Corrective Action Plans

Finding 390475 (2023-003)

Material Weakness 2023

NH

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

In order to meet the segregation of duties, the Department will explore the need to create a position to ensure requisite segregation of duties requirements. With regard to the segregation of duties, the SF-270 is required form that DMAVS submits to the National Guard Appendix Program Manager for re...

In order to meet the segregation of duties, the Department will explore the need to create a position to ensure requisite segregation of duties requirements. With regard to the segregation of duties, the SF-270 is required form that DMAVS submits to the National Guard Appendix Program Manager for reimbursement with all back up documentation. The National Guard Appendix Program Manager, National Guard Grants Officer Representative, and National Guard United States Property Fiscal Officer (USPFO)/controller located in Concord, NH review, sign and submit the form to the Department of Defense on behalf of DMAVS to request the cash draw. Prior to the submission of reimbursement of any funds, each billing and invoice is reviewed, entered into a ledger and reconciled by three members of the accounting team. Once reconciled, the SF-270 is prepared and signed by the Financial Administrator. The SF-270 is then submitted to the appendix program manager for concurrence and then to the federal fiscal agent (USPFO) for approval. No funds are drawn down until approved by the USPFO. If this is not a satisfactory level of review, the department will request a new position to ensure that there the business function has the proper level of staffing to meet the requirements for segregation of duties.

View Audit 301259

Finding 390474 (2023-002)

Material Weakness 2023

State of New Hampshire

NH

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

For clarity the Department will create a redundant manual ledger that duplicates the functions of the current ledger and Detailed Transaction Register (DTR). DMAVS has existing policies and procedures in place to track all federal funds, state funds and mixed funds, and uses spreadsheets for all tr...

For clarity the Department will create a redundant manual ledger that duplicates the functions of the current ledger and Detailed Transaction Register (DTR). DMAVS has existing policies and procedures in place to track all federal funds, state funds and mixed funds, and uses spreadsheets for all transactions that reconciles every month to NH First Detail Transaction Register (DTR), Federal Fund tracking sheet, and Federal reimbursement tracking sheet with backup documents. The tracking sheet for the federal register is not intended to account for the state share of billing. The state share is accurately accounted for in the DTR, the cumulative accounting in the SF-270 and associated back up documentation. Supporting documentation to substantiate the accuracy of lines a, c, e, and f is in the DTR, the cumulative accounting of each SF-270, the supporting documentation sent with the billing to the Federal Government, and Year-end Agency Report for Federal Awards. This includes reconciliation and analysis of SADB expenditures and revenues to the Statement of Appropriations by each Program Accounting Unit. The SF-270 form is continuous cumulative data that starts Oct 1st and runs through the end of that Federal Fiscal Year. The SF-270 is the required federal form DMAVS submits to the Federal National Guard Appendix Program Manager for reimbursement. Back up documentation is submitted with the SF-270. The National Guard Appendix Program Manager, National Guard Grants Officer Representative, and National Guard United States Property Fiscal Officer (USPFO)/controller located in Concord, NH review, sign and submit the form to the Department of Defense to affect the cash draw. DMAVS does not unilaterally make cash draws to the federal government. The USPFO, who is substantially involved provides an independent review and reconciles any discrepancies prior to approving any requests for reimbursement. One possible explanation for the finding is that the selected test works were not continuous.

View Audit 301259

Finding 390473 (2023-002)

Material Weakness 2023

Guthrie County Hospital

IA

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

Department of Health and Human Services: Federal Financial Assistance Listing #93.498 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 4 TIN #426037759 Activities Allowed or Unallowed and Allowable Costs/Cost Principles ...

Department of Health and Human Services: Federal Financial Assistance Listing #93.498 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 4 TIN #426037759 Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Material Weakness in Internal Control Over Compliance 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 entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: Guthrie County Hospital (the Hospital) reported expenses in the Department of Health and Human Services (HHS) special report for Period 4 that were not reduced by reimbursement from other sources or that other sources were obligated to reimburse. Additionally, the Hospital did not report its excess expenses as unreimbursed expenses attributable to Coronavirus in the HHS special report, did not report total interest earned on the ARP Rural Payments and Period 4 General Distribution Payments, and reported gross revenues/net charges from patient care by quarter for 2021 when net revenues should have been reported. In addition, there was no evidence retained that the HHS special report was reviewed by an individual separate from the preparer prior to submission. Planned Corrective Action: Management will implement an internal control policy for federal awards compliance to more diligently review the reporting of expenses and revenues to ensure all reporting requirements are met. However, had the errors in reporting of expenses and lost revenues been identified and corrected prior to reporting, the Hospital would have demonstrated that they had incurred eligible expenses and lost revenue in excess of the Period 4 funds received, including interest on such funds. Contact Person, Title and Phone Number: Christopher Stipe, Chief Executive Officer, (641)332-2201 Anticipated Date of Completion: June 30, 2024

View Audit 301254

Finding 390470 (2023-003)

Material Weakness 2023

The Be Kind People Project Foundation

AZ

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

2023‐003 Material Weakness in Internal Control over Compliance with Actvities Allowed Unallowed and Allowable Costs/Cost Principles Condition: The Organiza􀆟on did not retain the required documentation to support the review of expenditures. Cause: The Organization had turnover and limited staffing av...

2023‐003 Material Weakness in Internal Control over Compliance with Actvities Allowed Unallowed and Allowable Costs/Cost Principles Condition: The Organiza􀆟on did not retain the required documentation to support the review of expenditures. Cause: The Organization had turnover and limited staffing available. Management’s Response and Corrective Action Plan: The CEO will add a regular discussion point to the weekly finance meetings in which the finance department reports on both the status of federal funds and the expenditures using those funds. Responsible Individuals: -Maintain separate tracking account – Marcia Meyer, CEO, in conjunction with Board Finance Committee - Authorization for use of funds – Marcia Meyer - Maintenance of records for use – Jennie Myers - Confirmation with use of funds per allowable uses per national guidelines – Jennie Myers - Reporting on monthly finance report – Jennie Myers Anticipated Completion Date: This process is underway and will be visible at the fiscal year‐end audit in June 2024

View Audit 301253

Finding 390445 (2023-004)

Significant Deficiency 2023

Oregon Tech

OR

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

Student Financial Assistance Cluster – Assistance Listing No. 84.038 Recommendation: We recommend that they assign the loans back to the Department of Education or have the students resign the loans via Electronic MPN or Paper MPN and retain those in the proper manner. Explanation of disagreement ...

Student Financial Assistance Cluster – Assistance Listing No. 84.038 Recommendation: We recommend that they assign the loans back to the Department of Education or have the students resign the loans via Electronic MPN or Paper MPN and retain those in the proper manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management respectfully agrees on all findings and recommendations. Management will engage in additional staff training and is committed to consistent application of current policies and procedures to ensure all student loan documentation is maintained per the U.S. Department of Education policies. Management will assign the respective loans back to the Department of Education as to be in compliance with U.S. Department of Education requirements. Name(s) of the contact person(s) responsible for corrective action: Karissa Sultan Planned completion date for corrective action plan: June 30, 2024

View Audit 301235

Finding 390442 (2023-003)

Significant Deficiency 2023

Oregon Tech

OR

Significant Deficiency Internal Control / Segregation of Duties § 200.303

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007 Recommendation: We recommend that the University enhance its policies and procedures to ensure required contracts and contract components are provided to the U.S. Department of Education. Explanation of disagreeme...

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007 Recommendation: We recommend that the University enhance its policies and procedures to ensure required contracts and contract components are provided to the U.S. Department of Education. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management respectfully agrees on all findings and recommendations. Management will engage in additional staff training and is committed to consistent application of current policies and procedures to ensure all required information is provided to the U.S. Department of Education. Additionally, Management will work to ensure that the required contract URL is provided the U.S. Department of Education, following the agency’s requirements. Name(s) of the contact person(s) responsible for corrective action: Karissa Sultan Planned completion date for corrective action plan: June 30, 2024

View Audit 301235

Finding 390441 (2023-002)

Significant Deficiency 2023

Oregon Tech

OR

Significant Deficiency Internal Control / Segregation of Duties § 200.303

Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: CLA recommends that the University enhance its policies and procedures regarding stale-dated check escheatment to ensure that the funds are returned to the appropriate program within 240 days from the date of issue...

Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: CLA recommends that the University enhance its policies and procedures regarding stale-dated check escheatment to ensure that the funds are returned to the appropriate program within 240 days from the date of issue. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management respectfully agrees on all findings and recommendations. Management will engage in additional staff training and is committed to consistent application of current policies and procedures regarding stale-dated federal student financial aid outstanding checks. Management will implement additional procedures, returning checks issued directly by the University that stale-dated, similar to policies and procedures followed by the University’s third-party credit balance refund vendor. As part of this procedure, management will engage in student communication and outreach, similar to the University’s regular escheatment procedures. Management believes that a consistent practice between University-issued checks and third-party credit balance refund vendor-issued checks is in the best interest of students while also adhering to U.S. Department of Education timing requirements. Name(s) of the contact person(s) responsible for corrective action: Karissa Sultan Planned completion date for corrective action plan: June 30, 2024

View Audit 301235

Finding 390438 (2023-001)

Significant Deficiency 2023

Oregon Tech

OR

Student Financial Aid Subrecipient Monitoring Reporting § 200.303

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007 Recommendation: CLA recommends that the University enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting i...

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007 Recommendation: CLA recommends that the University enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting is completed accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management respectfully agrees on all findings and recommendations. Management will engage in additional staff training and is committed to consistent application of current policies and procedures to ensure enrollment reporting and monitoring of third-party service providers results in accurate and timely reporting by the third-party service provider. While the third-party service provider has a national monopoly on enrollment reporting, with other institutions of higher education also facing similar reporting issues by the third-party service provider, Management believes that enhanced training and internal procedures over enrollment reporting will mitigate accuracy and timeliness errors made by the third party service provider, resulting in the University meeting U.S. Department of Education requirements. Name(s) of the contact person(s) responsible for corrective action: Ashlie Pence Planned completion date for corrective action plan: June 30, 2024

View Audit 301235

Finding 390428 (2023-004)

Material Weakness 2023

Delaware State University

DE

Reporting Subrecipient Monitoring Material Weakness § 200.303 § 200.502 § 200.510

2023-004 Student Financial Aid Cluster – Schedule of Expenditure of Federal Awards (SEFA) Recommendation: We recommend that the University reevaluate its policies and controls related to the preparation of the SEFA to ensure its complete and accurate. Explanation of disagreement with audit finding: ...

2023-004 Student Financial Aid Cluster – Schedule of Expenditure of Federal Awards (SEFA) Recommendation: We recommend that the University reevaluate its policies and controls related to the preparation of the SEFA to ensure its complete and accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director will reevaluate the controls and set in place policies and procedures for SEFA completion. Name(s) of the contact person(s) responsible for corrective action: Director of Restricted Funds Accounting, Symone Merritt Planned completion date for corrective action plan: October 2024

View Audit 301226

Finding 390425 (2023-008)

Significant Deficiency 2023

Delaware State University

DE

Questioned Costs Cash Management § 200.303 § 200.305

2023-008 COVID-19, Education Stabilization Fund: Higher Education Emergency Relief Fund - Student Aid Portion and Institutional Portion – Federal Assistance Listing Nos. 84.425E and 84.425F – Cash Management Recommendation: We recommend the University formally document, establish controls and monito...

2023-008 COVID-19, Education Stabilization Fund: Higher Education Emergency Relief Fund - Student Aid Portion and Institutional Portion – Federal Assistance Listing Nos. 84.425E and 84.425F – Cash Management Recommendation: We recommend the University formally document, establish controls and monitor advances in federal funds to ensure time elapsing between the transfer of funds and disbursement is minimized and any interest required to be remitted is calculated and returned on a timely basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University will formally document, establish controls and monitor advances in federal funds to ensure time elapsing between the transfer of funds and disbursement is minimized and any interest required to be remitted is calculated and returned on a timely basis. Name(s) of the contact person(s) responsible for corrective action: Assistant Controller, Clifton Smith, II Planned completion date for corrective action plan: June 2024

View Audit 301226 Questioned Costs: $1

Finding 390424 (2023-007)

Significant Deficiency 2023

Delaware State University

DE

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

2023-007 COVID-19, Education Stabilization Fund: Higher Education Emergency Relief Fund - Student Aid Portion and Institutional Portion – Federal Assistance Listing Nos. 84.425E and 84.425F - Reporting Recommendation: We recommend the University enhances its procedures, controls, and review policie...

2023-007 COVID-19, Education Stabilization Fund: Higher Education Emergency Relief Fund - Student Aid Portion and Institutional Portion – Federal Assistance Listing Nos. 84.425E and 84.425F - Reporting Recommendation: We recommend the University enhances its procedures, controls, and review policies around HEERF reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Business & Finance will populate and upload the quarterly CARES HBCU and Institutional reports by the 10th day after the end of each calendar quarter. The Office of Student Accounts will create and upload the quarterly CARES Student Portion reports by the 10th day after the end of each calendar quarter. Name(s) of the contact person(s) responsible for corrective action: Assistant Controller, Clifton Smith, II & Executive Director of Student Accounts, Carold Boyer-Yancy. Planned completion date for corrective action plan: May 2024

View Audit 301226

Finding 390420 (2023-005)

Material Weakness 2023

Delaware State University

DE

Matching / Level of Effort / Earmarking Student Financial Aid Material Weakness § 200.303

2023-005 Student Financial Assistance Cluster – Federal Assistance Listing Nos. 84.063, and 84.268 – Enrollment Reporting Recommendation: We recommend the University evaluate its procedures and review policies in overseeing submissions to the NSLDS completed by the third-party servicer. Additionally...

2023-005 Student Financial Assistance Cluster – Federal Assistance Listing Nos. 84.063, and 84.268 – Enrollment Reporting Recommendation: We recommend the University evaluate its procedures and review policies in overseeing submissions to the NSLDS completed by the third-party servicer. Additionally, we recommend the University review its policies and procedures on reporting enrollment information to the NSLDS to ensure that all relevant information is being captured and reported timely in accordance with applicable regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Registrar’s Office will strengthen procedures and reporting practices to ensure timely submission to the National Student Clearinghouse (NSCL) & the National Student Load Data System (NSLDS). The Registrar’s Office will confirm and ensure the submissions to the National Student Clearinghouse (NSCL) corresponds with the timeframe the enrollment is rolled over to the National Student Loan Data System (NSLDS). Name(s) of the contact person(s) responsible for corrective action: Registrar, Dr. Genita Mangum Planned completion date for corrective action plan: July 2024

View Audit 301226

Finding 390416 (2023-009)

Material Weakness 2023

Delaware State University

DE

Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking § 200.303

2023-009 Student Financial Assistance Cluster – Federal Assistance Listing Nos. 84.007, 84.063, 84.033 and 84.268 – Gramm-Leach-Bliley Act (GLBA) Recommendation: We recommend the University review is policies and procedures and update the information security plan to be GLBA compliant. Explanation o...

2023-009 Student Financial Assistance Cluster – Federal Assistance Listing Nos. 84.007, 84.063, 84.033 and 84.268 – Gramm-Leach-Bliley Act (GLBA) Recommendation: We recommend the University review is policies and procedures and update the information security plan to be GLBA compliant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division of Information Technology is reviewing the written policies and procedures needed to safeguard the University’s applications and data. This includes all 3rd party developed/ implemented applications as well. Name(s) of the contact person(s) responsible for corrective action: Executive Director of Network Services, Russel Weaver & VP/ Chief Information Officer, Darrell McMillion. Planned completion date for corrective action plan: June 2024

View Audit 301226

Finding 390414 (2023-003)

Significant Deficiency 2023

Metropolitan Community College Area

NE

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

COVID-19 Education Stabilization Fund Recommendation: We recommend the College establish a system to ensure reports are submitted in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All HEERF funds ...

COVID-19 Education Stabilization Fund Recommendation: We recommend the College establish a system to ensure reports are submitted in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All HEERF funds have been spent and reports are posted on the website. No additional reports will need to be posted. Name(s) of the contact person(s) responsible for corrective action: Brenda Schumacher Planned completion date for corrective action plan: Prior to Summer 2023

View Audit 301214

Finding 390379 (2023-104)

Material Weakness 2023

Coconino County

AZ

Reporting Internal Control / Segregation of Duties § 200.303

Cluster name: WIOA Cluster Assistance Listings number and program name: 17.258 WIOA Adult Program 17.259 WIOA Youth Program 17.278 WIOA Dislocated Worker Formula Grants Contact person: Billy Francis, Executive Director, Coconino Workforce Development Board, County Administration Anticipated completi...

Cluster name: WIOA Cluster Assistance Listings number and program name: 17.258 WIOA Adult Program 17.259 WIOA Youth Program 17.278 WIOA Dislocated Worker Formula Grants Contact person: Billy Francis, Executive Director, Coconino Workforce Development Board, County Administration Anticipated completion date: June 30, 2024 Concur. The County Administration department acknowledges the required financial reports were not all submitted during FY23. The Department did not have a tracking mechanism in place to ensure that all staff were aware of the status of report submission. Additionally, due to recent turnover, the Department did not have staff trained to complete the reports. The Department will complete and submit missing federal financial reports according to the direction provided by the Arizona Department of Economic Security. The County will ensure that the staff responsible for grant reporting have the knowledge and skills necessary to do so in compliance with federal requirements and grant accounting practices. The County has implemented a mechanism to monitor and track reporting due dates and oversee reports to ensure accuracy.

View Audit 301196

Finding 390378 (2023-103)

Material Weakness 2023

Coconino County

AZ

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

Cluster name: WIOA Cluster Assistance Listings number and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Program 17.278 WIOA Dislocated Worker Formula Grants Contact person: Billy Francis, Executive Director, Coconino Workforce Development Board, County Administration Anticipated complet...

Cluster name: WIOA Cluster Assistance Listings number and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Program 17.278 WIOA Dislocated Worker Formula Grants Contact person: Billy Francis, Executive Director, Coconino Workforce Development Board, County Administration Anticipated completion date: June 30, 2024 Concur. The County Administration Department acknowledges the work experience (WEX) requirement was not met for the Workforce Innovation and Opportunity Act (WIOA) Youth Program Year 2021 allocation. The Department has a tracking mechanism in the financial system and other records to account for the percentage of youth expenditures made on WEX activities. Due to an oversight, the percentage of WEX expenditures in relation to the total allocation was not monitored by staff. Additionally, the amount of WEX funding allocated to the Youth program service provider was insufficient to meet the requirement. The Department will write procedures for the monitoring of earmarking requirements, including WEX, to ensure the roles and responsibilities of staff and key stakeholders are clearly defined. The calculation of funds allocated to the service provider will factor in the level of WEX expenditures needed for the County to meet the requirement. The Department will work with the WIOA Youth program service provider to employ best practices and strategies to recruit eligible in-school and out-of-school youth in need of WEX activities to further their skills and job readiness. The Department will monitor WEX expenditures made by the service provider and provide technical assistance as needed. If the Department projects the County will not meet the threshold for a certain program year allocation, it will seek technical assistance from the Arizona Department of Economic Security.

View Audit 301196 Questioned Costs: $1

Finding 390377 (2023-102)

Material Weakness 2023

Coconino County

AZ

Questioned Costs Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.320 § 200.327

Assistance Listings number and program name: 10.691 Good Neighbor Authority Contact persons: Lucinda Andreani, Deputy County Manager and Flood Control District Administrator Anticipated completion date: June 30, 2025 Concur. The Coconino County Flood Control District (FCD) acknowledges price was no...

Assistance Listings number and program name: 10.691 Good Neighbor Authority Contact persons: Lucinda Andreani, Deputy County Manager and Flood Control District Administrator Anticipated completion date: June 30, 2025 Concur. The Coconino County Flood Control District (FCD) acknowledges price was not considered as a factor for contractor selection in the procurement of construction services for the Good Neighbor Authority program in accordance with 2 CFR 200 Subpart D Procurement Standards. A procurement was completed for construction-manager at-risk (CMAR) services, authorized by A.R.S. 28-7366, because the FCD believed at that time that the method would also satisfy the federal standards. The CMAR method bases selection on qualification and competence, does not allow for pricing to be requested or considered before making the selection, and transfers the risk of budget overages to the contractor by agreement to a Guaranteed Maximum Price (GMP). After selecting the contractor for Good Neighbor Authority construction projects, the FCD worked closely with the County’s contracted engineering firm to ensure that the GMP was reasonable and cost efficiencies were identified and implemented throughout all stages of the project. The County believes the prices paid as a result of the procurement are reasonable and no excess federal expenditures were made due to the non-federal procurement method that was used in error. FCD fiscal and management staff will receive formal training on 2 CFR 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, also known as the Uniform Guidance, to ensure its requirements are understood. Additionally, the FCD will implement written internal procurement procedures to be used for future procurements so that they are made in accordance with all applicable laws, regulations and policies. The County Finance Department has a designated grant accounting team specializing in compliance with Federal award requirements. The FCD will request technical assistance from this team prior to initiating any procurement with Federal funds to help make sure Federal regulations are considered and met. The Finance Department will provide training to all departments on Uniform Guidance requirements. Training will also be provided on the County’s procurement policies and procedures to help departments gain a complete understanding of the requirements for acquiring goods and services with federal funds. In line with the County’s decentralized finance model in which financial management staff are located within the departments, the responsibility to meet requirements specific to certain federal awards rests with the department that manages the award. The Finance Department will identify the source of funding for procurements requested by departments. Staff who are knowledgeable about Federal procurement requirements and the County’s procurement policies and procedures will review and approve the procurements involving federal awards.

View Audit 301196 Questioned Costs: $1

Finding 390376 (2023-101)

Material Weakness 2023

Coconino County

AZ

Internal Control / Segregation of Duties Reporting § 200.301 § 200.302 § 200.303

Assistance Listings number and program name: 10.691 Good Neighbor Authority Contact person: Lucinda Andreani, Deputy County Manager and Flood Control District Administrator Anticipated completion date: June 30, 2024 Concur. The Coconino County Flood Control District (FCD) acknowledges the annual fi...

Assistance Listings number and program name: 10.691 Good Neighbor Authority Contact person: Lucinda Andreani, Deputy County Manager and Flood Control District Administrator Anticipated completion date: June 30, 2024 Concur. The Coconino County Flood Control District (FCD) acknowledges the annual financial and performance reports were not filed in accordance with the contract. The cash draw reports were completed for the award according to the contractual requirements. Therefore, the federal agency was aware of all expenditures made under the award. The FCD will submit all missing annual financial and performance reports. With assistance from the Finance Department, the FCD will develop procedures to ensure all reporting requirements are met. These procedures will include internal timelines, designated roles and responsibilities, and a tracking mechanism. Additionally, fiscal capacity will be created through the training of an additional staff member in reporting to serve as backup so contractual reporting requirements can be fulfilled when unforeseen challenges arise such as declared emergencies and flood events.

View Audit 301196

Finding 390344 (2023-001)

Material Weakness 2023

Hawaii Pacific University

HI

Allowable Costs / Cost Principles § 200.303

For payroll-related expenditures, management reviewed the duties of individuals and estimated the percentage of their time allocable to the program based upon knowledge of office functions, job duties, and additional demands and tasks related to the COVID-19 pandemic. This review and discussions wit...

For payroll-related expenditures, management reviewed the duties of individuals and estimated the percentage of their time allocable to the program based upon knowledge of office functions, job duties, and additional demands and tasks related to the COVID-19 pandemic. This review and discussions within the management team resulted in the amounts allocated to the HEERF program; the percentage allocations assigned were documented in the calculations used to support the payroll activity recorded during the fiscal year ended June 30, 2023. For non-payroll related expenditures, documented policies were not developed for the HEERF program expenditures and as a result supporting justifications were not consistently documented or maintained. For all expenditures associated with the HEERF program, when documentation was not obtained or maintained, management was basing decisions on all regulations available at the time and decisions made did not violate the intent of the program. The HEERF awards were fully expended as of June 30th, 2022 for the Student Portion and as of September 30th, 2022 for the Institutional Portion. Should similar programs become available in the future, management will develop, in advance of expending funds, documented policies and procedures to administer the program and will maintain documentation demonstrating compliance with program requirements and related institutional policy and procedure. Person Responsible: Assistant Vice President for the Office of Sponsored Projects; Manager, Office of Sponsored Projects; Director of Financial Aid. Targeted Correction Date: n/a, program has ended. Fiscal Year in which Finding Initially Occurred: 2021 (Finding Number 2021-002).

View Audit 301190

Finding 390294 (2023-003)

Material Weakness 2023

Commonspirit Health

IL

Allowable Costs / Cost Principles § 200.303 § 200.430

REFERENCE: 2023-003 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: St. Mary Medical Center – Long Beach Bailey-Boushay House Finding: At St. Mary Medical Center – Long B...

REFERENCE: 2023-003 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: St. Mary Medical Center – Long Beach Bailey-Boushay House Finding: At St. Mary Medical Center – Long Beach and Bailey-Boushay House, controls over the required allowability criteria with regard to payroll expense were not performed and/or documented throughout the year. Corrective Action Plan: At St. Mary Medical Center – Long Beach, the leadership team implemented a timecard review process to ensure timecards are properly signed off and approved each pay period, with exceptions confirmed via email from the appropriate manager. At Bailey-Boushay House, each Friday and Monday prior to running payroll, approval reminders will be sent to all staff with the time-keeping policy attached. At least two different leaders and/or the scheduling coordinator will send these reminders. Staff have been educated on the two-step approval system and it will impact their performance evaluation if there is continued non-compliance. The executive director will ensure supervisory follow-up with each name that shows up in the audit report each pay period by Kronos Reports. Person Responsible: Vo Phay Sin, Controller – St. Mary Medical Center, Long Beach Rob Hays, Executive Director – Bailey Boushay House Expected Completion: April 2024

View Audit 301158

Finding 390290 (2023-002)

Significant Deficiency 2023

Commonspirit Health

IL

Allowable Costs / Cost Principles § 200.303 § 200.430

REFERENCE: 2023-002 – Allowable Costs/Cost Principles Medical Assistance Program (Medicaid Cluster) (Assistance Listing No. 93.778) Federal Grantor: U.S. Department of Health and Human Services Facility: Mercy San Juan Medical Center Finding: At Mercy San Juan Medical Center, internal controls ove...

REFERENCE: 2023-002 – Allowable Costs/Cost Principles Medical Assistance Program (Medicaid Cluster) (Assistance Listing No. 93.778) Federal Grantor: U.S. Department of Health and Human Services Facility: Mercy San Juan Medical Center Finding: At Mercy San Juan Medical Center, internal controls over the required allowability criteria with regard to payroll expense were not performed for 2 of 25 employees selected for testing. Corrective Action Plan: In addition to timecard approval by supervisors, Mercy San Juan Medical Center Finance will review a sign-off report and obtain written approval via email for unapproved timecards. Person Responsible: Lianna Petrosyan, Director of Finance Expected Completion: April 2024

View Audit 301158

Finding 390289 (2023-001)

Material Weakness 2023

Commonspirit Health

IL

Eligibility Matching / Level of Effort / Earmarking § 200.303

REFERENCE: 2023-001 – Eligibility Medicaid Cluster (Assistance Listing No. 93.778) Federal Grantor: U.S. Department of Health and Human Services Facility: Dignity Health Medical Foundation Finding: The Dignity Health Medical Foundation did not retain evidence of Medicaid eligibility being reviewed...

REFERENCE: 2023-001 – Eligibility Medicaid Cluster (Assistance Listing No. 93.778) Federal Grantor: U.S. Department of Health and Human Services Facility: Dignity Health Medical Foundation Finding: The Dignity Health Medical Foundation did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided. Corrective Action Plan: For the Medical Assistance Program, eligibility is validated through a Medi-Cal system website. Dignity Health Medical Foundation personnel have implemented procedures to ensure documentation of eligibility checks are retained. The Clinic Operations manager has instructed staff and supervisors to save proof of eligibility for all months. The Clinic Operations manager checks for retention of eligibility documentation on a random basis and an internal audit will be performed to check for compliance with the documentation retention. Person Responsible: Nicole Hill, Clinic Operations Manager, Dignity Health Medical Foundation. Completion: September 1, 2022

View Audit 301158

Finding 390287 (2023-013)

Significant Deficiency 2023

Commonspirit Health

IL

Procurement, Suspension & Debarment Eligibility Reporting § 200.303

REFERENCE: 2023-013 – Activities Allowed or Unallowed Provider Relief Fund and American Rescue Plan (ARP) Rural Distributions (PRF) (Assistance listing No. 93.498) Federal Grantor: U.S. Department of Health and Human Services Facility: Catholic Health Initiatives Colorado (CHIC) Finding: Manageme...

REFERENCE: 2023-013 – Activities Allowed or Unallowed Provider Relief Fund and American Rescue Plan (ARP) Rural Distributions (PRF) (Assistance listing No. 93.498) Federal Grantor: U.S. Department of Health and Human Services Facility: Catholic Health Initiatives Colorado (CHIC) Finding: Management did not consistently retain evidence to support that internal controls were in place and operating effectively for approval of invoices with purchase orders and to ensure that bonuses paid to employees related to COVID-19 were eligible to receive the bonus. Corrective Action Plan: This program has ended. CHIC has no additional funding to apply expenses to.

View Audit 301158

Finding 390285 (2023-012)

Significant Deficiency 2023

Commonspirit Health

IL

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

REFERENCE: 2023-012 – Special Tests and Provisions – Return of Title IV Funds SFA Cluster (Assistance Listing No. 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Good Samaritan College of Nursing and Health Science did no...

REFERENCE: 2023-012 – Special Tests and Provisions – Return of Title IV Funds SFA Cluster (Assistance Listing No. 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Good Samaritan College of Nursing and Health Science did not calculate and return Title IV funds in a timely manner to the U.S. Department of Education, within 45 days after the date the institution determined that a student withdrew. Good Samaritan College of Nursing & Health Science did not provide evidence of an effective review process to ensure the timely calculation and return of Title IV funds to the U.S. Department of Education. Corrective Action Plan: To ensure timely returns, Financial Aid Services will incorporate an additional step to the return disbursement process. The additional step will occur after each return to ensure the Common Origination and Disbursement (COD) system shows the return successfully processed for the student. Financial Aid Services will review the student’s disbursement detail history in COD to confirm the return credit adjustment has been applied to the appropriate record and it shows an applied date at ED within the appropriate timeframe for the return. To document this process has been completed, Financial Aid Services will maintain a spreadsheet for all returns. The spreadsheet will document the student, amount of the return, date processed in Financial Aid and Student Accounts, date processed in G5, and date applied at ED per COD. If any issues arise during this review where the return did not successfully apply at ED, Financial Aid Services will review and resolve rejects immediately so the record can move forward and process successfully within the required timeframe. The Dean of Financial Services will validate the report submitted by Financial Aid Services on a monthly basis and submit the document to the President. Both will review and sign the documentation. This documentation will be presented to the GSC Compliance Oversight Committee to ensure monthly verification of time return of Title IV funds. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science Expected Completion: April 2024

View Audit 301158

Finding 390280 (2023-007)

Material Weakness 2023

Commonspirit Health

IL

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

REFERENCE: 2023-007 – Special Tests and Provisions – Disbursements to or on Behalf of Students SFA Cluster (Assistance Listing No. 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Find...

REFERENCE: 2023-007 – Special Tests and Provisions – Disbursements to or on Behalf of Students SFA Cluster (Assistance Listing No. 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Finding: Good Samaritan College of Nursing & Health Science did not send loan notifications to 3 of 30 students selected for disbursement testing for direct loans within 30 days of funds being disbursed. CHI Health School of Radiologic Technology did not send loan notifications to 14 of 14 students for disbursement testing with direct loans within 30 days of funds being disbursed. Corrective Action Plan: This finding has been corrected for Good Samaritan. As of May 2023, for April 2023 loan disbursements, compliance is verified monthly through internal audit of student disbursements. A sample of disbursements is checked for proper and timely notifications. Timeliness of notifications is checked and verified by the Compliance Oversight Committee monthly. CHI Health School of Radiologic Technology will review their processes to develop and implement internal controls that ensure compliance with federal regulations. Evidence of the internal control being performed will be retained. Person Responsible: Judy Kronenberger, President, Good Samaritan College of Nursing and Health Science David Velasquez, Nuclear Medicine Technologist Coordinator CHI Health School of Radiologic Technology Completion/Expected Completion: April 2023 (Good Samaritan)/June 2024 (CHI Health School of Radiologic Technology)

View Audit 301158

Corrective Action Plans

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