Corrective Action Plans

Finding 42532 (2022-001)

Significant Deficiency 2022

Mosaic

NE

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Significant Deficiency: 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 ...

Significant Deficiency: 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. The terms and conditions of the CARES Act Provider Relief Fund (PRF) distributions state that funds are to only be used to prevent, prepare for, and respond to coronavirus, and that funds may only be used for healthcare related expenses or lost revenue that is attributable to the coronavirus. The Health Resources and Services Administration (HRSA) provided guidance on how an organization was to report usage of PRF distributions received. Period 1 and Period 2 reporting required an organization to illustrate how PRF funds received were used. An organization was allowed to include eligible expenditures from January 1, 2020 through December 31, 2021 depending on the period reporting. Condition: During the process of identifying expenses that were incurred to prevent, prepare for, or respond to the coronavirus pandemic, management included expenses incurred which were not supported by management in relation to prepare, prevent, or respond to coronavirus. Planned Corrective Action: Management agrees with the noted finding. However, Mosaic also incurred and reported unreimbursed expenses attributable to coronavirus of $3,530,376 which could be used to replace the identified costs unrelated to coronavirus. Management will continue to refine its processes to more diligently review expenditures to ensure only those eligible costs incurred are included in future reporting. Planned Completion Date: June 30, 2023 Person Responsible: Scott Hoffman, CFO

View Audit 43985

Finding 42507 (2022-002)

Significant Deficiency 2022

New Mexico Coalition to End Homelessness

NM

Reporting Matching / Level of Effort / Earmarking § 200.303 § 200.502 § 200.510

As requested, the New Mexico Coalition to End Homelessness has completed its corrective action plan for the audit findings in the 2022 fiscal year annual audit report. We have reviewed the findings and have made a corrective action plan to address each of the findings with completion dates. 2022-...

As requested, the New Mexico Coalition to End Homelessness has completed its corrective action plan for the audit findings in the 2022 fiscal year annual audit report. We have reviewed the findings and have made a corrective action plan to address each of the findings with completion dates. 2022-002?PREPARATION OF SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS Federal Agency: All presented in the Schedule of Expenditures of Federal Awards. Program Name: All presented in the Schedule of Expenditures of Federal Awards. Assistance Listing Nos. and Program Expenditures: All presented in Schedule of Expenditures of Federal Awards. Award Number and Program Award Year: All presented in Schedule of Expenditures of Federal Awards. Compliance Requirement: Other ? Schedule of Expenditures of Federal Awards preparation Type of Finding: E Questioned Costs: None Statement of Condition While conducting the audit, the following was reviewed; the Coalition?s Federal grants report for the fiscal year and identified the federal grants, Assistance Listing # (AL#) and the amounts of the federal expenditures and all of the other items required to properly present the Schedule of Expenditures of Federal Awards (SEFA). The finance staff of the Coalition confirm the correctness of the SEFA. Despite the confirmation of accuracy, additional federal expenditures and grouping of grant expenditures were identified after several reviews of the SEFA. Criteria 2 CFR 200.510 indicates that the auditee must prepare a schedule of expenditures of Federal awards (SEFA) for the period covered by the auditee?s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502 Basis for Determining Federal Awards Expended. Per 2 CFR 200.502 the determination of when a Federal award is expended should be based on when the activity related to the Federal award occurs. Generally, the activity pertains to events that require the non-Federal entity to comply with Federal statutes, regulations, and the terms and conditions of Federal awards, such as expenditure/expense transactions associated with awards. In addition, 2 CFR Part 200.303 requires the program establish and maintain effective internal controls over Federal awards that provides reasonable assurance of compliance with Federal statutes, regulations, and the terms and conditions of Federal awards. Effect Without an established process governed by effective internal controls, the Coalition may not prevent or detect material misstatements on its SEFA in a timely manner. In addition, the errors could result in improper selections of major program(s) for the single audit and a substandard single audit. Cause Historically, the Coalition has requested the auditor assist in identifying accruals related to federal grant expenditures as the organization has maintained these records on a cash basis. As the organization has taken more responsibility on maintaining its federal grant expenditures on an accrual basis, an incomplete SEFA has been provided. Recommendation It is recommended the Coalition prepare the Schedule of Expenditures of Federal Awards and submit this to the auditor for testing. The SEFA should include the name of the grant, name of grantor, the AL #, the pass-through number if applicable and a reconciliation of the federal revenues and expenditures to the Coalition?s general ledger. The Coalition staff should perform more detailed reviews of the reports to ensure they properly reflect grant receipts and expenditures. This review should be performed by someone other than the preparer and should include documented evidence of agreeing the reported data to the accounting records. We further recommend training for those individuals involved in the preparation and review of the reports to ensure they are fully aware of the requirements. View of Responsible Officials and Corrective Action Plan: The corrective Action Plan will be carried out in the 2023 Fiscal Year and information will be given to the auditors when requested for the 2023 Audit. The Coalition will ensure that all information needed for the SEFA is kept and entered accurately. When the fiscal year closes out, the Coalition will provide the auditors with a test SEFA to confirm that the information we are collecting throughout the year and are asserting are the correct numbers for our federal grants, is indeed the correct information. Corrective Action Plan Timeline: Completed by October 31, 2023 (Final copy of the SEFA will not be given to the auditors until requested for the 2023 Audit) Designation Of Employee Position Responsible For Meeting Deadline: Executive Director, Monet Silva will oversee this project and work closely with the auditors to make sure that the information saved and shared is correct. Thank you, Monet Silva Executive Director

View Audit 40302

Finding 42428 (2022-003)

Material Weakness 2022

Clark-Pleasant Community School Corporation

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.303

FINDING 2022-003 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Austin Fruits Contact Phone Number: 317-535-7579 Views of Responsible Official: We concur with the finding that there was not an effective internal control system in place to ensure compliance with...

FINDING 2022-003 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Austin Fruits Contact Phone Number: 317-535-7579 Views of Responsible Official: We concur with the finding that there was not an effective internal control system in place to ensure compliance with the Reporting requirement in the COVID-19 ESSER grants. Description of Corrective Action Plan: The school corporation will implement an internal control of dual signatures on all reporting related to the ESSER and GEER grants. This will provide an extra layer of oversight to ensure complete accuracy with reporting. Anticipated Completion Date: 4/30/23

View Audit 40116

Finding 42426 (2022-001)

Material Weakness 2022

Clark-Pleasant Community School Corporation

IN

Subrecipient Monitoring Eligibility Material Weakness § 200.303

FINDING 2022-001 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Austin Fruits Contact Phone Number: 317-535-7579 Views of Responsible Official: We concur with the finding that there was not an effective control system in place to ensure the correct information ...

FINDING 2022-001 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Austin Fruits Contact Phone Number: 317-535-7579 Views of Responsible Official: We concur with the finding that there was not an effective control system in place to ensure the correct information entered in the Eligible Schools Summary section in the Title I application for Nonpublic schools was accurate. Description of Corrective Action Plan: The school corporation will work with the non-public schools within our district to implement a set of procedures to ensure the accuracy in reporting poverty counts in the Title I application. Anticipated Completion Date: 4/30/23

View Audit 40116

Finding 42424 (2022-002)

Material Weakness 2022

Clark-Pleasant Community School Corporation

IN

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

FINDING 2022-002 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Austin Fruits Contact Phone Number: 317-535-7579 Views of Responsible Official: We concur with the finding that there was not an effective internal control system in place to ensure compliance with...

FINDING 2022-002 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Austin Fruits Contact Phone Number: 317-535-7579 Views of Responsible Official: We concur with the finding that there was not an effective internal control system in place to ensure compliance with the Matching, Level of Effort, and Earmarking requirements in the Special Education grant. Description of Corrective Action Plan: The school corporation will continue to hold regular meetings with the nonpublic schools in our district to ensure they spend their allocations appropriately and timely. If the non-public schools do not spend their allocations within the grant period, Clark-Pleasant will request a waiver from the DOE to repurpose those funds in the grant. Anticipated Completion Date: 4/30/23

View Audit 40116

Finding 42418 (2022-003)

Significant Deficiency 2022

City of Providence, Rhode Island

RI

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

Finding 2022-003 Internal Control Over Compliance Description of Finding The School Department does not have policies and procedures designed to ensure that appropriate written documentation is maintained for all students who withdraw from the district. Statement of Concurrence or Nonconcurrence Ma...

Finding 2022-003 Internal Control Over Compliance Description of Finding The School Department does not have policies and procedures designed to ensure that appropriate written documentation is maintained for all students who withdraw from the district. Statement of Concurrence or Nonconcurrence Management concurs with the finding. Corrective Action Public entities throughout the Country were impacted the hardest during the Global Pandemic, PPSD was not an exception, the District realized a high number of student withdrawals, employee turnover, and are still dealing with staff shortages due to labor market conditions. As a result, new staff members were not fully trained on some of the practices and procedures that needed to be followed. As a corrective next step, the District will ensure employees will be trained on the procedures that need to be followed regarding Students transfer and withdrawal practices. Name of Contact Person John Welch Projected Completion Date 6/30/2023

View Audit 38214

Finding 42415 (2022-001)

Significant Deficiency 2022

National Railroad Passenger Corporation

DC

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

Amtrak agrees with the recommendation to redesign key controls to help ensure that the monitoring of the observations happens on a preventive basis to help identify any exposure to non-compliance before it occurs. 1. Amtrak has completed on-time its Phase I engagement with an outside consulting fi...

Amtrak agrees with the recommendation to redesign key controls to help ensure that the monitoring of the observations happens on a preventive basis to help identify any exposure to non-compliance before it occurs. 1. Amtrak has completed on-time its Phase I engagement with an outside consulting firm that delivered a baseline assessment of Amtrak?s enterprise asset management program and high-level corrective action plans to address observations that were identified across the equipment life cycle. Corrective action plans (CAPs) were developed across process areas with key impact recommendations to address policy and governance around single auditable assets; the people and processes needed for a complete lifecycle oversight of equipment management; and the technology needed to support more robust internal controls, compliance, and timely audits. Amtrak is currently in discussion with this firm for Phase II that involves the implementation of these CAPs. 2. The Asset Management team will pursue enterprise-wide governance through new policies, procedures, and controls throughout the equipment lifecycle. For instance, the Asset Management team, as of February 2023, has been added as an approver to the PR workflow whenever a requester indicates that the PR contains equipment greater than or equal to $5,000 per unit as defined in the Equipment Control policy 3.19. This has helped to ensure that an asset record is created in the asset management system, that it is purchased using a capital code, and it has provided visibility to help ensure that once a purchase order has been created and the asset is received, the asset number that is physically placed on the asset is the same as what was created for the PR. 3. The Asset Management team will train and assist the Capital Accounting team to be able to detect issues with our equipment at the time the asset is placed in service. One goal of this training is to help ensure that at the time the asset is placed in service, it has a complete record, including, but not limited to the asset?s condition and location. We expect to complete this training by July 2023. 4. A technology solution needs to be adopted to better track and locate Amtrak?s assets, as well as support field personnel in ensuring compliance with federal regulations. Amtrak plans to utilize existing tracking technology on assets whenever possible and is exploring adding tracking technology to asset classes, such as yard equipment (e.g., forklifts and golf carts) that currently have no technology in a risk/cost effective manner at an enterprise level, and subsequently integrate with the existing systems to the maximum extent possible. Asset Management is also coordinating with the Company?s Digital Technology department to prioritize the development of a mobile application to help field personnel with performing audits. In the short-term, Asset Management has developed a SharePoint site to support other departments and divisions in completing and submitting audits specifically for single auditable assets. Currently, Procurement and the Automotive group utilize this SharePoint site for completing audits. Asset Management will be expanding this to the Operations & Transportation and Engineering departments. The Company expects to complete this roll out to these departments by June 2023. The Asset Management team is also working on enhanced reporting specific to the Mechanical department to assist with their observations. This new reporting is expected to be completed by September 2023. 5. Since June 2022, the Asset Management team has consistently been working with Capital Accounting to improve the non-compliant single audit equipment report. The Asset Management team is in the process of automating the Capital Accounting report. The team is managing the distribution of the report and assisting with data review. 6. Additionally, over this same period the Asset Management team has worked with the various departments that are responsible for single audit equipment. These actions have reduced the out of compliance assets in each of the departments. The Asset Management team will continue to actively work with the departments that manage these assets and assist these departments with ensuring their assets are physically inspected, tracked for location, and listed in the appropriate condition within the Company?s systems of record for asset tracking. 7. The Asset Management team is actively engaged with the various departments and divisions and continues to go on site visits to perform, as well as assist the equipment managers in performing, observations and audits of equipment and vehicle assets. The contacts for this item are Ian Hinke, AVP Supply Chain Management, and Carol Hanna, VP Controller. The Company anticipates the implementation of the above procedures, along with continual process monitoring and refinement, will fully remediate this finding by June 2026.

View Audit 39281

Finding 42260 (2022-001)

Significant Deficiency 2022

Bon Secours Mercy Health

OH

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

Management recognizes that Per Title 2, U.S. Code of Federal Regulations Part 200 (2 CRF 200), Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award, (Subpart D, Section 200.303), the nonfederal entity must establish and maintain effective internal control ov...

Management recognizes that Per Title 2, U.S. Code of Federal Regulations Part 200 (2 CRF 200), Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award, (Subpart D, Section 200.303), the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Under the terms and conditions of the award, Provider Relief Funds (PRF) is subject to 45 CFR section 75.302 (Financial management and standards for financial management systems). The PRF program requires special reporting through the Provider Relief Fund Reporting Portal that contains key line items containing critical information, which includes the Calculation of Lost Revenues Attributable to Coronavirus. In all instances Bon Secours Mercy Health (BSMH) has adequate lost revenue to be eligible for PRF funding and has maintained a correct list of the assigned lost revenue amounts; the Cares Act portal was not updated correctly to incorporate certain lost revenue amounts. As recommended, Management will employ additional review steps to ensure that the portal tracking of lost revenues is properly stated going forward. The contact for this finding is Kim Ralston, VP, Reimbursement, KMRalston@mercy.com.

View Audit 47065

Finding 42258 (2022-003)

Significant Deficiency 2022

Bon Secours Mercy Health

OH

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

BSMH has implemented enhanced policy and procedures to assist with managing data and enrollment reporting. The procedures include an enhanced review by the Registrar of the student data reports prior to NSLDS submission to ensure no omissions. The contact for this finding is Mark McKellip, Regis...

BSMH has implemented enhanced policy and procedures to assist with managing data and enrollment reporting. The procedures include an enhanced review by the Registrar of the student data reports prior to NSLDS submission to ensure no omissions. The contact for this finding is Mark McKellip, Registrar, Mark.McKellip1@mercycollege.edu.

View Audit 47065

Finding 42257 (2022-002)

Significant Deficiency 2022

Bon Secours Mercy Health

OH

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303 § 200.305

Management is implementing an enhanced, more detailed invoice review process where invoices will be reviewed irrespective of materiality by leadership on the RETAIN team. In addition, the invoice process will include periodic meetings to go through expenditures in detail prior to invoice submission...

Management is implementing an enhanced, more detailed invoice review process where invoices will be reviewed irrespective of materiality by leadership on the RETAIN team. In addition, the invoice process will include periodic meetings to go through expenditures in detail prior to invoice submission. The contacts for this finding are Kori Smith, RETAIN Program Manager, KASmith4@mercy.com and Alice Parisi, Foundation System Director, Alice_Parisi@mercy.com.

View Audit 47065 Questioned Costs: $1

Finding 42256 (2022-001)

Material Weakness 2022

City of Laporte

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2022-001 Contact Person Responsible for Corrective Action: Courtney Parthun, Clerk-Treasurer Contact Phone Number: 219-362-9512 Views of Responsible Official: Due to an overlap in the timeframe between the 2021 audit which was filed on 8/26/2022 and SLFRF expenditures in 2022, the City conti...

FINDING 2022-001 Contact Person Responsible for Corrective Action: Courtney Parthun, Clerk-Treasurer Contact Phone Number: 219-362-9512 Views of Responsible Official: Due to an overlap in the timeframe between the 2021 audit which was filed on 8/26/2022 and SLFRF expenditures in 2022, the City continues to collect certifications and update contracts including the suspension and debarment clause language. Description of Corrective Action Plan: The City of La Porte will require a clause in every contract which states the following: By signing this contract, the company/contractor complies with Federal procurement requirements and has not been suspended or disbarred from doing business. Anticipated Completion Date: on-going

View Audit 47061

Finding 42161 (2022-001)

Significant Deficiency 2022

Southern California Institute of Architecture

CA

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

Management?s Corrective Action Plan - For the Year Ended August 31, 2022 - Finding number 2022-001 - Reporting: Significant Deficiency Over Internal Controls Over Compliance - Contact person responsible for corrective action: Sue Gosney, Chief Financial Officer, (213) 356-5330 Expected date of corr...

Management?s Corrective Action Plan - For the Year Ended August 31, 2022 - Finding number 2022-001 - Reporting: Significant Deficiency Over Internal Controls Over Compliance - Contact person responsible for corrective action: Sue Gosney, Chief Financial Officer, (213) 356-5330 Expected date of corrective action: The corrective action was implemented in October 2022. The school's management agrees with the finding and has implemented procedure whereby the CFO will send calendar reminders to the Financial Aid Manager and other parties involved to set a reminder of submission deadlines for each quarterly report and set an internal deadline prior to such due date. Due dates are specified by OMB Control Number 1840-0849; the reporting deadline for quarterly reports is 10 days after each reporting period. In addition to the calendar invitation above, once the report is uploaded, the uploader will send a follow up email to all parties involved to confirm that the upload to the website has occurred. If the uploader has not posted the report to the website within two business days of receipt, the Financial Aid Manager will follow-up with the uploader to ensure the posting happens before the reporting deadline.

View Audit 50238

Finding 42149 (2022-002)

Significant Deficiency 2022

Taylor County, Texas

TX

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding 2022-002 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Finding Summary: The County?s annual performance reports submitted to the ...

Finding 2022-002 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Finding Summary: The County?s annual performance reports submitted to the Department of Treasury were not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Elijah Anderson, County Auditor Corrective Action Plan: Taylor County will implement a policy for all Federal and State reporting will be reviewed by an individual outside of the preparer. This review will be documented and maintained by the auditor?s office. Anticipated Completion Date: 4/30/2023

View Audit 45341

Finding 42148 (2022-001)

Material Weakness 2022

Taylor County, Texas

TX

Subrecipient Monitoring § 200.303 § 200.332

Finding 2022-001 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Finding Summary: The County provided a subaward of SLFRF funds to a subreci...

Finding 2022-001 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Finding Summary: The County provided a subaward of SLFRF funds to a subrecipient. The County did not include the required data elements in the subaward document, did not perform an assessment of the risk of subrecipient noncompliance with federal guidelines and grant terms, and did not review to determine that the subrecipient was not suspended or debarred. The County did not have a subrecipient monitoring policy in place that required compliance with these guidelines. Responsible Individuals: Elijah Anderson, County Auditor Corrective Action Plan: Taylor County will adopt a subrecipient grant policy before any other subrecipient awards are approved. The policy will include all required elements noted at 2 CFR 200.331-333. Policy provisions will provide for the review of contracts so that all required clauses are included, an assessment of risk for potential subrecipients, and monitoring guidelines to ensure compliance with federal requirements. The review of suspension or debarment performed by the County will be documented in the future so that verification of this step can be reviewed. Anticipated Completion Date: Ongoing

View Audit 45341

Finding 42121 (2022-001)

Material Weakness 2022

Seaway Valley Council for Alcohol/substance Abuse Prevention, Inc.

NY

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.302 § 200.303

Seaway Valley Prevention Council has implemented a system that identifies the source of each funding stream the agency receives or is in the process of completing a request for awards for. This system allows for early determination of the need for a federal single audit. If a funding stream source ...

Seaway Valley Prevention Council has implemented a system that identifies the source of each funding stream the agency receives or is in the process of completing a request for awards for. This system allows for early determination of the need for a federal single audit. If a funding stream source is identified as originating from a federal award, then all related information is recorded as well as retention of all federal funding requirements related to the federal assistance listing number.

View Audit 39328

Finding 42043 (2022-003)

Material Weakness 2022

Jacksonville College

TX

Matching / Level of Effort / Earmarking Cash Management Material Weakness § 200.303

Finding 2022-003: Information on the Federal Program: 84.42SF - Higher Education Emergency Relief Fund - institutional Portion, 84.42SE- Higher Education Emergency Relief Fund - Student Portion Compliance Requirement: Cash Management Type of Finding: Material Weakness Criteria: Under 2 CFR Section 2...

Finding 2022-003: Information on the Federal Program: 84.42SF - Higher Education Emergency Relief Fund - institutional Portion, 84.42SE- Higher Education Emergency Relief Fund - Student Portion Compliance Requirement: Cash Management Type of Finding: Material Weakness Criteria: Under 2 CFR Section 200.303(a), non-federal entities must establish and maintain effective internal controls to provide reasonable assurance that the entity is managing the federal awards in compliance with statutes, regulations, and the terms and conditions of the award. Additionally, under HEERF award, grantees are under an obligation to minimize the time between drawing down funds from GS and paying obligations incurred by the grantee (liquidation). If a HEERF grantee is using HEERF grant funds to make financial aid grants to students, the Department may evaluate for compliance with the rule grantees who have not drawn down the funds from GS and not paid the obligations (the financial aid grants to students) to the students within fifteen calendar days. The Supplemental Agreement published by the U.S. Depaitment of Education pe1tammg to Supplemental Grant Funds identifies that funds not disbursed within 3 days of being drawn down may be subject to heightened scrutiny by the U.S. Department of Education, the institution's auditors, and/or the Department's Office of the Inspector General. Internal controls over compliance with direct and material compliance requirements should be sufficient to prevent or detect and correct material noncompliance in a timely manner. Condition: During testing of cash management compliance requirements, it was noted that Jacksonville College had drawn down the entirety of the HEERF awards in 2021 and recorded $1,302,078. In 2022, the College had expended the majority of the funds but continues to report a deferred liability of $42,887 related to prematurely drawn-down HEERF funds. Context: Jacksonville College did not review compliance requirements related to drawing down of grant funds and over-drew funds related to the HEERF grant. Questioned Costs: $42,887 remaining in Deferred Income. Cause: A material weakness in internal control over compliance exists relating to cash management. Personnel responsible for maintaining compliance with cash management did not have sufficient education on the cash management requirements. In addition, there was no review over compliance with cash management requirements to monitor compliance. Effect or Potential Effect: The College was not in compliance with Federal requirements of the COVID-l 9 Education Stabilization Fund. 44 Repeat Finding: Not a repeat finding. Recommendation: We recommend that the College put into place controls that require review of grant requirements prior to drawing down funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College regrets that this was the process that was used. The failure to review the requirements for the draw-down of HEERF funds was managed by a previous administration. When it was discovered that the proper process was not used by the previous administration, immediate controls and policy reviews were put into place to avoid any further issues of non-compliance. Specifically, Cabinet held weekly meetings where the Executive Vice President was responsible to update Executive Administration with the current status on the utilization of funds. Since that time, a new president has been put into place by the Board of Trustees. The president is committed to following whatever requirements are mandated for all federal programs. In collaboration with all Cabinet members, relevant departments on campus, and a financial consultant, the College will avoid any further issues of non-compliance.

View Audit 41904

Finding 42038 (2022-004)

Significant Deficiency 2022

Salina Regional Health Center, Inc.

KS

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding 2022-004 Federal Agency Name: Department of the Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing #21.027 Compliance Requirement: Reporting Finding Summary: No controls were in place to provide for an adequate review of the rep...

Finding 2022-004 Federal Agency Name: Department of the Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing #21.027 Compliance Requirement: Reporting Finding Summary: No controls were in place to provide for an adequate review of the report submitted for the federal award by a separate individual outside of the preparer. Responsible Individuals: Kevin Hoffman, Controller Corrective Action Plan: Prior to submission, reports will be reviewed by a separate individual than the preparer. Anticipated Completion Date: 9/30/2023

View Audit 41903

Finding 42026 (2022-001)

Material Weakness 2022

Northumberland School District

NH

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303 § 200.430

SAU 58 had a big transition our office with the replacement of all three of our accounting positions; Business Manager, Payroll/HR and Accounts Payable & Grants. The Accounts Payable position was then vacated for a second time and we found a new replacement in Jan 2022. During this transition peri...

SAU 58 had a big transition our office with the replacement of all three of our accounting positions; Business Manager, Payroll/HR and Accounts Payable & Grants. The Accounts Payable position was then vacated for a second time and we found a new replacement in Jan 2022. During this transition period the Time and Effort for two positions that were grant funded, was overlooked. We did provide documentation of payroll from Payroll/HR but did not get the signature of the teacher or other staff member on the Certification form. Typically, we would have been able to rectify the omission but the employees had both left our district at the end of the school year. The Business manager is ultimately responsible for the implementing of the process and internal controls and will follow up with the Accounts Payable clerk to be sure each month all documentation is on file. Since the new AP person came on, she has implemented a spreadsheet to track each employee paid by Federal Funding. This way we know who has submitted their certification, and at what point we are at during the year. We will be looking at electronic documents in the future for easier tracking and getting signatures on certification documents but as of now the spreadsheet has made this process much easier to track and be sure we do not miss documents. If a big transition happens again the Accounts Payable Clerk will be responsible for all grant compliance paper work. The Business Manager will oversee this process. The above processes and procedures have already been implemented and the Business Manager will follow up monthly with the Accounts Payable clerk. Name of Contact Person and Completion Date: Name 1 Heather McMann Name 2 Tiffany Griffin Anticipated Completion Date ? Already implemented.

View Audit 39260 Questioned Costs: $1

Finding 42005 (2022-007)

Significant Deficiency 2022

State of New York

NY

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

State Agency: New York State Education Department Single Audit Contact: Heidi Nark Title: Internal Auditor 3 Telephone: 518-402-3446 E-mail Address: Heidi.Nark@nysed.gov Federal Program(s) (ALN # [s]): Title I Grants to Local Educational Agencies (84.010) S010A180032, S010A190032, S010A200032, S010A...

State Agency: New York State Education Department Single Audit Contact: Heidi Nark Title: Internal Auditor 3 Telephone: 518-402-3446 E-mail Address: Heidi.Nark@nysed.gov Federal Program(s) (ALN # [s]): Title I Grants to Local Educational Agencies (84.010) S010A180032, S010A190032, S010A200032, S010A210032 Audit Report Reference: 2022-007 Anticipated Completion Date: December 2022 Corrective Action Planned: The Department acknowledges that one exam storage certificate for one school out of 40 local school districts selected for testing lacked the principal signature. To address this, the Department will review and reinforce existing procedures to ensure certificates are properly completed and have all required signatures.

View Audit 49189

Finding 41994 (2022-003)

Significant Deficiency 2022

State of New York

NY

Subrecipient Monitoring § 200.303 § 200.332 § 200.521

State Agency: Department of Health Single Audit Contact: Melissa Fiore Title: Audit Services Director Telephone: 518-473-0525 E-mail Address: Melissa.Fiore@health.ny.gov Federal Program(s) (ALN # [s]): Child & Adult Care Food Program (10.558) Audit Report Reference: 2022-003 Anticipated Completion D...

State Agency: Department of Health Single Audit Contact: Melissa Fiore Title: Audit Services Director Telephone: 518-473-0525 E-mail Address: Melissa.Fiore@health.ny.gov Federal Program(s) (ALN # [s]): Child & Adult Care Food Program (10.558) Audit Report Reference: 2022-003 Anticipated Completion Date: 12/31/2023 Corrective Action Planned: The Department?s Audit Clearinghouse will continue to work with NYS Office of Information Technology Services to develop a system to better track grantees that require a single audit report, when a single audit report is available for review, and, if a management decision letter is needed. This will provide better assurance of timely review of all submitted single audit reports and communication to Child & Adult Care Food Program staff of findings in need of management decision letters.

View Audit 49189

Finding 41954 (2022-005)

Significant Deficiency 2022

Youthprise

MN

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

Management agrees with this finding and is in the process of developing internal controls to ensure timely and appropriate actions are made on the deficiency noted.

View Audit 39981

Finding 41945 (2022-001)

Material Weakness 2022

Seattle Good Business Network

WA

Subrecipient Monitoring § 200.303 § 200.332

Contact Person: Erin Adams, Executive Director Corrective Action Plan: The Organization will update their subrecipient monitoring policy to include the requirements outlined in CFR 200.332, which will also include a requirement to formally document all relevant award information for each subrecipie...

Contact Person: Erin Adams, Executive Director Corrective Action Plan: The Organization will update their subrecipient monitoring policy to include the requirements outlined in CFR 200.332, which will also include a requirement to formally document all relevant award information for each subrecipient under a federal award. Anticipated Completion Date: The Organization will update their policy no later than December 31, 2023.

View Audit 39887

Finding 41940 (2022-001)

None 2022

Freeport Regional Health Care Foundation and Subsidiaries

IL

Reporting Internal Control / Segregation of Duties § 200.303

2022-001: Overstatement of Expense Finding: Expenses reported as General and Administrative expenses and Healthcare Related expenses that were reported in Period 2 in the Provider Relief Fund Reporting Portal (the ?Portal?) were also report in Period 4 in the Portal. Corrective Action Taken: Goi...

2022-001: Overstatement of Expense Finding: Expenses reported as General and Administrative expenses and Healthcare Related expenses that were reported in Period 2 in the Provider Relief Fund Reporting Portal (the ?Portal?) were also report in Period 4 in the Portal. Corrective Action Taken: Going forward, there will be a review of all applicable reporting when there are overlapping funding periods to ensure no expenses are duplicated. An additional review of material will also be done to verify data. Contact Person Responsible for Correct Action: Angie Meade, Director of Finance Anticipated Completion Date: December 31, 2023

View Audit 38292

Finding 41921 (2022-002)

Significant Deficiency 2022

1890 Universities Foundation

DC

Subrecipient Monitoring § 200.303 § 200.330

Finding 2022-002 Condition: Management did not verify that its subrecipient?s were not suspended or debarred or otherwise excluded from participating in the transactions. Foundation?s Response: The Foundation does not concur. 2 CFR Part 180 provides OMB guidance ?only to Federal agencies? (2CFR ?...

Finding 2022-002 Condition: Management did not verify that its subrecipient?s were not suspended or debarred or otherwise excluded from participating in the transactions. Foundation?s Response: The Foundation does not concur. 2 CFR Part 180 provides OMB guidance ?only to Federal agencies? (2CFR ? 180.5). As a pass-through entity, the Foundation falls under Uniform Guidance requirements at 2 CFR 200.332. Verification that subrecipients are not suspended, debarred or otherwise excluded is not a requirement of 200.332. However, the Foundation is committed to diligence in our stewardship of Federal funds, therefore we took the auditor?s comment into consideration, and incorporated an annual review of the Do Not Pay list into our subrecipient pre-award risk assessments.

View Audit 44502

Finding 41910 (2022-001)

Significant Deficiency 2022

Phoebe Devitt Homes

PA

Allowable Costs / Cost Principles § 200.303

Finding 2022-001 Condition During the testing of expenditures related to increased nurse agency costs and benefits allocation calculations, we observed that for 2 of the 2 calculations tested did not contain a review and approval prior to submission to detect potential errors in the calculations. ...

Finding 2022-001 Condition During the testing of expenditures related to increased nurse agency costs and benefits allocation calculations, we observed that for 2 of the 2 calculations tested did not contain a review and approval prior to submission to detect potential errors in the calculations. Corrective Action Plan Corrective Action Planned: Beginning with PRF reporting period 4 reporting the Organization will begin formally documenting the review of all calculations as part of the submission review process. CFO and Executive Director of Finance will both review all calculations and submissions. Name(s) of Contact Person(s) Responsible for Corrective Action: Thomas Baer, CFO and Mike Pfleegor, Executive Director of Finance Anticipated Completion Date: 3/31/2023

View Audit 38975

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