-003: Establish and maintain effective internal control over the Federal award Plan: We have ensured all policies and procedures have been vetted by an attorney and approved by the River View Board of Trustees and the Claremont Learning Partnership Board of Directors. Moving forward, the...
Finding 2023-003: Establish and maintain effective internal control over the Federal award Plan: We have ensured all policies and procedures have been vetted by an attorney and approved by the River View Board of Trustees and the Claremont Learning Partnership Board of Directors. Moving forward, the Executive Director will ensure that all policies and procedures stay current and are reviewed by the Board annually. FY-22 & FY-23 Audits were completed in tandem, all corrections were made as soon as the issue was identified. Expected Implementation Date: RiverView amended the policy on June 17, 2025, CLP amended the policy on July 3, 2025. Contact: Cathy Pellerin Executive Director, Claremont Learning Partnership 169 Main Street; Claremont, NH 03743 603-287-7120
Finding 1155375 (2023-004)
Material Weakness 2023
FINDING 2023-004 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment The County had not performed procedures to ensure the vendors were not suspended or debarred or otherwise excluded or disqualified from participation in federal assistance progra...
FINDING 2023-004 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment The County had not performed procedures to ensure the vendors were not suspended or debarred or otherwise excluded or disqualified from participation in federal assistance programs or activities during the audit period on all of the 3 vendors determined to have covered transactions, totaling $141,131, that were paid with SLFRF funds. Contact Person Responsible for Corrective Action: Larry Hutchings Larry.hutchings@vigocounty.in.gov 812-462-3361 Views of Responsible Officials: We concur with the findings Description of The Corrective Action Plan: The Auditors Office has created a Policy for Suspension and Debarment within the Subrecipient Ploicy. A clause or condition must also be included in the covered transaction with that entity to require reporting of any debarment or suspension occurring during the subgrant period; and, Maintain documentation to support the verification was done before or at the time of contract execution. Anticipated Completion Date – 08/13/2025
Finding 1155374 (2023-003)
Material Weakness 2023
FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Subrecipient Monitoring The County received an allocation of the COVID-19 - State and Local Fiscal Recovery Funds (SLFRF) from the U.S. Department of the Treasury to support its response and recovery fro...
FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Subrecipient Monitoring The County received an allocation of the COVID-19 - State and Local Fiscal Recovery Funds (SLFRF) from the U.S. Department of the Treasury to support its response and recovery from the novel coronavirus. A portion of the County's allocation was then used to subaward funds to another entity (i.e., the subrecipient) to carry out an eligible use. The County did not have policies and procedures in place to perform monitoring procedures of the subrecipients. Contact Person Responsible for Corrective Action: Larry Hutchings larry.hutchings@vigocounty.in.gov 812-462-3361 Views of Responsible Officials: We concur with this finding : Description of The Corrective Action Plan: The Auditors Office has created a subrecipient policy The Auditor’s Office requires all departments who contract with subrecipients to complete a Subrecipient Contractor Checklist on a fiscal year basis. Anticipated Completion Date – 08/13/2025
2023-008 Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend implementing a formal policy and procedure where there is a review of all required reporting by an individual that did not prepare the report. Documentation should be retained to support the review/a...
2023-008 Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend implementing a formal policy and procedure where there is a review of all required reporting by an individual that did not prepare the report. Documentation should be retained to support the review/approval occurrence. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a formal review process for reporting and retain documentation of review. This has been incorporated in subsequent reporting years. Name(s) of the contact person(s) responsible for corrective action: Bobby Royal Planned completion date for corrective action plan: December 2025
2023-007 Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend in the future the Organization retain documentation of key control processes occurring for a reasonable retention period to be able to support control activities around grant compliance and financial...
2023-007 Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend in the future the Organization retain documentation of key control processes occurring for a reasonable retention period to be able to support control activities around grant compliance and financial reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will retain timesheet documentation moving forward to support control process in place. Name(s) of the contact person(s) responsible for corrective action: Bobby Royal Planned completion date for corrective action plan: December 2025
Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the Organization is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Con...
Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the Organization is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: The Organization's special reports submitted to the Department of Health and Human Services were not reviewed and approved by a separate individual outside of the preparer. Context: Key line items were tested on the Period 4 special reports submitted to the Department of Health and Human Services. 2 reports were tested, which both lacked appropriate approval. Response: Copa Health, Inc will continue to monitor and review internal control systems and implement new policies and/or procedures when necessary or applicable
Finding Number 2023-106 Subject Heading (Financial) or AL no. and program name (Federal) 93.575 – CCDF Planned Corrective Action The Oklahoma Department of Human Services (DHS) does not concur with the implication that all $12,396,987 in payments under the Kith Care program were unallowable. DHS ack...
Finding Number 2023-106 Subject Heading (Financial) or AL no. and program name (Federal) 93.575 – CCDF Planned Corrective Action The Oklahoma Department of Human Services (DHS) does not concur with the implication that all $12,396,987 in payments under the Kith Care program were unallowable. DHS acknowledges that improvements could have been made to documentation protocols and long-term record retention when working with a third-party platform; however, DHS does not agree with the assertion that the program was administered in violation of federal requirements. The Kith Care initiative was developed in response to a national crisis—the COVID-19 pandemic—during which ensuring continuity of child care for essential workers became a top priority. The program’s design followed the flexibility allowed under 42 USC § 601(a)(1) and 45 CFR § 98.67, with the aim of supporting low-income working families, including foster and adoptive parents, through innovative but time-limited means. The use of relative caregivers met the federal allowance for informal, license-exempt care and was consistent with CCDF guidance. Eligibility determinations were made by designated administrators in partnering agencies or by DHS staff in the child care subsidy and child welfare program areas. Weekly timesheets were submitted by caregivers and certified by parents through the application before payment was processed. Invoices submitted to DHS contained individual-level details on each child and caregiver, the dates of service, and the requested payment amounts. DHS further notes that delays in retrieving requested records were due in part to the age of the program, the sunset of the platform, and staff attrition. These limitations should not be construed as a lack of eligibility verification or failure of internal control at the time of program execution. Anticipated Completion Date This award is now closed. Responsible Contact Person Trevor Shelby, Deputy Director
View Audit 367158 Questioned Costs: $1
Finding Number 2023-104 Subject Heading (Financial) or AL no. and program name (Federal) 93.575 – CCDF Cluster Planned Corrective Action The Oklahoma Department of Human Services (OKDHS) respectfully does not concur with the finding as written. We believe the State Auditor and Inspector (SAI) has no...
Finding Number 2023-104 Subject Heading (Financial) or AL no. and program name (Federal) 93.575 – CCDF Cluster Planned Corrective Action The Oklahoma Department of Human Services (OKDHS) respectfully does not concur with the finding as written. We believe the State Auditor and Inspector (SAI) has not fully considered the federal flexibility afforded under the American Rescue Plan (ARP) Act, and that some conclusions were drawn from incomplete documentation. The Child Care Desert Grant program was thoughtfully developed in response to urgent needs during the COVID-19 recovery, with the goal of expanding access to child care in underserved communities using the discretion and authority granted to states under federal guidance. While OKDHS acknowledges that improvements could have been made to certain aspects of the program’s implementation—particularly regarding documentation clarity, post-award monitoring, and technical assistance— the SAI findings do not reflect the intent, structure, or compliance framework outlined in federal guidance. 2 CFR § 200.303(a) – Internal Controls DHS has strengthened internal controls consistent with federal expectations. For example, in the instance involving a grantee related to a DHS official, the potential conflict was identified and escalated by OKDHS to SAI as well as the Ethics Commission, and the individual was not directly involved in the reviewing and approving award process. In addition, the employee’s spouse was not included on any documentation included in the facilities application. This demonstrates that internal controls operated effectively. 2 CFR § 200.403 – Allowability of Costs This regulation applies to allowability under the Uniform Guidance, but per 45 CFR § 75.101(d), Subpart E (which ncludes § 200.403) does not apply to CCDF ARP discretionary funds unless explicitly stated. Federal guidance, including ACF-IM-2021-03, affirms that states were given broad flexibility in the design and implementation of such programs. Accordingly, DHS used its discretion to structure payments and allowable uses consistent with that guidance. Many costs questioned by SAI—such as business technology, minor remodeling, and start-up costs—were clearly allowable per the Desert Grant Guidance. 42 U.S. Code § 9858c(c)(2)(I) DHS did not fund sectarian instruction or activities. Expenditures were related to facility compliance and licensing, which is expressly permitted under this section when needed to meet health and safety standards. Providers affirmed compliance in their applications. 42 U.S. Code § 9858k(a) No funding was used for sectarian worship or instruction. All grantees signed affirmations that they would comply with all federal requirements, including those related to religious neutrality. Where expenditures were found that may raise concerns, they are being reviewed for compliance with these requirements. 42 U.S. Code § 9858k(b) DHS did not provide funding for services rendered during the regular school day or for academic credit. In the referenced after-school program, funds were used to expand access to licensed child care outside of regular instructional hours. Documentation of use is being reviewed, and additional guidance will be provided to ensure clarity in future programs. 42 U.S. Code § 9858d(b) and 45 CFR § 98.2 – Construction and Renovation DHS recognizes that one provider exceeded the $350,000 minor remodeling limit. This was an isolated case. At the time, DHS did not interpret the project scope as meeting the federal definition of "major renovation." DHS is enhancing its oversight process and guidance to providers to ensure full alignment with federal cost limits moving forward. Additional Clarifications • Expenditures cited as unallowable often fall within the scope of minor remodeling, technology, or business development explicitly allowed in Desert Grant FAQs and ACF guidance. • SAI’s estimate of questioned costs includes speculative assumptions based on documentation gaps—not confirmed misuse. • Many of the questioned costs SAI appears to be extrapolating were supplied directly from OKDHS’ own internal audit team and have either been addressed or are under investigation and should not be included in any additional questioned cost extrapolation. • The program was developed under severe federal timelines (obligation by 9/30/23), and ACF’s memoranda explicitly encouraged innovative approaches, including expansion grants to new and small providers. Corrective Actions (Planned or Completed) to be implemented on future emergency awards 1. Policy & Procedure Enhancements – Revised award language, documentation standards, and milestone disbursement options are being implemented. 2. Conflict of Interest Controls – OKDHS had a conflict of interest control in place to try and capture all potential conflicts based on the structure of the agency. OKDHS is expanding the process to extend to any staff members that have decision making approval. 3. Improved Monitoring – Targeted post-award reviews, site checks, and spending verification measures are being conducted. 4. Provider Training & Technical Assistance – Providers are receiving additional education on fiscal documentation, grant compliance, and reporting expectations. Anticipated Completion Date N/A Responsible Contact Person Kayla Urtz
View Audit 367158 Questioned Costs: $1
Finding Number 2023-103 Subject Heading (Financial) or AL no. and program name (Federal) 93.575 – CCDF Cluster Planned Corrective Action The QRIS incentive payments were designed as a strategic investment to increase participation in Oklahoma’s redesigned Stars Quality Rating and Improvement System ...
Finding Number 2023-103 Subject Heading (Financial) or AL no. and program name (Federal) 93.575 – CCDF Cluster Planned Corrective Action The QRIS incentive payments were designed as a strategic investment to increase participation in Oklahoma’s redesigned Stars Quality Rating and Improvement System (QRIS), which aligns directly with the statutory purposes outlined in 42 USC 9858c(c)(3)(B) — specifically, improving the quality and availability of child care services. The incentive structure was intentionally crafted to encourage engagement among providers who had not previously participated in quality rating efforts. Encouraging this engagement is a nationally recognized strategy to improve the quality of care across the system. 42 USC § 9858c(c)(3)(B) The incentive payments were issued for the express purpose of engaging providers in a new QRIS system designed to improve child care quality, directly aligned with this statute. The law permits “activities that improve the quality or availability of such services” and “any other activity that the State determines to be appropriate.” DHS determined the incentive model was an appropriate and effective method to encourage participation in quality rating, a commonly accepted CCDF quality activity. 45 CFR § 98.67(a) DHS did follow its internal policies and procedures in disbursing incentive payments. Providers submitted applications, were vetted through an internal process, and received payments based on eligibility criteria and Stars level requests. This structure complied with DHS’s established process and satisfied the requirements of §98.67(a). The regulation does not impose a requirement for retrospective receipts or cost documentation for incentive payments. 45 CFR § 98.67(c)(2) QRIS incentive payments were disbursed through traceable, documented transactions—each tied to a provider’s application, Stars level requested, and approved amount. These records are maintained in DHS’s internal systems. There was no requirement in the federal Notice of Award (NOA) to trace QRIS incentive funds to the recipient expenditure level 2 CFR § 200.303(a) DHS established pre-award internal controls, including a structured QRIS application process, eligibility screening, and fixed incentive tiers linked to Stars level requests. The Department maintained auditable records of participation and payment amounts. There was no requirement in the federal Notice of Award to trace these funds to the recipient expenditure level, as the child care providers were not subrecipients under 2 CFR § 200.1. Instead, they received non-reimbursement incentive payments tied to participation in a state-defined quality improvement activity. The internal control standard calls for “reasonable assurance,” which DHS satisfied through documented eligibility reviews, centralized approvals, and audit-ready payment tracking. Anticipated Completion Date N/A Responsible Contact Person Kayla Urtz
View Audit 367158 Questioned Costs: $1
Finding Number 2023-099 Subject Heading (Financial) or AL no. and program name (Federal) 93.575 – CCDF Cluster Planned Corrective Action The Oklahoma Department of Human Services (DHS) respectfully disagrees with several assertions made in this finding and believes the State Auditor has misapplied c...
Finding Number 2023-099 Subject Heading (Financial) or AL no. and program name (Federal) 93.575 – CCDF Cluster Planned Corrective Action The Oklahoma Department of Human Services (DHS) respectfully disagrees with several assertions made in this finding and believes the State Auditor has misapplied certain federal guidance, including Section 2202(e)(1) of the ARP Act, and incorrectly characterized the Department’s internal controls and program intent. Specifically: 1. Allowability of Costs: The activities cited as “unallowable” by the auditor do not appear to violate Section 2202(e)(1) of the ARP Act. That provision explicitly allows for a broad set of uses including “goods and services necessary to maintain or resume child care services.” DHS maintains that the expenditures made by the providers fall within the permissible categories outlined in the statute and that the audit applies a narrower interpretation than what federal guidance supports. 2. Documentation and Internal Controls: DHS issued grant funding as stabilization support to preserve child care operations during a critical period of recovery and transition, as encouraged by the federal guidance. In accordance with ARP Act expectations around expediting support, DHS designed a simplified reapplication process focused on accessibility and participation, especially for providers historically underrepresented in the quality rating system. While DHS did not require pre-spending documentation from providers—consistent with the stabilization nature of the funding—it did provide clear guidance on allowable uses and will further strengthen post-award monitoring protocols going forward. DHS acknowledges that improvements could be made in documentation expectations and will take steps to implement a structured sampling and review process for provider expenditures to enhance accountability without deterring participation. 3. Stars System Reapplication and Ratings: The temporary policy to waive certain visits and allow self-nominated Stars levels was a deliberate effort to incentivize participation and improve provider engagement with the new QRIS. The assertion that increased Star ratings led to unjustified funding increases does not consider the system’s transitionary design nor the planned monitoring that follows implementation. DHS was transparent in its guidance to providers and structured the increases to align with system reforms in development since before the ARP funding was issued. 4. Commingling of Funds: DHS did not require separate accounts for stabilization grants, consistent with federal practice and provider burden considerations. We do, however, acknowledge that clearer expectations and technical assistance on fund tracking would be beneficial. DHS will issue revised guidance encouraging, but not mandating, the separation of grant-related expenditures and will explore cost-effective technical supports for provider-level financial documentation. Anticipated Completion Date N/A Responsible Contact Person Kayla Urtz
View Audit 367158 Questioned Costs: $1
Finding Number 2023-100 Subject Heading (Financial) or AL no. and program name (Federal) 93.568 - LIHEAP Planned Corrective Action Detail eligibility data is not used to complete the Household Report. OKDHS uses system-generated summary reports and eligibility data to complete the Household Report. ...
Finding Number 2023-100 Subject Heading (Financial) or AL no. and program name (Federal) 93.568 - LIHEAP Planned Corrective Action Detail eligibility data is not used to complete the Household Report. OKDHS uses system-generated summary reports and eligibility data to complete the Household Report. The reports are EN600R02, EN600R03, EN600R04, and EN601R. OKDHS provided SAI copies of these reports for both FFY 2022 and 2023 on January 15, 2025. An image of the email is attached below: Anticipated Completion Date N/A Responsible Contact Person Caleb Turner
Finding Number 2023-084 Subject Heading (Financial) or AL no. and program name (Federal) 93.568 - LIHEAP Planned Corrective Action DHS agrees that improvements are needed in documentation and coordination to support the accurate identification and tracking of ARPA payments. While all recipients of t...
Finding Number 2023-084 Subject Heading (Financial) or AL no. and program name (Federal) 93.568 - LIHEAP Planned Corrective Action DHS agrees that improvements are needed in documentation and coordination to support the accurate identification and tracking of ARPA payments. While all recipients of the supplemental ARPA payments had documented arrearages and met general LIHEAP eligibility at the time of payment, we recognize the need for improved system documentation and reporting processes to support eligibility determinations and data integrity. It is also important to note that the ARPA funding was a onetime, temporary supplement to LIHEAP and is no longer active in the current program year. OKDHS is taking the following steps to strengthen system documentation, reporting accuracy, and cross-divisional reconciliation: • System and Reporting Enhancements: The Data Transformation Office (DTO) and Finance Division are collaborating to develop system functionality and reporting tools that clearly identify funding sources and improve the readability and completeness of payment data used for audit and program oversight. • Cross-Divisional Reconciliation Effort: AFS, Finance, and DTO are jointly working to establish a coordinated reconciliation process that ensures eligibility data aligns with payment records and federal reporting, including future SEFA submissions. • Process Documentation: OKDHS is documenting the updated processes and reporting requirements to ensure consistency in implementation and to support audit readiness going forward. • Internal Audit Oversight and Support: OKDHS has recently reorganized its Internal Audit division to enhance independence, improve reporting structure, and expand its capacity to support internal control consultation and program integrity reviews. Internal Audit will assist in evaluating reconciliation efforts, documentation standards, and data reporting controls as they are implemented. Anticipated Completion Date Ongoing Responsible Contact Person Kayla Urtz
Finding Number 2023-032 Subject Heading (Financial) or AL no. and program name (Federal) 93.568 - LIHEAP Planned Corrective Action The Oklahoma Department of Human Services will ensure data used to calculate LIHEAP Quarterly Performance Data and Management report is clearly documented regarding the ...
Finding Number 2023-032 Subject Heading (Financial) or AL no. and program name (Federal) 93.568 - LIHEAP Planned Corrective Action The Oklahoma Department of Human Services will ensure data used to calculate LIHEAP Quarterly Performance Data and Management report is clearly documented regarding the data is being used, how it was calculated for this report, and ensure this documentation saved at the time the report is created. Anticipated Completion Date 4/30/2025 Responsible Contact Person Matthew Conley
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