Corrective Action Plans

Finding 391584 (2023-007)

Significant Deficiency 2023

NY

Eligibility Internal Control / Segregation of Duties Student Financial Aid § 200.303

Finding No. 2023-007 Department(s): New York City Administration for Children’s Services Program(s): Assistance Listing Number 93.658, Foster Care – Title IV - E Corrective Action(s): • ACS will review all outstanding non-finalized Redetermination packages and re-request outstanding Court Order...

Finding No. 2023-007 Department(s): New York City Administration for Children’s Services Program(s): Assistance Listing Number 93.658, Foster Care – Title IV - E Corrective Action(s): • ACS will review all outstanding non-finalized Redetermination packages and re-request outstanding Court Orders. • Moving forward, if the hard copy Court Order has not been received by ACS within 90 days of the Permanency Hearing, ACS will request a court transcript of the Permanency Hearing. • ACS will finalize IV-E Redetermination packages if a Reasonable Effort determination finding has not been conferred within four months of the request for court action. • ACS will work with the Office of Court Administration to address challenges in timely completion of hearings and receipt of Court Orders. Anticipated Completion Date: September 2024 Person(s) Responsible for Implementation: Andrew Martin, Executive Director, Central Eligibility Office (212)-341-2816

View Audit 302042

Finding 391582 (2023-013)

Material Weakness 2023

The City of New York

NY

Questioned Costs Internal Control / Segregation of Duties Eligibility § 200.303

Finding No. 2023-013 Department(s): New York City Administration for Children’s Services and New York City Human Resources Administration Program(s): Assistance Listing Number 93.575, Child Care and Development Block Grant Corrective Action(s): ACS: ACS will work with other agencies to promote co...

Finding No. 2023-013 Department(s): New York City Administration for Children’s Services and New York City Human Resources Administration Program(s): Assistance Listing Number 93.575, Child Care and Development Block Grant Corrective Action(s): ACS: ACS will work with other agencies to promote compliance and internal controls going forward. HRA: In response to the findings, HRA made the following training requests to address the specific findings identified in this audit: 1. Training ID 2344 - Childcare liaisons and Childcare Review Team (CCRT) require training for the appropriate documentation necessary for the approval and provision of childcare. Audit findings confirmed that the staff charged with approval and authorizing childcare will take refresher training about the appropriate documentation requirements (i.e., CS-274w, LDSS 4699, LDSS 4700, etc.). The training will emphasize the requirement that any approved childcare must have support underlying employment/education documentation to justify the provision of the childcare. Childcare is a supportive service, so any childcare must have employment/engagement/education as a condition precedent. 2. Training ID 2343 - The training will include information about the client's employment, rate of pay, frequency of pay, and getting the appropriate documentation into the case records. Audits confirmed that 1) when the agency budgeted income and approved supportive services (i.e., childcare), the record did not have supporting income and employment related documents; 2) training will include the process for budgeting the earned income and applied any earned income disregards. Anticipated Completion Date: April 2024 and ongoing Person(s) Responsible for Implementation: ACS: Rahel Getachew, Associate Commissioner (212)-676-8818. HRA: Ramon E. Flores, Deputy Commissioner, Family Independence Administration (FIA) floresra@hra.nyc.gov

View Audit 302042 Questioned Costs: $1

Finding 391579 (2023-008)

Significant Deficiency 2023

The City of New York

NY

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.303

Finding No. 2023-008 Department(s): New York City Department of Health and Mental Hygiene Program(s): Assistance Listing Number 93.323, Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Corrective Action(s): DOHMH agrees with the recommendation that “DOHMH strengthen its intern...

Finding No. 2023-008 Department(s): New York City Department of Health and Mental Hygiene Program(s): Assistance Listing Number 93.323, Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Corrective Action(s): DOHMH agrees with the recommendation that “DOHMH strengthen its internal controls over the reporting process to include documented review and approval of all financial and special performance reports prior to submission within the required timeframe.” DOHMH Finance will ensure sufficient time to meet and discuss the status of spending and plans for remaining balance before the end of the award period. For example, such meeting will occur at least a month before the end of the award period. DOHMH Finance will ensure sufficient time for review and approval process of the FFR and submit within the required timeframe. For example, send annual FFR for program review at least 2 weeks before the report deadline. Approval deadline date will be added to the approval email and followed up on a consistent basis. The Division of Disease Control will document review of ELC-related reports prior to submission. Anticipated Completion Date: Effective Immediately; 3/20/2024 Person(s) Responsible for Implementation: Anthony Faciane, Assistant Commissioner, afaciane@health.nyc.gov Wai ting Yu, Assistant Commissioner, wyu4@health.nyc.gov Jennifer Carmona, Senior Director, jcarmona@health.nyc.gov Yuming Li, Director, yli@health.nyc.gov Xiu mei Mai, Director, xmai@health.nyc.gov Jenny Tejada, Director, jtejada@health.nyc.gov James Chan, Assistant Director, jchan6@health.nyc.gov Inna Dubrovenska, Assistant Director, idubrovenska@health.nyc.gov Yulia Gudzinskiy, Grants Manager, ygudzinskiy@health.nyc.gov

View Audit 302042

Finding 391569 (2023-009)

Significant Deficiency 2023

The City of New York

NY

Equipment & Real Property Management Internal Control / Segregation of Duties § 200.303 § 200.313

Finding No. 2023-009 Department(s): New York City Department of Investigation Program(s): Assistance Listing Number 16.922, Equitable Sharing Program Corrective Action(s): Based on the recommendations outlined in the audit report, we have developed the following corrective action plan to address...

Finding No. 2023-009 Department(s): New York City Department of Investigation Program(s): Assistance Listing Number 16.922, Equitable Sharing Program Corrective Action(s): Based on the recommendations outlined in the audit report, we have developed the following corrective action plan to address the deficiencies and improve compliance with equipment and real property management requirements. • Strengthen Controls over the Inventory Process: We developed and implemented additional controls over the inventory process to ensure that equipment dispositions are updated in the equipment records, inventories performed are reconciled back to equipment records, and biennial inventory counts are consistently performed over all equipment within the required timeframe. • Training for Personnel: We provide training to all personnel involved in the equipment and real property management process, including property officers and program managers, to ensure they are aware of the new controls and standard operating procedure, and understand their roles and responsibilities related to compliance requirements. • Continuous Monitoring: We developed a continuous monitoring program to ensure that the new controls and procedures are being followed, and to identify any areas for improvement. • We developed Equitable Sharing Program Standard Operating Procedures (“SOPs”) for the New York City Department of Investigation (“DOI” or “Department”) apply to the Department’s use of U.S. Department of Justice (“DOJ”) Equitable Sharing Program (“Program”) funds. These SOPs are intended to complement, not replace, the required guidance found in the “Guide to Equitable Sharing for State, Local, and Tribal Law Enforcement Agencies” (July 2018) (“Guide”) and Equitable Sharing Wires (“Wires”), as well as any relevant Department and City policies and procedures. The agency is actively pursuing a centralized inventory management system to improve the effectiveness of inventory management. These corrective actions will help to ensure that federally funded equipment is accurately recorded on inventory records and that inventory is not misplaced, misappropriated, or otherwise disposed of outside of the requirements of federal guidelines. We appreciate the opportunity to address the audit findings, and we are committed to implementing these corrective actions. Anticipated Completion Date: March 31, 2025 Person(s) Responsible for Implementation: Caspar Barrow, Executive Director of Finance/CFO CBarrow@doi.nyc.gov (212)-825-0666 Orane Gordon, Internal Auditor OGordon@doi.nyc.gov (212)-825-0123

View Audit 302042

Finding 391568 (2023-016)

Material Weakness 2023

The City of New York

NY

HUD Housing Programs Eligibility Material Weakness § 200.303

Finding No. 2023-016 Department(s): New York City Housing Preservation & Development Program(s): Assistance Listing Number 14.871, Housing Voucher Cluster: Section 8 Housing Choice Vouchers Corrective Action(s): During the pandemic, HPD adopted HUD CARES Act waivers, intended to minimize health ...

Finding No. 2023-016 Department(s): New York City Housing Preservation & Development Program(s): Assistance Listing Number 14.871, Housing Voucher Cluster: Section 8 Housing Choice Vouchers Corrective Action(s): During the pandemic, HPD adopted HUD CARES Act waivers, intended to minimize health and safety risks to applicants, participants, owners and staff, and which included the temporary suspension of adverse actions. Although HPD continued to request recertification packages during the period of the waivers until today, from February 2020 through December 2021, HPD did not penalize families who did not submit complete recertification packages. Additionally, HPD is among the City agencies that experienced a staff retention crisis, with attrition rates among its Rental Subsidy Program administrative teams swelling from 12 percent in 2020 to 27 percent in 2022. During the audit period, HPD was experiencing its highest vacancy rate. This meant standard recertifications were delayed because participants did not respond to recertification packages they were asked to complete, HPD did not have the capacity to revoke subsidies for those who did not comply, and the agency had significant backlog as a result of staff vacancies. Though HPD’s vacancy rate improved, it takes significant time to train and prepare staff to do the work. Finally, even though HPD’s COVID-era policies involving adverse action have ceased and normal processes are now in effect, due process requires intensive tracking and follow up to ideally have participants comply with requirements but if necessary to terminate assistance for those who do not comply. Therefore, there will be a significant lag between the re-implementation of HPD’s policy to take enforcement actions when recertification packages are not completed or missing and HPD’s actually terminating assistance. Corrective Action(s): 1. Build on existing systems to more closely track recertifications that are mailed and not returned. 2. Develop more robust digital operations that were started during the pandemic leading to reporting capabilities that will help with tracking overdue recertifications. 3. Work more closely with Community Based Organizations that can assist participants complete and return recertification package. 4. Continue close coordination to implement the Housing Access and Stability staffing plan and identify priority hires to onboard critically needed staff timely. 5. Invest in a training team to meet the training needs of new staff. Anticipated Completion Date: April 2025 Person(s) Responsible for Implementation: Dinsiri Fikru, Assistant Commissioner, Division of Program Policy and Innovation, Office of Housing Access and Stability FIKRUD@hpd.nyc.gov

View Audit 302042

Finding 391565 (2023-015)

Material Weakness 2023

The City of New York

NY

HUD Housing Programs Internal Control / Segregation of Duties Special Tests & Provisions § 200.303

Finding No. 2023-015 Department(s): New York City Housing Preservation & Development Program(s): Assistance Listing Numbers: 14.249, Section 8 Project-Based Cluster: Section 8 Moderate Rehabilitation Single Room Occupancy 14.856, Section 8 Project-Based Cluster: Lower Income Housing Assistance P...

Finding No. 2023-015 Department(s): New York City Housing Preservation & Development Program(s): Assistance Listing Numbers: 14.249, Section 8 Project-Based Cluster: Section 8 Moderate Rehabilitation Single Room Occupancy 14.856, Section 8 Project-Based Cluster: Lower Income Housing Assistance Program – Section 8 Moderate Rehabilitation Corrective Action(s): These deficiencies result from HPD adopting HUD CARES Act waivers, intended to minimize health and safety risks to applicants, participants, owners and staff, and which included the temporary suspension of inspections and adverse actions. HPD conducted limited inspections and did not take enforcement action during the waiver period of 2/1/2020 through 12/31/2021. These waivers ended in 2022 in the midst of a significant HPD staffing shortage. HPD is among the City agencies that experienced a staff retention crisis, with attrition rates among its Housing Maintenance Code inspection team that mirrored the 27 percent experienced in HPD’s rental subsidy program administration team. Although HPD’s COVID-era policies have ceased, and normal processes are now in effect, it will take a significant period of time for full standard operations to resume. Corrective Action(s): 1. Develop a detailed tracking process for routine inspection scheduling. 2. Prioritize inspections for units that are upcoming or those that have gone the longest without an inspection. 3. Develop a detailed tracking and follow up process for enforcing failed inspections. 4. Make every effort to ensure staff vacancy rates are addressed through in house recruitment or other means as needed. Anticipated Completion Date: April 2025 Person(s) Responsible for Implementation: Dinsiri Fikru, Assistant Commissioner, Division of Program Policy and Innovation, Office of Housing Access and Stability FIKRUD@hpd.nyc.gov

View Audit 302042

Finding 391564 (2023-014)

Material Weakness 2023

The City of New York

NY

HUD Housing Programs Eligibility Material Weakness § 200.303

Finding No. 2023-014 Department(s): New York City Housing Preservation & Development Program(s): Assistance Listing Numbers: 14.249, Section 8 Project-Based Cluster: Section 8 Moderate Rehabilitation Single Room Occupancy 14.856, Section 8 Project-Based Cluster: Lower Income Housing Assistance P...

Finding No. 2023-014 Department(s): New York City Housing Preservation & Development Program(s): Assistance Listing Numbers: 14.249, Section 8 Project-Based Cluster: Section 8 Moderate Rehabilitation Single Room Occupancy 14.856, Section 8 Project-Based Cluster: Lower Income Housing Assistance Program – Section 8 Moderate Rehabilitation Corrective Action(s): During the pandemic, HPD adopted HUD CARES Act waivers, intended to minimize health and safety risks to applicants, participants, owners and staff, and which included the temporary suspension of adverse actions. Although HPD continued to request recertification packages during the period the waivers, February 2020 through December 2021, HPD did not penalize families who did not submit complete recertification packages at that time until more recently. Additionally, HPD is among the City agencies that experienced a staff retention crisis, with attrition rates among its Rental Subsidy Program administrative teams swelling from 12 percent in 2020 to 27 percent in 2022. During the audit period, HPD was experiencing its highest vacancy rate. This meant standard recertifications were delayed because participants did not respond to recertification packages they were asked to complete, HPD did not have the capacity to revoke subsidies for those who did not comply, and the agency had significant backlog as a result of staff vacancies. Though HPD’s vacancy rate improved, it takes significant time to train and prepare staff to do the work. Finally, even though HPD’s COVID-era policies involving adverse action have ceased and normal processes are now in effect, due process requires intensive tracking and follow-up to ideally have participants comply with requirements (but if necessary to terminate assistance for those who do not comply). Therefore, there will be a significant lag between the re-implementation of HPD’s policy to take enforcement actions when recertification packages are not completed or missing and HPD’s actually terminating assistance. Corrective Action(s): 1. Build on existing systems to more closely track recertifications that are mailed and not returned. 2. Develop more robust digital operations that were started during the pandemic leading to reporting capabilities that will help with tracking overdue recertifications. 3. Work more closely with Community Based Organizations that can assist participants complete and return recertification package. 4. Continue close coordination to implement the Housing Access and Stability staffing plan and identify priority hires to onboard critically needed staff timely. 5. Invest in a training team to meet the training needs of new staff. Anticipated Completion Date: April 2025 Person(s) Responsible for Implementation: Dinsiri Fikru, Assistant Commissioner, Division of Program Policy and Innovation, Office of Housing Access and Stability FIKRUD@hpd.nyc.gov

View Audit 302042

Finding 391561 (2023-005)

Significant Deficiency 2023

The City of New York

NY

HUD Housing Programs Internal Control / Segregation of Duties Eligibility § 200.303

Finding No. 2023-005 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Numbers 14.241, Housing Opportunities for Persons with AIDS (HOPWA) Corrective Action(s): HASA will enhance its data management system to flag housing units where rent amounts are repor...

Finding No. 2023-005 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Numbers 14.241, Housing Opportunities for Persons with AIDS (HOPWA) Corrective Action(s): HASA will enhance its data management system to flag housing units where rent amounts are reportedly above the prevailing Fair Market Rent (FMR) limits per bedroom size, and document follow up activities accordingly. Staff will continue to review support documentation during monitoring visits to ensure client rent calculations are current and accurately completed. HASA will continue facilitating monthly technical assistance meetings and convene training sessions with housing providers to address emerging issues and contract compliance findings from monitoring visits. Anticipated Completion Date: April 1, 2024 and ongoing Person(s) Responsible for Implementation: Xiomara Pamela Farquhar, Assistant Deputy Commissioner farquharx@hra.nyc.gov

View Audit 302042

Finding 391560 (2023-004)

Significant Deficiency 2023

The City of New York

NY

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring § 200.303

Finding No. 2023-004 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Number 14.241, Housing Opportunities for Persons with Aids Corrective Action(s): HASA will revamp its contract monitoring policies and procedures to ensure sampling of housing inspectio...

Finding No. 2023-004 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Number 14.241, Housing Opportunities for Persons with Aids Corrective Action(s): HASA will revamp its contract monitoring policies and procedures to ensure sampling of housing inspection reports and related maintenance and repairs documentation are included to assess compliance with housing quality standards. Documentation reviewed will also include confirmation of apartments’ readiness prior to occupancy and corrective action measures taken to address outstanding deficiencies, including failed inspections. Anticipated Completion Date: April 1, 2024 and ongoing Person(s) Responsible for Implementation: Xiomara Pamela Farquhar, Assistant Deputy Commissioner farquharx@hra.nyc.gov

View Audit 302042

Finding 391558 (2023-002)

Material Weakness 2023

The City of New York

NY

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

Finding No. 2023-002 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s): This FY23 audit was conducted on the heels of the FY22 audit where the questioned cost finding is a similar er...

Finding No. 2023-002 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s): This FY23 audit was conducted on the heels of the FY22 audit where the questioned cost finding is a similar error type but significantly decreased to $296 from over $18,000. Included in the FY22 recommended Corrective Action was the onboarding of the Executive Director to shepherd the charge with strengthening the teams’ internal governance, appropriate monitoring and future compliance. Adversely, the onboarding of the executive director was lengthy and only recently finalized in the 2nd quarter of FY24. HRA agrees to strengthen internal controls and the new Executive Director is working with the team to ensure they are intentional in appropriately applying the correct formula for calculating allowable cost, particularly the inclusion of “gross” and not “net” income. The Quality Assurance Tool has been updated including specific sub-items to ensure allowable cost is correctly calculated as well as the other deliverables. Corrective Action(s) • Strengthen internal governance and future compliance. • Executive Director for the Home-TBRA now on board. • Update the Quality Assurance tool that includes sub-items information that supports improved review and approval. • Provide refresher training for staff involved with TBRA to improve performance and outcomes. Anticipated Completion Date: June 30, 2024 and ongoing Person(s) Responsible for Implementation: Dori Hopkins-Figeroux, Director - HTBRA hopkinsfigerouxd@hra.nyc.gov 929-252-6089 Jordan Worrell, Executive Director RAP/HTBRA worrellj@hra.nyc.gov 929-252- 5403 Dwana Abraham, Assistant Deputy Commissioner abrahamd@hra.nyc.gov 929-221-6726

View Audit 302042 Questioned Costs: $1

Finding 391440 (2023-001)

Significant Deficiency 2023

Community Action Partnership of Oregon

OR

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Corrective Action: Susan Matlack Jones (SMJ) took over as CAPO’s fiscal service provider in July of 2022. The first six months were spent largely cleaning and correcting journal entries from FY22 – a significant task. CAPO did not begin to receive truly accurate and trustworthy financial statements ...

Corrective Action: Susan Matlack Jones (SMJ) took over as CAPO’s fiscal service provider in July of 2022. The first six months were spent largely cleaning and correcting journal entries from FY22 – a significant task. CAPO did not begin to receive truly accurate and trustworthy financial statements until early in 2023. CAPO also experienced two staff losses in the finance department from March through May of 2023. In light of our growth and increased administrative needs, we revised our job posting to increase the level of fiscal skill and responsibility needed for the Finance Manager role. In September of 2023, CAPO was successful in hiring a Finance and Grants Manager with experience in federal fund accounting for Community Action and in SSVF (our major grant). Since that time, he has organized, revamped, and significantly improved internal processes to assure timely review of all finances and reconciliations and works closely with SMJ to assure overall accuracy. Person Responsible: Janet Allanach, CAPO Executive Director Timing for Implementation: Complete as of October 2023

View Audit 301926

Finding 391432 (2023-004)

Material Weakness 2023

County of Nevada

CA

Reporting Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking § 200.302 § 200.303

The Auditor-Controller’s office will provide additional training to applicable departments to educate staff on appropriate records maintenance related to grant files and the importance documented review and approval processes. This training will provide additional education over appropriate supporti...

The Auditor-Controller’s office will provide additional training to applicable departments to educate staff on appropriate records maintenance related to grant files and the importance documented review and approval processes. This training will provide additional education over appropriate supporting documentation to verify internal controls and compliance requirements are being reasonably followed

View Audit 301919

Finding 391426 (2023-003)

Material Weakness 2023

County of Nevada

CA

Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.320

The County is continuing to implement a county-wide contract clause that will be added to covered transaction contracts to comply with 2 CFR 180, to ensure covered transactions receive verification that the person or entity is not excluded or disqualified. Review and approval of this suspension and ...

The County is continuing to implement a county-wide contract clause that will be added to covered transaction contracts to comply with 2 CFR 180, to ensure covered transactions receive verification that the person or entity is not excluded or disqualified. Review and approval of this suspension and debarment verification will be performed during the contract approval process, which will include this standardized clause. The County’s purchasing policy and procedures manual will be updated to include this standard suspension and debarment verification process to ensure this procedure is communicated county-wide and followed. Additionally, the County will develop standard justification forms to document method of procurement to be maintained in the procurement file. The County will also update its contract templates to include applicable suspension and debarment attestation language which meets Federal requirements and update its purchasing policy and procedures manual to reflect these changes.

View Audit 301919

Finding 391403 (2023-002)

Significant Deficiency 2023

County of Nevada

CA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking § 200.302 § 200.303 § 200.403 § 200.430 § 200.431

The County is continuing to draft and establish written procedures for county-wide and department specific use when determining the allowability of personnel costs related to federal awards. A primary function of this policy will be to provide guidance to county staff to ensure personnel costs are r...

The County is continuing to draft and establish written procedures for county-wide and department specific use when determining the allowability of personnel costs related to federal awards. A primary function of this policy will be to provide guidance to county staff to ensure personnel costs are recognized in accordance with cost principles, statues, regulations, and terms and conditions of federal awards.

View Audit 301919

Finding 391374 (2023-005)

Significant Deficiency 2023

Board of Education of Prince George's County Maryland

MD

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.344

Special Education-Grants for Infants and Families– Assistance Listing No. 84.181 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit fin...

Special Education-Grants for Infants and Families– Assistance Listing No. 84.181 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Infants and Toddlers Supervisor will conduct monthly reviews of outstanding purchase orders in Oracle, addressing issues promptly with the Business Operation Officer/Financial Analyst. Professional development sessions will be attended to enhance invoice scrutiny for allowable expenses within the grant period. Quarterly reminders and Financial Quarterly Review meetings will be instituted for supervisors, ensuring timely action on outstanding purchase orders. Following will be implemented: 1. Infants and Toddler Supervisor will hold monthly meetings with the Financial Analyst and the secretarial staff to ensure consistent actions are taken when generating purchase orders and processing invoices. 2. The Infants and Toddler secretary will review invoice dates against contracts and purchase orders to ensure they fall within grant timelines before submitting them to the supervisor for signature. 3. Infants and Toddler Supervisor will confirm that purchases made with grant funds are allowable and within the designated grant period. The Supervisor will cross-reference invoice dates against grant periods before signing and sending to accounts payable. 4. The infants and Toddler Supervisor will confirm the work being invoiced has been completed and vendor details are checked, and dates verified. 5. Grant Accountants will provide transaction detail reports (at least quarterly). The Infant and Toddlers Coordinating Supervisor will review and sign-off on the quarterly transaction reports. 6. The Financial Analyst will meet monthly with the Infants and Toddler Supervisor and Coordinating Supervisor to ensure grant allowable expenses are adhered to and invoicing is updated and falls within grant-specific timelines. Name(s) of the contact person(s) responsible for corrective action: Office of Infant and Toddlers/Coordinating Supervisor & Fiscal Analyst and Business Operation Office/Fiscal Analyst & Office of Infant and Toddlers/Coordinating Supervisor Planned completion date for corrective action plan: June 2024

View Audit 301912 Questioned Costs: $1

Finding 391341 (2023-004)

Significant Deficiency 2023

Board of Education of Prince George's County Maryland

MD

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.344

Special Education Cluster – Assistance Listing No. 84.027 & 84.173 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit finding: There is...

Special Education Cluster – Assistance Listing No. 84.027 & 84.173 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Infants and Toddlers Supervisor will conduct monthly reviews of outstanding purchase orders in Oracle, addressing issues promptly with the Business Operation Officer/Financial Analyst. Professional development sessions will be attended to enhance invoice scrutiny for allowable expenses within the grant period. Quarterly reminders and Financial Quarterly Review meetings will be instituted for supervisors, ensuring timely action on outstanding purchase orders. Following will be implemented: 1. Infants and Toddler Supervisor will hold monthly meetings with the Financial Analyst and the secretarial staff to ensure consistent actions are taken when generating purchase orders and processing invoices. 2. The Infants and Toddler secretary will review invoice dates against contracts and purchase orders to ensure they fall within grant timelines before submitting them to the supervisor for signature. 3. Infants and Toddler Supervisor will confirm that purchases made with grant funds are allowable and within the designated grant period. The Supervisor will cross-reference invoice dates against grant periods before signing and sending to accounts payable. 4. The infants and Toddler Supervisor will confirm the work being invoiced has been completed and vendor details are checked, and dates verified. 5. Grant Accountants will provide transaction detail reports (at least quarterly). The Infant and Toddlers Coordinating Supervisor will review and sign-off on the quarterly transaction reports. 6. The Financial Analyst will meet monthly with the Infants and Toddler Supervisor and Coordinating Supervisor to ensure grant allowable expenses are adhered to and invoicing is updated and falls within grant-specific timelines. Name(s) of the contact person(s) responsible for corrective action: Office of Infant and Toddlers/Coordinating Supervisor & Fiscal Analyst and Business Operation Office/Fiscal Analyst & Office of Infant and Toddlers/Coordinating Supervisor Planned completion date for corrective action plan: June 2024

View Audit 301912 Questioned Costs: $1

Finding 391324 (2023-006)

Material Weakness 2023

Ashley Medical Center

ND

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Reporting Federal Agency Name: Department of Hea lth and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center claimed lost revenues that were incorrectly calculated or not supp...

Reporting Federal Agency Name: Department of Hea lth and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center claimed lost revenues that were incorrectly calculated or not supported. These were improperly included within the HHS Report Period 4 and caused the Report to be inaccurate. Responsible Individuals: Corey Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure that the required reports are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: 6/30/2024

View Audit 301891

Finding 391323 (2023-005)

Material Weakness 2023

Ashley Medical Center

ND

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

Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center selected lo...

Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center selected lost revenue ca lculation option i which is actual to actual methodology of calculating lost revenues attributable to coronavirus. The Medical Center did not incorporate the financial audit adjustments into the actual revenue amounts reported within the HHS special report for the fiscal years 2019, 2020, and 2021. Responsible Individuals: Corey Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure the lost revenue calculation is supported by internal financia ls. We will also implement control policies to ensure a secondary review and approval over the final lost revenue calculation. Anticipated Completion Date: 6/30/2024

View Audit 301891

Finding 391322 (2023-004)

Material Weakness 2023

Ashley Medical Center

ND

Allowable Costs / Cost Principles § 200.303

Activities Allowed or Unallowed, Allowable Costs/Costs Principles, and Reporting Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Cen...

Activities Allowed or Unallowed, Allowable Costs/Costs Principles, and Reporting Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center's final expenditure listing, lost revenue calculation identified as eligible and claimed under the Provider Relief Fund program, and special report submitted to the Department of Health and Human Services for Period 4 did not have evidence of being reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Cory Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure all invoices are reviewed and approved to ensure all expenses claimed under the federal program are necessary, correct, and meet the requirements of the federal program. We will also implement a control process which includes a secondary review and approval of the final expenditure listing and lost revenue calculation used to claim the allowable costs under the federal program and that there is documented evidence of the review and approval. In addition, the Report submitted to HHS will have a secondary review and approval that is documented. Anticipated Completion Date: 6/30/2024

View Audit 301891

Finding 391321 (2023-003)

Material Weakness 2023

Ashley Medical Center

ND

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

Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center does not ha...

Activities Allowed or Unallowed, Allowable Costs/Costs Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center does not have an adequate internal control policy in place to ensure review and approval of cash disbursements claimed under the federal programs were documented and to ensure that expenses claimed in the Report were complete, accurate, and reduced by other funding sources. Responsible Individuals: Corey Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure all amounts reimbursed by other funding sources are adequately documented and reduced from the eligible expenditure listing and are properly recorded in the Report required to be submitted to the federal agency. We will also implement internal control policies to ensure that the required Report are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the Report required to be submitted to the federal agency. Anticipated Completion Date: 6/30/2024

View Audit 301891

Finding 391258 (2023-002)

Significant Deficiency 2023

The Children's Home Society of Florida

FL

Subrecipient Monitoring Eligibility Significant Deficiency § 200.303

Identifying Number: 2023-002 – Eligibility Finding: The Code of Federal Regulations (CFR) Section 200.303(a) states the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the feder...

Identifying Number: 2023-002 – Eligibility Finding: The Code of Federal Regulations (CFR) Section 200.303(a) states the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). The State of Florida’s Department of Financial Services’ State Projects Compliance Supplement Part Five: Internal Controls Section D. Eligibility states that recipients should develop Control Objectives to provide reasonable assurance that only eligible individuals and organizations receive assistance under state projects, that subawards are made only to eligible subrecipients, and that amounts provided to or on behalf of eligibles were calculated in accordance with project requirements. During our testing of participant eligibility, we noted that supervisory personnel did not properly review and approve their eligibility documentation prior to the participant entering the program for ten of 80 participants selected for eligibility testing. Corrective Actions Taken or Planned: Corrective measures were taken with the Program Leadership responsible for the eligibility documentation noted above. The following corrective actions are in the process of being implemented: • CHS’s Program Leadership and their teams will conduct a review of respective intake forms completed after July 1, 2023 to ensure that all were properly reviewed and approved. Any unapproved intake forms identified will be verified and retroactively approved by the designated supervisor. • In cases where there are instances of unapproved intake forms, the Program Leadership will collaborate with the respective Talent Business Partner to follow up with formal corrective action. Such corrective action will include: o A thorough review of the CHS policies and practices relative to the management and approval of intake forms. o Mandatory refresher education and training with all staff to ensure they understand the steps required to document review and approval of the intake process, as well as the importance of maintaining evidence that the process was adequately performed. Person(s) Responsible for Corrective Actions: Barbara McDonald, Chief Financial Officer and Chief Administrative Officer and Heather Brungardt, Chief Program and Clinical Officer Anticipated Completion Date for Corrective Actions: Implementation of the Corrective Actions outlined above will begin immediately to be completed by June 30, 2024.

View Audit 301878

Finding 391242 (2023-003)

Significant Deficiency 2023

Anna Marie's Alliance

MN

Cash Management Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

SD Crime Victim Assistance – Assistance Listing No. 16.575 Recommendation: A separate individual with supervisory authority over the preparer should be assigned to review and approve the cash drawdowns and reports prior to submission. Explanation of disagreement with audit finding: There is no disag...

SD Crime Victim Assistance – Assistance Listing No. 16.575 Recommendation: A separate individual with supervisory authority over the preparer should be assigned to review and approve the cash drawdowns and reports prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will designate a separate individual to review and approve the cash reimbursement requests and reports prior to submission. Name(s) of the contact person(s) responsible for corrective action: Tracy Johnson, Director of Finance Planned completion date for corrective action plan: June 30, 2024

View Audit 301868

Finding 391189 (2023-003)

Significant Deficiency 2023

City and Borough of Juneau, Alaska

AK

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

Finding: 2023-003 Significant Deficiency in Internal Controls over Compliance and Compliance – Reporting (Bartlett Regional Hospital enterprise fund) Name of Contact Person: Joe Wanner, Chief Financial Officer Corrective Action: For any unusual or new grant reporting, management will implement add...

Finding: 2023-003 Significant Deficiency in Internal Controls over Compliance and Compliance – Reporting (Bartlett Regional Hospital enterprise fund) Name of Contact Person: Joe Wanner, Chief Financial Officer Corrective Action: For any unusual or new grant reporting, management will implement additional review procedures to ensure information is captured as expected. The unallowable expense, which had previously been reported and was mistakenly included in the report again, will be “replaced” by unreimbursed lost revenues, which was the intended use of the funds from the beginning. Proposed Completion Date: March 26, 2024

View Audit 301806 Questioned Costs: $1

Finding 391171 (2023-004)

Significant Deficiency 2023

Mercy Health

MO

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

Finding 2023-004 Reporting Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantor: State of Missouri, State Emergency Management Agency Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially D...

Finding 2023-004 Reporting Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantor: State of Missouri, State Emergency Management Agency Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (“FEMA”) Pass-Through Award Numbers: Project# 699963 P/W# 624; Project# 185883 P/W# 529; and Project# 150136 P/W# 171 Condition: Timeliness and submission of the quarterly reports required by the State of Missouri could not be verified. Views of Responsible Officials and Planned Corrective Actions: The state of Missouri requires all quarterly reports be mailed. While we did send in our quarterly reports to the state of Missouri as required, we do not have proof of submissions as we did not send by certified mail. All future quarterly reporting will be documented with an email to our State SEMA representative when we send out quarterly reports so there is documentation for our records. Responsible Party: Emily Bruening, Director – Finance Date of Completion: This will be implemented for our next round of quarterly reporting, due in April 2024.

View Audit 301777

Finding 391170 (2023-003)

Material Weakness 2023

Mercy Health

MO

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.333 § 200.403

Finding 2023-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantors: State of Missouri, State Emergency Management Agency Arkansa...

Finding 2023-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantors: State of Missouri, State Emergency Management Agency Arkansas Division of Emergency Management Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (“FEMA”) Pass-Through Award Numbers and Award Periods: Project# 185883 P/W# 529 01/20/2020–09/14/2020 Project# 699963 P/W# 624 01/01/2022–07/01/2022 Project# 699667 P/W# 233 01/01/2022–07/01/2022 Project# 699670 P/W# 211 01/01/2022–07/01/2022 Condition: Adequate documentation was not retained to support the average unit cost applied to COVID-19 personal protective equipment (PPE) inventory usage charged to the FEMA program as Force Account Material (FAM) costs. In addition, for 12 of 40 non-FAM costs (including purchased equipment, purchased supplies and rental equipment) charged to the program, we noted adequate documentation was not retained to evidence review and approval of the expenditure for allowability. Views of Responsible Officials and Planned Corrective Actions: Mercy Health has a system to calculate average cost of inventory items. We rely on this system, but it was not tested as part of compliance. In addition, Mercy Health has a robust capital approval process (for all equipment) and financial approval thresholds. All COVID purchases were logged in the capital system (VFA) and approvals were documented. During this time, we changed approval systems from VFA to Strata. We will implement testing of our inventory system (Lawson) to ensure calculations are accurate. All review and approvals of capital equipment will be maintained in Strata. Responsible Party: Jill McCart, VP Accounting and Reporting Date of Completion: By 6/30/24

View Audit 301777 Questioned Costs: $1

Corrective Action Plans

Filters