Corrective Action Plans

Finding 48243 (2022-003)

Significant Deficiency 2022

NJ

Equipment & Real Property Management § 200.303 § 200.313

Finding No. 2022-003 Compliance Requirement ? Equipment and Real Property ? Significant Deficiency and Noncompliance Planned Corrective Action The University will ensure that each individual fixed asset is appropriately tagged and that the information for the asset reconciles to the information ...

Finding No. 2022-003 Compliance Requirement ? Equipment and Real Property ? Significant Deficiency and Noncompliance Planned Corrective Action The University will ensure that each individual fixed asset is appropriately tagged and that the information for the asset reconciles to the information reported in the Stevens Kuali Financial System. The Division of Finance has instituted an additional procedure to generate monthly asset tagging reports to address this issue and ensure that all assets are tagged in a timely manner. In addition, the Staff Accountant takes a picture of the asset tag for new assets which is attached to the supporting documentation in the Kuali Financial System. The Senior Accountant reviews the documentation for each asset and ensures that the appropriate asset tag is reflected in the Kuali Financial System. The Division of Finance engages an outside firm to conduct a complete physical inventory every two years. The Executive Director of Finance and Controller, the Senior Accountant and the Staff Accountant will ensure that all asset records are properly reflected in the Kuali Financial System. Timing of Completion This corrective action has been implemented in FY23. Responsible for Corrective Action Joseph Cassidy, Associate Vice President for Finance (201) 216-5287, Jamie Houghtaling, Executive Director of Finance and Controller (201) 216-3348, Roger Moussallem, Senior Accountant (201) 216-3491 and Punam Patel, Staff Accountant (201) 216-8550.

View Audit 42638

Finding 48242 (2022-002)

Significant Deficiency 2022

Stevens Institute of Technology

NJ

Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.320 § 200.326

Finding No. 2022-002 Compliance Requirement ? Procurement ? Significant Deficiency and Noncompliance Planned Corrective Action The University will ensure that all procurement decisions comply with the Stevens Procurement Policy and are properly documented, including the procurement method used (e.g....

Finding No. 2022-002 Compliance Requirement ? Procurement ? Significant Deficiency and Noncompliance Planned Corrective Action The University will ensure that all procurement decisions comply with the Stevens Procurement Policy and are properly documented, including the procurement method used (e.g., competitive bidding or sole source justification). The Director of Procurement will ensure that all Stevens employees responsible for making purchasing decisions at the University are familiar with the Procurement Policy and the need to ensure full compliance even when making purchasing decisions during emergency situations (e.g., COVID pandemic). The Director of Procurement will ensure compliance with the Stevens Procurement Policy. Timing of Completion This corrective action has been implemented in FY23. Responsible for Corrective Action Joseph Cassidy, Associate Vice President for Finance (201) 216-5287 and Brian Seabold, Director of Procurement (201) 216-8722.

View Audit 42638

Finding 48240 (2022-001)

Significant Deficiency 2022

Stevens Institute of Technology

NJ

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

Finding No. 2022-001 Compliance Requirement ? Reporting ? Significant Deficiency and Noncompliance Planned Corrective Action The University will ensure that each report submission that is required to support spending under each of the Higher Education Emergency Relief Funds and other related fundi...

Finding No. 2022-001 Compliance Requirement ? Reporting ? Significant Deficiency and Noncompliance Planned Corrective Action The University will ensure that each report submission that is required to support spending under each of the Higher Education Emergency Relief Funds and other related funding programs has formal supporting documentation to evidence appropriate review of the report. This issue of how eligible students were determined and how the amounts distributed were determined was identified on the Q4 2021 Report due to the timing of the test work in the prior year Single Audit. This issue was corrected in the Q1 2022 Report and all available funding has been spent. The Assistant Vice President for Financial Aid has ensured that the total number of students eligible to receive a grant and the total number of students who receive grants is properly reviewed and documented. The Manager of Financial Planning, Budgeting and Analysis will ensure that all submitted Institutional Aid Reports are properly reconciled to actual expenditures rather than anticipated expenditures. The Q4 2021 Report was revised and reposted to reflect that expenditures were related to other costs rather than lost revenue. Each Student Aid Report and Institutional Aid Report will be reviewed and approved by the Associate Vice President for Finance. This review and approval will be documented in the file. The submitted Reports will also be provided to the CFO, Vice President for Finance and Treasurer. Timing of Completion This corrective action was implemented in FY22 and FY23.

View Audit 42638

Finding 48234 (2022-002)

Significant Deficiency 2022

Monument Health, Inc.

SD

Allowable Costs / Cost Principles Cash Management Significant Deficiency § 200.303

Finding: 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 HRSA Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund Federal Financial Assistance Listing #: #93.461 Finding Summary: Audit testing identified one instance ...

Finding: 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 HRSA Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund Federal Financial Assistance Listing #: #93.461 Finding Summary: Audit testing identified one instance in which health services provided to a patient were reimbursed under the federal program, and the health services provided did not meet the terms and conditions of the federal program. Through the coding process, an incorrect diagnosis code was included in the system, and therefore, the patient?s health services flowed into Monument Health?s Uninsured Program workflow which resulted in $3,563 of health services being reimbursed under the federal program. As part of the audit, a sample of 60 patients were selected for testing, accounting for $1,659,497 of $4,344,728 of monies received from the federal agency. Responsible Individuals: Austin Willuweit, Vice President of Finance Jen Schmaltz, Corporate Controller Corrective Action Plan: Monument Health will develop a review process to identify claims that could have a diagnosis coding issue. A return of any excess reimbursement will be completed. Anticipated Completion Date: June 30, 2023

View Audit 40813

Finding 48214 (2022-002)

Significant Deficiency 2022

Raleigh County Community Action Association, Inc.

WV

Reporting Matching / Level of Effort / Earmarking § 200.303

2022-002 REPORTING Recommendation: We recommend that RCCAA revisit controls over the report submission process. At a minimum, such controls should include a documented review and approval process that ensures reported amounts agree with supporting documentation. We recommend that the review be perf...

2022-002 REPORTING Recommendation: We recommend that RCCAA revisit controls over the report submission process. At a minimum, such controls should include a documented review and approval process that ensures reported amounts agree with supporting documentation. We recommend that the review be performed by an individual independent of the data entry process. Additionally, management should maintain supporting documentation for the amounts reported in the reports. Action taken: The report submission process has been reviewed and additional controls have been implemented to ensure that, going forward, supporting documentation agrees with the amounts being reported. This documentation will be filed with the report. The report will be reviewed by a staff member who is not a part of the data entry process.

View Audit 46935

Finding 48213 (2022-005)

Material Weakness 2022

Winner Regional Healthcare Center

SD

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Finding 2022-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution FFAL #93.498 Finding Summary: The review process for the Period 4 HHS report submitted did not detect the error reported regard...

Finding 2022-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution FFAL #93.498 Finding Summary: The review process for the Period 4 HHS report submitted did not detect the error reported regarding the actual reported revenues for 2019 that were incorrectly keyed into the portal submission. Additionally, the revenues for 2022 were reported based upon actual revenue billed and reported within the electronic medical records (EMR) system which does not include monthly or quarterly adjustments posted to the general ledger. Responsible Individuals: Amanda Soesbe, Chief Finance Officer Corrective Action Plan: There are no further PRF Portal submissions. The control aspect implemented to involve review of the portal submission will be expanded if further submissions are warranted. An expanded control would require the CFO to review in detail with the reviewer how the numbers were obtained and provide all supporting documentation for cross reference against the requirements. This may require extra time to educate and inform the reviewer of the PRF program and requirements. Anticipated Completion Date: 12-31-2023

View Audit 46933

Finding 48210 (2022-007)

Significant Deficiency 2022

Winner Regional Healthcare Center

SD

Student Financial Aid Reporting Significant Deficiency § 200.303

Finding 2022-007 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: The fiscal year 2021 audit report was requited to be submitted to the federal agency by September 30th, 2022. We did not provide the 2021 audit report wi...

Finding 2022-007 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: The fiscal year 2021 audit report was requited to be submitted to the federal agency by September 30th, 2022. We did not provide the 2021 audit report within the timeframe requested by the federal agency representative. Responsible Individuals: Amanda Soesbe, Chief Finance Officer Corrective Action Plan: The CFO will send the audited financial statements to USDA by the deadline. Anticipated Completion Date: 9-30-2023

View Audit 46933

Finding 48181 (2022-004)

Significant Deficiency 2022

Summit Academy Oic

MN

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

2021-004 COVID-19 HEERF Student Aid Portion and COVID-19 HEERF Institutional Portion Recommendation: We recommend the Organization establish a system to track due dates of reports to ensure timely submission and retain documents to support the submission and accuracy of the reports. Explanation of d...

2021-004 COVID-19 HEERF Student Aid Portion and COVID-19 HEERF Institutional Portion Recommendation: We recommend the Organization establish a system to track due dates of reports to ensure timely submission and retain documents to support the submission and accuracy of the reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: I do not disagree with this finding, however it is important to clarify that this is not a repeat finding from 2021, but rather, this is the exact same incident of the 2021 finding. The 2021 audit was not conducted until February 2022 which happens to also fall into our FY2022. As a result, this finding was corrected immediately following the FY21 discovery and the corrective action was put into place at that time and remains in place and effective. That corrective action was and is as follows: Summit did and continues to have the due dates for the various reporting deadlines, and we did meet those deadlines, however the issue remains that once our reports were updated to the website as required, there exists no audit log of the dates of the changes. As a solution to this issue, we have created a due date log that will be updated with the change date and the log will be signed by the originator of the report as well as the overseer of the website. This signed log will be preserved for review. Names of the contact persons responsible for corrective action: Reports will continue to be filed by the CFO (Marc Carrier) and the Digital Marketing Specialist (Rachel Prost) will be responsible for the website update. This was implemented March 31,2022 and remains in place.

View Audit 51844

Finding 48131 (2022-001)

Material Weakness 2022

Los Angeles County Museum of Natural History Foundation

CA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.430

In response to Finding #2022-001, the Foundation will implement two additional mitigating efforts into the existing processes and procedures to address the conditions in this finding. (1) A Missed Approval report will be generated from the payroll system to identify which hourly employee timecards h...

In response to Finding #2022-001, the Foundation will implement two additional mitigating efforts into the existing processes and procedures to address the conditions in this finding. (1) A Missed Approval report will be generated from the payroll system to identify which hourly employee timecards have not been approved after each pay period. Supervisors will be required to provide approvals on timecards of hourly employees identified in this step. (2) The Foundation will develop a time allocation form to document an after-the-fact review of any budgeted payroll costs allocated to awards to ensure they are reflective of actual time incurred. Such time allocation forms will be required on at least a quarterly basis. These steps will be in place by December 31, 2022. Implementation will be overseen and ensured by Dr. Luis Chiappe, Senior Vice President, Research & Collections, 213-763-3361.

View Audit 46323

Finding 48123 (2022-003)

Material Weakness 2022

City of Goshen

IN

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

FINDING 2022-003: COVID-19 ? Coronavirus State and Local Fiscal Recovery Funds ? Internal Controls Contact Person Responsible for Corrective Action: Clerk-Treasurer Richard Aguirre Contact Phone Number: (574) 533-8623 Views of Responsible Official: We concur with the finding. Description of Correcti...

FINDING 2022-003: COVID-19 ? Coronavirus State and Local Fiscal Recovery Funds ? Internal Controls Contact Person Responsible for Corrective Action: Clerk-Treasurer Richard Aguirre Contact Phone Number: (574) 533-8623 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: To enhance internal controls, the City of Goshen Clerk-Treasurer?s Office has identified and segregated duties related to the preparation of the Schedule of Federal Awards (SEFA). Using the checklist from the SBOA as a reference, an internal checklist has been created to use for annual review of the policies and procedures. For this year in particular, a revisiting of the policies and procedures is necessary to address and clarify segregation of duties, both for internal and external purposes. The design, including segregation of duties, exists between the Clerk-Treasurer, Deputy Clerk-Treasurer, and the Grants Manager. However, the reporting procedures can be improved, specifically in how implementation generates verifiable proof and documentation. What is cited below is more of a ?retroactive finding? from 2021, since SBOA did not audit these funds previously. There also had been a series of difficulties with the Treasury portal; by the time the system was corrected, the reports were submitted. Regarding the procedures, the City of Goshen undertook data entry, review, and submission using three different individuals, and there is evidence of this review that has not been acknowledged by the SBOA. The review and oversight process, however, is being improved in light of this new finding. The revision of policies will more effectively articulate the steps that effect internal control and ensure consistent implementation. To ensure the accuracy of Project and Expenditure Reports prior to submission to the U.S. Department of Treasury, the preparer will email the reviewer when a report is ready for review. The reviewer will respond to the email when the information is reviewed and include any errors noted that need to be corrected. This email correspondence will be kept and provided to state auditors. The City also will maintain an approval sheet indicating that the review of the report has been completed and the reviewer will sign and date the approval sheet and note any errors found during the review. Anticipated Completion Date: This process should be reviewed and ready by the next SEFA preparation, in January 2024. ? Completed and submitted to the State Board of Accounts, Aug. 29, 2023

View Audit 41399

Finding 48122 (2022-002)

Material Weakness 2022

City of Goshen

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2022-002: COVID-19 ? Coronavirus State and Local Fiscal Recovery Funds ? Suspension and Debarment Contact Person Responsible for Corrective Action: Clerk-Treasurer Richard Aguirre Contact Phone Number: (574) 533-8623 Views of Responsible Official: We concur with the finding. Description of C...

FINDING 2022-002: COVID-19 ? Coronavirus State and Local Fiscal Recovery Funds ? Suspension and Debarment Contact Person Responsible for Corrective Action: Clerk-Treasurer Richard Aguirre Contact Phone Number: (574) 533-8623 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The City of Goshen responds that this finding is an outlier to the otherwise effective system of internal controls already in place. The former Mayor proposed the expenditures in question during a state, national and global emergency pandemic and in direct consultation with at least three other anchor institutions of healthcare. However, the City did not formally determine the status of suspension, debarment or exclusion because of the extraordinary circumstances facing Goshen and a lack of knowledge of this requirement. It?s important to recognize that Goshen was in the midst of a state and national emergency and was seeking to safeguard health, and because the normal channels for procuring essential medical equipment were extraordinary and under duress, human error occurred when City staff members acted quickly in response to the drastic shortage of COVID-19 test kits. The other transaction involved a long-time vendor for the City of Goshen that has not been suspended, debarred or otherwise excluded. With every other transaction, the City secured legal agreements, which is part of its City?s normal policies and procedures. It is important to acknowledge that the City of Goshen has policies in place to ensure suspension and debarment clauses are included and certified through signed, fully executed legal agreements. The City is now fully aware that the use of email and confirmation from vendors regarding certification of non-suspension and non-debarment is sufficient, and staff will use this verification procedure in the future. If the City has any additional need to verify that a vendor has not been suspended, debarred or otherwise excluded, staff members also will check SAM.gov?s exclusionary lists and save a screenshot of that verification to share with state auditors. The City of Goshen will continue to rely on suspension and debarment clauses in legal agreements and contracts, and the steps outlined above will serve as the remainder of the corrective action. Again, these two transactions were exceptions to the City?s improved internal control procedures. Anticipated Completion Date: The City of Goshen?s elected officials and their immediate staff will be reminded of these verification procedures, either by email or print, or both. Department heads will be reminded of this during the next review of procurement policies or staff handbook, which is normally an annual process.

View Audit 41399

Finding 48116 (2022-001)

Significant Deficiency 2022

Barrow County Board of Education

GA

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.403 § 200.404

Corrective Action Plan - FEDERAL AWARD FINDINGS AND QUESTIONED COSTS FA 2022-001 Improve Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principles Procurement and Suspension and Debarment I...

Corrective Action Plan - FEDERAL AWARD FINDINGS AND QUESTIONED COSTS FA 2022-001 Improve Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principles Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.4250 - Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425U - American Rescue Plan Elementary And Secondary School Emergency Relief Fund Federal Award Number: S425D200012 (Year: 2020), S425D210012 (Year: 2021) S45U210012 (Year: 2021) Questioned Costs: $358,390 Repeat of Prior Year Finding: None Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over expenditures as it relates to the Elementary and Secondary School Emergency Relief Fund program. Corrective Action Plans: We acknowledge this finding, however the School District relied on the advance, written approval of Georgia Department of Education Federal Programs staff that our request was a proper use of federal funds and that we had all the documentation needed for this cost to be allowable. It was pointed out to us during the audit that the contract with the custodial staff did not have the language needed to cover the bonus to our custodial contract staff in the view of the Department of Audits. The Department took this position even though both parties agreed to these payments, the Board of Education voted to approve this expenditure, the agreement was documented and the Board of Education General Counsel concluded this was permissible under the Contract. In order to accommodate the Department?s concerns, the School District will monitor contracts to ensure that all expenditures are compliant with the School District?s purchasing policies and procedures as well as compliance requirements for the ESSER program. Estimated Completion Date: May 2023 Contact Person: Jennifer Houston Telephone: 770-867-4527 Email: Jennifer.houston@barrow.k12.ga.us

View Audit 54405 Questioned Costs: $1

Finding 48089 (2022-005)

Material Weakness 2022

Liberty-Perry Community School Corporation

IN

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

FINDING 2022-005 Contact Person Responsible for Corrective Action: Brenda Layne, Food Service Director Contact Phone Number: 765-289-7323 Views of Responsible Official: We concur with the findings Description Qf Corrective Action Plan: The prompts have been fixed on the Distribution Report, so it wi...

FINDING 2022-005 Contact Person Responsible for Corrective Action: Brenda Layne, Food Service Director Contact Phone Number: 765-289-7323 Views of Responsible Official: We concur with the findings Description Qf Corrective Action Plan: The prompts have been fixed on the Distribution Report, so it will include all Cafeteria employees. The F.S.D. will also initial each time card and Distribution Report. In the future ALL Claims will be initialed by the F.S.D. And as additional control the Superintendent will also initial all claims prior to the School Board meeting. Anticipated Completion Date: February 2023

View Audit 54302

Finding 48054 (2022-001)

Significant Deficiency 2022

Texas Guaranteed Student Loan Corporation

TX

Matching / Level of Effort / Earmarking § 200.303

Corrective Action Plan: FFEL variable interest rates must be updated annually in July. For example, a claim paid in December 2019 would need 0% interest rate updates on March 13, 2020, July 1, 2020, July 1, 2021, and annually thereafter until the present date. The original query was designed to s...

Corrective Action Plan: FFEL variable interest rates must be updated annually in July. For example, a claim paid in December 2019 would need 0% interest rate updates on March 13, 2020, July 1, 2020, July 1, 2021, and annually thereafter until the present date. The original query was designed to search only for updates made to the most recent annual interest rate anniversary. The query has been modified to look at each annual variable rate anniversary to ensure that all updates, including March 13, 2020 were completed. All loans identified were updated with the correct interest rates as of September 15, 2022. The reports mentioned in the recommendation will be reviewed weekly. Accounts identified in the reports will be updated timely. Responsible Person: Susan High, VP of Operations Anticipated Completion Date: Ongoing until notified by USDE of the required end date.

View Audit 46041

Finding 47974 (2022-001)

Significant Deficiency 2022

Colquitt County Board of Education

GA

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.403

FA 2022-001 Improve/Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding ...

FA 2022-001 Improve/Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund Federal Award Number: S425D200012 (Year: 2020), S425D210012 (Year: 2021), S425U2120012 (Year: 2021) Questioner Costs: $265,630 Description: The polices and procedures of the School District were insufficient to provide adequate internal controls over expenditures as it relates to the Elementary and Secondary School Emergency Relief Fund program. Corrective Action Plans: We concur with this finding. The process used to pay retention wages to staff has been reviewed and will only be paid to staff employed by the Colquitt County Board of Education. Estimated Completion Date: Contact Person: Jeremy Jones, CFO Telephone: 229-890-6224 Email: jeremy.jones@colquitt.k12.ga.us

View Audit 40794 Questioned Costs: $1

Finding 47958 (2022-002)

Significant Deficiency 2022

Adams Central Community Schools

IN

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.208 § 200.303 § 200.403

FINDING 2022-002 Information on the federal program: Subject: Special Education Cluster (IDEA) - Earmarking Federal Agency: Department of Education Federal Program: Special Education Grants to States Assistance Listing Number: 84.027 Federal Award Number: 20611-001-PN01 Pass-Through Entity: Indiana ...

FINDING 2022-002 Information on the federal program: Subject: Special Education Cluster (IDEA) - Earmarking Federal Agency: Department of Education Federal Program: Special Education Grants to States Assistance Listing Number: 84.027 Federal Award Number: 20611-001-PN01 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Matching, Level of Effort, Earmarking Audit Findings: Significant Deficiency Condition: The School Corporation is a member of the Adams Wells Special Services Cooperative (Cooperative). During fiscal year 2021-2022, the Cooperative operated the special education programs and spent the federal money on behalf of all its member schools. As the grant agreements were between the Indiana Department of Education (IDOE) and each member school, the school corporation was responsible for ensuring and providing oversight of the Cooperative. There was inadequate oversight performed by the School Corporation in order to ensure compliance with the Matching, Level of Effort, Earmarking compliance requirement. The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the earmarking requirements. The Cooperative did not have adequate procedures in place to ensure that the required level of expenditures for non-public school students with disabilities was met for each member school. The Cooperative did not have effective internal controls to ensure non-public school expenditures were appropriately identified and reported. Context: The Non-Public Proportionate Share expenditures for the 20611-001-PN01 grant award could not be verified for the individual member schools. Total non-public expenditures were posted as expended. The member school proportionate share expenditures were then determined by applying a budgeted percentage to the total non-public expenditures. These were the amounts reported to IDOE. As such, we were unable to identify if the minimum amount per member school was expended and properly reported to IDOE as required. The School Corporation?s Non-Public Proportionate Share for the 20611-001- PN01 grant application was $5,368. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Our corrective action plan is following the AWSSC plan of: Co-ops cannot combine proportionate share funds. Funds must be spent within each LEA?s geographic boundary. We will not receive a repeat finding for FY21. We will correct for FY22 and forward. Time & Effort Logs are being completed to show how many hours personnel are servicing Non-Pub school students with a service plan. If Materials and Equipment are purchased for a specific student?s need, per the service plan, then those expenditures are 100% school specific. Per the DOE, Materials used by our Speech Language Pathologist for Speech Therapy for all six school corporations, those expenditures are split evenly across all school corporations with a non-pub proportionate share allocation. Responsible Party and Timeline for Completion: The Superintendent and Corporation Treasurer will work with the Adams Wells Special Services Cooperative to monitor and verify those expenditures are allocated appropriately across all school corporations with a non-pub proportionate share allocation.

View Audit 52770

Finding 47955 (2022-001)

Material Weakness 2022

Adams Central Community Schools

IN

Questioned Costs School Nutrition Programs Cash Management § 200.303

FINDING 2022-001 Information on the federal program: Subject: Child Nutrition Cluster ? Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Numbers: 10.553, 10.555 Pass-Through Entity: Indiana Departm...

FINDING 2022-001 Information on the federal program: Subject: Child Nutrition Cluster ? Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Numbers: 10.553, 10.555 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the reporting compliance requirement. Context: We noted that for one claim in a sample of four, the school lunch meal count was overclaimed for the month. We noted that in October 2020 the School Corporation had overclaimed lunches by 173 meals. We noted that the sponsor claim reimbursement form had been reviewed, however, the lack of an effective review allowed the error to go unnoticed. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Going forward, we will have multiple people verifying the data before submission to reimbursement for claims to make sure all meals submitted meet the criteria and eligibility of the Child Nutrition Cluster. Responsible Party and Timeline for Completion: The Food Service Director and the Corporation Treasurer are the responsible parties for this corrective action. This has already been implemented.

View Audit 52770 Questioned Costs: $1

Finding 47913 (2022-002)

Significant Deficiency 2022

Enterprise State Community College

AL

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

Item 2022-002 ? Eligibility Contact person: Chellye Stump, Dean of Administrative Services Finding ? During a dual purpose tests of controls and compliance there were 3 participants who were identified that did not certify to the fact that they were a citizen, national, or permanent resident of the ...

Item 2022-002 ? Eligibility Contact person: Chellye Stump, Dean of Administrative Services Finding ? During a dual purpose tests of controls and compliance there were 3 participants who were identified that did not certify to the fact that they were a citizen, national, or permanent resident of the United States, a requirement for eligibility of the TRIO program. Management Response ? The College will implement additional controls to ensure there is evidence of review of certifying statement from participant prior to services being rendered. TRIO Services Director will be responsible for the corrective action and anticipates completion of corrective action will be taken before 9/30/23. Effective date of completion: within the fiscal ending September 30, 2023

View Audit 46519

Finding 47910 (2022-001)

Material Weakness 2022

Enterprise State Community College

AL

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Item 2022-001 ? Suspension & Debarment Contact person: Chellye Stump, Dean of Administrative Services Finding ? Adequate controls were not in place to provide for proper review of covered transactions for suspension and debarment. Covered transactions, over $25,000 paid with grant funding were not r...

Item 2022-001 ? Suspension & Debarment Contact person: Chellye Stump, Dean of Administrative Services Finding ? Adequate controls were not in place to provide for proper review of covered transactions for suspension and debarment. Covered transactions, over $25,000 paid with grant funding were not reviewed for suspension and debarment. Management Response ? The College will implement additional controls to ensure there is evidence of review of covered transactions over $25,000 for suspension and debarment prior to payment. Dean of Administrative Services will be responsible for the corrective action and anticipates completion of corrective action will be taken before 9/30/23. Effective date of completion: within the fiscal ending September 30, 2023

View Audit 46519

Finding 47865 (2022-001)

Significant Deficiency 2022

Mission Consolidated Independent School District

TX

Matching / Level of Effort / Earmarking Subrecipient Monitoring HUD Housing Programs § 200.303

The District is currently compliant with ESSA LEA MOE. The Texas Education Agency (TEA) will issue FY 2022 ESSA LEA MOE compliance determinations in Spring 2023. If it is determined that the District will not meet ESSA LEA MOE compliance, then the District understands that it has two potential av...

The District is currently compliant with ESSA LEA MOE. The Texas Education Agency (TEA) will issue FY 2022 ESSA LEA MOE compliance determinations in Spring 2023. If it is determined that the District will not meet ESSA LEA MOE compliance, then the District understands that it has two potential avenues of relief: 1. 5-year flexibility: If a District is non-compliant with FY 2022 ESSA LEA MOE (determinations that FFCR will issue in Spring 2023) but was compliant in FYs 2017, 2018, 2019, 2020, and 2021 then the District would not have its FY 2024 (the school year 2023?2024) ESSA allocations reduced. However, the District would still be considered non-compliant, and FY 2023 expenditures would be compared to FY 2021. 2. USDE waiver: A non-compliant District can submit a waiver request to the U.S. Department of Education (USDE), as TEA does not have the authority to waive ESSA LEA MOE. USDE considers each request on a case-by-case basis and has not shared the criteria they use to evaluate requests. If a District is non-compliant, even if they are eligible for the 5-year flexibility, FFCR staff contact the impacted Districts to advise them on the steps to submit a waiver request to USDE. The District met ESSA LEA MOE in fiscal years 2017, 2018, 2019, 2020, and 2021. Therefore, the District will utilize the allowable 5-year flexibility and submit the USDE waiver. The District will continue to run the state aid template every six weeks to monitor student enrollment and attendance to project revenue. The District will facilitate meetings with the program directors, Human Resources, and Payroll department. In addition, the District will monitor actual expenditures compared to the budget every six weeks to ensure that MOE tests are met by year-end. Contact person: Joel Garcia, Assistant Superintendent for Finance Proposed Completion Date: November 15. 2022 "See full CAP in report"

View Audit 51195

Finding 47811 (2022-044)

Material Weakness 2022

State of Oregon

OR

Matching / Level of Effort / Earmarking § 200.303

2022-044 Oregon Health Authority Implement a consistent methodology for calculation of maintenance of effort Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.958 Block Grants for Community Mental Health Services; 93.959 Block Grants for ...

2022-044 Oregon Health Authority Implement a consistent methodology for calculation of maintenance of effort Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.958 Block Grants for Community Mental Health Services; 93.959 Block Grants for Prevention and Treatment of Substance Abuse Federal Award Numbers and Years: 93.958: 1B09SM082625, 2020; 1B09SM083823, 2021; 1B09SM086032, 2022; 93.959: 1B08TI083068, 2020; 6B08TI083472, 2021; 6B08TI084667, 2022 Compliance Requirement: Matching, Level of Effort, Earmarking Type of Finding: Material Weakness Prior Year Finding: N/A Questioned Costs: N/A Criteria: 42 USC 300x-2(a)(1)(C); 42 USC 300x-4(b)(1); 42 USC 300x-9(c)(1); 42 USC 300x-22(b)(1)(C); 42 USC 300x-30(a); 2 CFR 200.303 The Mental Health Block Grant and Substance Abuse Block Grant are subject to various Maintenance of Effort and Earmarking requirements. These requirements ensure the department meets minimum expenditure thresholds. Federal regulations require recipients of federal awards establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. Based on auditor recalculations, we determined the department was in compliance with the applicable Maintenance of Effort and Earmarking requirements during state fiscal year 2022. However, we noted the following control weaknesses in the department?s calculations and demonstration of their compliance with the requirements: The department is required to expend 10% of the federal award for early serious mental illness and a first episode psychosis treatment services under the Mental Health Block Grant. The 10% set aside is calculated and budgeted when federal awards are granted. However, tracking of expenditures is not performed to ensure compliance is achieved. The department is required to maintain state expenditures for community mental health services and authorized substance abuse activities at a level not less than the average expenditures of the prior two state fiscal years. The department is also required to ensure expenditures for systems of integrated services for children with serious emotional disturbance and substance abuse treatment for pregnant women and women with dependent children is not less than the amount expended for these services in fiscal year 1994. The applicable expenditures were not consistently or accurately calculated by the department in each of the state fiscal years included in the Maintenance of Effort determinations. Additionally, no written procedures exist for the calculations. The department is at risk of noncompliance without controls in place to help ensure expenditures are tracked and calculations are consistently applied across fiscal years. We recommend department management implement controls to ensure applicable expenditures are adequately tracked and calculations applicable to the maintenance of effort requirements are consistently performed across fiscal years. We further recommend department management work with the federal awarding agency to submit corrected maintenance of effort totals to ensure appropriateness of future maintenance of effort determinations. MANAGEMENT RESPONSE: We agree with this recommendation. There were inconsistencies in how Maintenance of Effort (MOE) has been calculated. The applicable expenditures were not consistently or accurately calculated in each state fiscal year. The use of Marijuana paid expenses were not consistently used for both Mental Health and Substance Abuse Block Grant. We have met with SAMHSA MHBG State Project Office (SPO) for clarification on how Marijuana funds can be utilized in the calculation for the MOE. We have received guidance and clarification. We have recalculated MOE for the Block grants for SFY2022, SFY2021, and SFY2020 and are still doing data checks on these recalculations. With any changes to be made to previous years? MOE calculations, we must resubmit the request and reasons behind the changes to the SAMHSA project officers. HSD Budget is working on a written desk procedures to ensure applicable expenditures are adequately tracked and calculated to the maintenance of effort requirements and are consistently performed. Anticipated Completion Date: February 28, 2024 Contact: Annabelle Atalig, Budget and Fiscal Manager

View Audit 45093

Finding 47808 (2022-041)

Material Weakness 2022

State of Oregon

OR

Reporting Allowable Costs / Cost Principles Material Weakness § 200.303

2022-041 Oregon Health Authority Ensure expenditures of federal funds are recorded to the appropriate program Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.958 Block Grants for Community Mental Health Services (COVID-19) 93.959 Bloc...

2022-041 Oregon Health Authority Ensure expenditures of federal funds are recorded to the appropriate program Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.958 Block Grants for Community Mental Health Services (COVID-19) 93.959 Block Grants for Prevention and Treatment of Substance Abuse (COVID-19) Federal Award Numbers and Years: 93.958 ? 1B09SM083994, 1B09SM085378 (COVID-19); 93.959 ? 1B08TI083513, 1B08TI083963 (COVID-19) Compliance Requirement: Activities Allowed or Unallowed Type of Finding: Material Weakness; Material Noncompliance Prior Year Finding: N/A Questioned Costs: 93.958 - $2,268,421 (known COVID-19) Criteria: 2 CFR 200.303; 42 USC 300x-1 The department was required to submit a spending plan documenting the intended use of the awarded COVID-19 funding allocations under the Mental Health Block Grant (MHBG) and Substance Abuse Block Grant (SABG). The expenditure of COVID-19 funding should align with each block grant?s approved spending plan. Federal regulations also require recipients of federal awards establish and maintain internal controls designed to reasonably ensure compliance with federal statutes, regulations, and terms and conditions of the Federal award. Our testing of state fiscal year 2022 MHBG COVID-19 expenditures identified $10.4 million in workforce development incentive payments inappropriately recorded under the MHBG. Further inquiry into the payments revealed the department determined during state fiscal year 2023 these expenditures were not included in the MHBG COVID-19 spending plans and were not allowable activities under the MHBG. The department determined incentive payments totaling $8.1 million in COVID-19 expenditures should have been recorded under the SABG in accordance with the SABG COVID-19 spending plans. The department subsequently moved the $8.1 million of the combined $10.4 million total COVID-19 incentive payment expenditures to the SABG; however, the remaining $2.3 million in incentive payment expenditures were left in the MHBG as a funding source had yet to be determined. An adjustment to the Schedule of Expenditures of Federal Awards (SEFA) was required to move the $8.1 million in COVID-19 spending from the MHBG to SABG. The remaining $2.3 million is considered questioned costs under the MHBG. We recommend department management ensure controls are properly designed and implemented to record only allowable expenditures to the appropriate federal programs. MANAGEMENT RESPONSE: We agree with this recommendation. The identified expenditures were initially charged to the MHBG in error, and when the error was found by OHA staff, the funding source was corrected to SAPT for the authorized $8.1 million prior to the SOS audit beginning. There was still $2.3 million remaining coded to MHBG which after extensive review and leadership decision, has now been re-coded appropriately. OHA?s existing internal controls identified this issue initially, no additional corrective action is needed. Anticipated Completion Date: July 5, 2023 Contact: Sarah Adelhart, Interim Manager

View Audit 45093

Finding 47800 (2022-033)

Material Weakness 2022

State of Oregon

OR

Reporting § 200.303 § 200.328

2022-033 Oregon Housing and Community Services Ensure financial reports are submitted Federal Awarding Agency: U.S. Department of Health and Human Services, Administration for Children and Families Assistance Listing Number and Name: 93.568 Low-Income Home Energy Assistance Program 93.568 Low-Inc...

2022-033 Oregon Housing and Community Services Ensure financial reports are submitted Federal Awarding Agency: U.S. Department of Health and Human Services, Administration for Children and Families Assistance Listing Number and Name: 93.568 Low-Income Home Energy Assistance Program 93.568 Low-Income Home Energy Assistance Program (COVID-19) Federal Award Numbers and Years: 2002ORLIEA, 2020; 2102ORE5C6, 2021 (COVID-19) Compliance Requirement: Reporting Type of Finding: Material Weakness; Material Noncompliance Prior Year Finding: 2021 ? 012 Questioned Costs: N/A Criteria: 2 CFR ? 200.303(a), (c)-(d); 2 CFR ? 200.328 Department management is responsible for establishing and maintaining effective internal control that provides reasonable assurance the department is managing the federal award in compliance with the terms and conditions of the federal award. Additionally, management is responsible for evaluating and monitoring the department?s compliance with the terms and conditions of federal awards and taking prompt action when instances of noncompliance are identified. Federal Financial Reports, SF-425?s, are required to be submitted annually for each open grant award ninety days after the end of the federal fiscal year. The department did not submit SF-425?s for two of the four open grants for the federal fiscal period ended September 30, 2021. This is an improvement from the prior fiscal year when the department hadn?t submitted any of the SF-425 reports for open grants. Department management cited a federal reporting system issue where awards are not appropriately tied to the correct grant identification number, which has hindered their ability to submit financial reports. As a result, the department was not in compliance with financial reporting requirements in accordance with the terms and conditions of their grant agreements. We recommend department management work with their federal partners to determine if unsubmitted reports should be completed and to ensure reporting compliance in future fiscal periods. MANAGEMENT RESPONSE: We agree with this recommendation. OHCS submitted 2 of the 4 required reports but was unable to submit the remainder due to technical issues with the federal reporting system. OHCS compiled all requisite reporting information timely and is in correspondence with the federal funder to enable report submission. Anticipated Completion Date: December 31, 2023 Contact: Beth Brown, Accounting M

View Audit 45093

Finding 47790 (2022-052)

Significant Deficiency 2022

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.303

2022-052 Oregon Health Authority Improve review of expenditure transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and Years: 6 NU...

2022-052 Oregon Health Authority Improve review of expenditure transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and Years: 6 NU50CK000541, 2021 (COVID-19) Compliance Requirements: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Type of Finding: Significant Deficiency, Noncompliance Prior Year Finding: N/A Questioned Costs: $35,416 (known) (COVID-19) Criteria: 2 CFR 200.303 As part of our testing, we reviewed expenditures charged to the program to ensure they were properly approved and an appropriate use of program resources. We randomly selected 25 of 2,355 non-payroll transactions as the basis for our testing. For one of the transactions, there was no evidence the expenditures had been reviewed and approved as appropriate expenditures for the program. The specific transaction was for cell phones and data plans on wireless devices and consisted of 584 separate devices. Only 24 (2.5%) of those devices had been approved by a manager. The department will pay the vendor for the full amount of the invoice. Managers are expected to review the charges for their unit and verify they are directed to the proper cost center. The $35,416 in questioned costs represents the charges for the devices without approval. Also, during fiscal year 2022, payroll for the department was processed through the Oregon State Payroll Application (OSPA). As part of each monthly payroll cycle, managers are expected to review and approve employee?s reported hours to ensure expenditures are accurate and are billed to the correct program(s). Although state policy requires managers to review the timesheets, the automated controls in the system will process the payroll without a review, effectively making the managerial review optional. The OSPA was retired as of November 30, 2022; however, the replacement payroll system operates in a similar manner for managerial review. As part of our testing of payroll expenditures, we found one of 25 randomly selected timesheets were not reviewed by a manager prior to release into the payroll system. We were able to perform alternative procedures to verify the amounts charged to the program were appropriate and there are no questioned costs. The lack of review increases the risk that inappropriate costs may be charged to federal programs. We recommend management ensure wireless device charges are properly reviewed, and expenditures are charged to the correct cost center or program. We also recommend management implement procedures to ensure all employee payroll submissions are reviewed and approved by program management. MANAGEMENT RESPONSE: We agree with this recommendation. The questioned costs related to cell phone charges appear to have resulted from a lack of formal process in the Coronavirus Response and Recovery Unit. This unit has closed and departments have returned to standardized formal processes. Corrective action plan: ? Prior to ?COVID-19? processes and procedures will be followed ? Administrative staff will parse cell phone charges and code invoices according to employee payroll ? Approving manager will review coding for accuracy prior to approval Anticipated Completion Date: January 1, 2023 Contact: Merry Carlson, ELC Contracts Manager

View Audit 45093 Questioned Costs: $1

Finding 47787 (2022-045)

Significant Deficiency 2022

State of Oregon

OR

Subrecipient Monitoring Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303

2022-045 Oregon Health Authority Submit required FFATA reports Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.268 Immunization Cooperative Agreements; 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases; 93.958 Bloc...

2022-045 Oregon Health Authority Submit required FFATA reports Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.268 Immunization Cooperative Agreements; 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases; 93.958 Block Grants for Community Mental Health Services; 93.959 Block Grants for Prevention and Treatment of Substance Abuse Federal Award Numbers and Years: 93.268: 5 NH23IP922626; 6 NH23IP922626; 93.323: 6 NU50CK000541; 93.958: 1B09SM083823, 2021; 93.959: 6B08TI083472, 2021; 6B08TI084667, 2022 Compliance Requirement: Reporting Type of Finding: Significant Deficiency; Noncompliance Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 170 Appendix A; 2 CFR 200.303 Federal regulations require recipients of federal awards to report certain subaward information in the FFATA Subaward Reporting System (FSRS) for subawards meeting the criteria for reporting. Reports must be submitted no later than the end of the month following the month in which the subawards were made. Federal regulations also require recipients of federal awards establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. We identified and reviewed the reporting status of all the department?s subawards subject to FFATA reporting during the audit period. We determined: Five of 30 Mental Health Block Grant (MHBG) subawards were not reported, totaling $4.2 million in obligations. 12 of 65 Substance Abuse Block Grant (SABG) subawards were not reported, totaling $6.2 million in obligations. Four of 37 Epidemiology and Laboratory Capacity (ELC) subawards were not reported, totaling almost $55.5 million in obligations. Five of 39 Immunization Cooperative Agreements subawards were not reported, totaling $6.3 million in obligations. Of the total not reported, one SABG, one ELC, and two Immunization subawards were not reported in the FSRS due to oversights in the department?s reporting process. The remaining unreported subawards resulted from the department?s suspension of FFATA reporting stemming from the federal replacement of the DUNS number with the Unique Entity Identifier (UEI) in May 2022. The department did not have UEI numbers for all subrecipients at the time of the replacement which prevented the department from submitting accurate reports. FFATA reporting was suspended through the end of state fiscal year 2022 and into the following state fiscal year. Although the department suspended FFATA reporting in the FSRS, a tracking spreadsheet was maintained that included all subaward award information needed for reporting once reporting is resumed. We recommend department management resume FFATA reporting as soon as feasible and ensure all necessary subawards are reported. We further recommend department management implement controls to ensure all subawards are appropriately tracked and reported. MANAGEMENT RESPONSE: We agree with this recommendation. On April 4, 2022, the federal government made a switch in the identifying information required for a subrecipient, changing from the previously used DUNS to a newly assigned Unique Entity Identifier (UEI). ODHS/OHA was not made aware of the upcoming federal switch until late March 2022. OHA?s Office of Contracts & Procurement (OC&P) is working directly with Program Contract Administrator?s to request the missing UEIs. As the data comes in from Program it is being validated for accuracy and updated in the appropriate systems, so when all missing UEIs from a given FAIN?s report month are collected, all NTE changes can be made immediately. OC&P is confident all FFATA reporting related to this audit will be submitted by July 31, 2023. Anticipated Completion Date: July 31, 2023 Contact: Brenda Brown, Procurement Manager

View Audit 45093

Corrective Action Plans

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