Corrective Action Plans

REFERENCE: 2022-007 ? Allowable Costs/Cost PrinciplesHIV Emergency Relief Project Grants (Assistance listing No. 93.914)Federal Grantor: Health Resources and Services AdministrationFacility: St. Mary?s Medical Center ? San FranciscoVirginia MasonFinding: At St. Mary?s Medical Center ? San Francisco and Virginia Mason, controls over the requiredallowability criteria with regard to payroll expense were not performed and/or documented throughout the year.Corrective Action Plan: This finding has been corrected. At St. Mary?s Medical Center ? San Francisco, as of July2021 invoices were prepared using actual payroll as opposed to budget. At Virginia Mason, beginning in April 2022,managers receive notification from the payroll department of unapproved time cards that are waiting for approval.A reminder email is sent to managers and employees to approve and submit their time cards on time. Trainingsessions were implemented to instruct all employees and the managers of this requirement. Once the training hasbeen completed and employees or managers miss approving the timecard then disciplinary actions will be taken.Payroll sends out messages of outstanding timecards awaiting approval.Person Responsible: Doug Amarelo ? St. Mary?s Medical Center, San FranciscoRebecca Kiser ? Virginia MasonCompletion: April 2022

REFERENCE: 2022-015 ? Allowable Costs/Cost PrinciplesMedical Assistance Program (Medicaid Cluster) (93.778)Federal Grantor: U.S. Department of Health and Human ServicesFacility: Dignity Health Connected LivingFinding: At Dignity Health Connected Living, internal controls over the required allowability criteria with regard to payroll expense were not performed for 1 of 25 employees selected for testing.Corrective Action Plan: In addition to timecard approval by supervisors, Dignity Health Connected Living finance will review a TEAMs salary report to review that time charged to the grant is accurate and appropriate. Review will be completed on a payperiod basis.Person Responsible: Marcela Ashinhurst, Senior Financial AnalystExpected Completion: April 2023

REFERENCE: 2022-012 ? EligibilityMedicaid Cluster (93.778)Federal Grantor: U.S. Department of Health and Human ServicesFacility: Dignity Health Medical FoundationDignity Health Connected LivingFinding: The Dignity Health Medical Foundation and Dignity Health Connected Living did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided.Corrective Action Plan: For the Medical Assistance Program eligibility is validated through a Medi-Cal system website. Dignity Health Medical Foundation personnel have implemented procedures to ensure documentation of eligibility checks are retained. The Clinic Operations manager has instructed staff and supervisors to save proof of eligibility for all months. The Clinic Operations manager checks for retention of eligibility documentation on a random basis and an internal audit will be performed to check for compliance with the documentation retention.At Connected Living the staff will identify participants who may be ineligible for continued services at the beginning of each service month. The Medi-Cal eligibility report is produced on the first business day of each month. The list includes all eligible and ineligible participants. This report will be saved each month for tracking purposes. The report will be reviewed each month for ineligible participants or factors that may impact eligibility for the coming month. Steps will be taken to obtain proof of eligibility or being termination proceedings.Person Responsible: Nicole Hill, Clinic Operations Manager, Dignity Health Medical Foundation.Kristina Devan, Dignity Health Connected LivingCompletion: July 1, 2022

REFERENCE: 2022-017 ? Special Tests and Provisions ? Disbursements to or on Behalf of StudentsSFA Cluster (84.268)Federal Grantor: U.S. Department of EducationFacility: Good Samaritan College of Nursing and Health ScienceFinding: Good Samaritan College of Nursing & Health Science did not send loan notifications to 2 of 28 students selected for disbursement testing for direct loans.Corrective Action Plan: Compliance will be verified through internal audit of student disbursements. A sample of disbursements will be checked for proper notifications on periodic basis throughout the semester.Person Responsible: James Younger, Dean of Financial Services and DevelopmentExpected Completion: April 2023

REFERENCE: 2022-001 ? Special Tests and Provisions ? Disbursements to or on Behalf of StudentsStudent Financial Assistance Cluster (Assistance listing No. 84.268)Federal Grantor: U.S. Department of EducationFacility: Good Samaritan College of Nursing and Health ScienceFinding: Good Samaritan College of Nursing & Health Science did not have evidence of whether the quality assurance system was operating effectively during the fiscal year ended June 30, 2022.Corrective Action Plan: This finding was corrected by June 30, 2022. In January 2021 the institution updated the Financial Aid Department Policy and Procedure Manual to include a section that address quality assurance oversight. The Quality Assurance Plan developed includes the following: reports loan records, disbursements, and adjustments to disbursements correctly to the Common Origination Disbursement system; disburses and returns loan funds in accordance with regulatory requirements; disburses the correct loan amount to the correct student; completes monthly reconciliation and Program Year Closeout. Program will be reviewed annually and updated accordingly by FAS and GSC Management. Compliance with the quality assurance policy is monitored through the reconciliation process which was implemented in June 2022.Person Responsible: Judy Kronenberger ? President Good Samaritan College of Nursing and Health ScienceCompletion: June 2022

REFERENCE: 2022-002 ? Special Tests and Provisions ? Borrower Data and Reconciliation (Direct Loan)Student Financial Assistance Cluster (Assistance Listing No. 84.268)Federal Grantor: U.S. Department of EducationFacility: Good Samaritan College of Nursing and Health ScienceFinding: Good Samaritan College of Nursing & Health Science did not perform the direct loan monthlyreconciliations for FY22.Corrective Action Plan: Good Samaritan implemented a formal monthly reconciliation process, includingcomparison of all systems for the period, a final review of G5 funds prior to draw down, a cover sheet noting anyexplaining any differences, proper sign off for preparation and review and the date by Good Samaritan management.A year end reconciliation will also be performed following the same process.Person Responsible: Judy Kronenberger ? President Good Samaritan College of Nursing and Health Scienceand Financial Aid Services (FAS)Completion: June 2022

REFERENCE: 2022-003 ? Reporting ? Common Origination and Disbursement (COD) SystemStudent Financial Assistance Cluster (Assistance listing No. 84.063)Federal Grantor: U.S. Department of EducationFacility: Good Samaritan College of Nursing and Health ScienceFinding: Good Samaritan College of Nursing & Health Science did not perform its internal control over therequirement to submit Pell payment data to the Department of Education through the COD system, which consists ofmonthly Pell COD reconciliations.Corrective Action Plan: Good Samaritan will implement a formal monthly reconciliation process, includingcomparison of all systems for the period, a final review of G5 funds prior to draw down, a cover sheet noting anyexplaining any differences, proper sign off for preparation and review and the date by Good Samaritan management.A year end reconciliation will also be performed following the same process.Person Responsible: Judy Kronenberger ? President Good Samaritan College of Nursing and Health Scienceand Financial Aid Services (FAS)Completion: June 2022

REFERENCE: 2022-005 ? Special Tests and Provision ? Enrollment ReportingStudent Financial Assistance Cluster (Assistance listing No. 84.007, 84.063, 84.268)Federal Grantor: U.S. Department of EducationFacility: Good Samaritan College of Nursing and Health ScienceFinding: Good Samaritan College of Nursing & Health Science did not have internal controls over enrollmentreporting.Corrective Action Plan: Monthly reconciliations are conducted by the Bursar and Financial Aid departments.Monthly reconciliation reports are presented to the Dean of Enrollment Management at all monthly reconciliationupdate meetings.Person Responsible: Judy Kronenberger ? President Good Samaritan College of Nursing and Health ScienceCompletion: June 2022

REFERENCE: 2022-004 ? Cash ManagementStudent Financial Assistance Cluster (Assistance listing No. 84.007, 84.063, 84.268)Federal Grantor: U.S. Department of EducationFacility: Good Samaritan College of Nursing and Health ScienceFinding: Per discussion with management, Good Samaritan College of Nursing & Health Science has processes andinternal controls in place to ensure requests for funding are allowable under the terms of the grant agreement. Theseinternal controls included validating the draw agreed between the G5 system, COD, and Good Samaritan College ofNursing & Health Science?s internal records for student financial need. However, management did not consistentlyretain documentation evidencing the performance of these internal controls.Corrective Action Plan: Good Samaritan will implement a formal monthly reconciliation process, includingcomparison of all systems for the period, a final review of G5 funds prior to draw down, a cover sheet noting anyexplaining any differences, proper sign off for preparation and review and the date by GSC management and FASmanagement. A year end reconciliation will also be performed following the same process.Person Responsible: Judy Kronenberger ? President Good Samaritan College of Nursing and Health ScienceCompletion: June 2022

REFERENCE: 2022-014 ? Allowable Costs/Cost PrinciplesCoronavirus Relief Fund (21.019)Federal Grantor: U.S. Department of TreasuryFacility: CHI MemorialFinding: At CHI Memorial, controls over the required allowability criteria and period of performance with regard to payroll expense were not performed and/or documented.Corrective Action Plan: Hospital staff will be provided training to refresh the requirement to approve timecards for supervisees. Accounting/finance will review payroll reports to ensure only time properly approved is charged to grant for reimbursement.Person Responsible: Craig Nielsen, Market Director Operational FinanceExpected Completion: April 2023

REFERENCE: 2022-018 ? Procurement and Suspension and DebarmentResearch and Development Cluster (12.420, 93.103 and 93.853)Federal Grantor: U.S. Department of Defense and U.S. Department of Health and Human ServicesFacility: St. Joseph?s Hospital and Medical CenterFinding: St. Joseph?s Hospital and Medical Center did not prepare and retain documentation of sole source justification for three procurements over the micro-purchase threshold made without competition.Corrective Action Plan: Training was provided to program and operations managers to add additional documentation to requisitions. An updated work instruction will be developed by the research administration department outlining the necessary documentation for non-competitive purchases.Person Responsible: Sheri Sanders, Division Director Research AdministrationExpected Completion: April 2023

REFERENCE: 2022-016 ? Subrecipient MonitoringResearch and Development Cluster (12.420, 93.279, 93.853, and 93.866)Federal Grantor: U.S. Department of Defense and U.S. Department of Health and Human ServicesFacility: St. Joseph?s Hospital and Medical CenterFinding: St. Joseph?s Hospital and Medical Center?s subrecipient monitoring tracking document, while designed appropriately, is not being maintained effectively and includes errors, since line items on the tracking document for several subrecipients appear to be incorrect with regards to audit findings. Findings appear to have been left off of the tracking document or added incorrectly for a particular subrecipient or may not apply to the subrecipient but to a different subrecipient.Corrective Action Plan: To check for completeness and accuracy, additional review of the subrecipient monitoring tracking document will completed by the Division Director Research Administration and System Director Grant Accounting.Person Responsible: Sheri Sanders, Division Director Research Administration and Jenny Lewis-Whelan, System Director Grant AccountingExpected Completion: June 2023

REFERENCE: 2022-011 ? Special Tests and Provisions ? Key PersonnelResearch and Development Cluster (Multiple)Federal Grantor: U.S. Department of DefenseU.S. Department of Health and Human ServicesFacility: St. Joseph?s Hospital and Medical CenterFinding: St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Corrective Action Plan: On a quarterly basis, program managers and grant managers meet with the principal investigator on all of their federal grants. During the meeting, level of effort is reviewed and certified by PI?s.Person Responsible: Research Ops Managers; Tomas Cortez, Grant Accounting ManagerCompletion: September 2022

REFERENCE: 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Research and Development Cluster (Multiple)Federal Grantor: U.S. Department of DefenseU.S. Department of Health and Human ServicesFacility: St. Joseph?s Hospital and Medical CenterFinding: St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Corrective Action Plan: On a quarterly basis, program managers and grant managers meet with the principal investigator on all of their federal grants. During the meeting, the actual hours for all individuals are reviewed. Additionally, a reconciliation of actual to budget is performed. Documentation of the quarterly reviews is maintained on a google shared drive. Quarterly meetings include evaluation of salary charged to grant in comparison to NIH salary cap.Person Responsible: Research Ops Managers; Tomas Cortez, Grant Accounting ManagerCompletion: September 2022

REFERENCE: 2022-008 ? Activities Allowed or UnallowedResearch and Development Cluster (Multiple)Federal Grantor: U.S. Department of DefenseU.S. Department of Health and Human ServicesFacility: St. Joseph?s Hospital and Medical CenterFinding: St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Corrective Action Plan: On a quarterly basis, program managers and grant managers meet with the principal investigator on all of their federal grants. During the meeting, the actual hours for all individuals are reviewed. Additionally, a reconciliation of actual to budget is performed. Documentation of the quarterly reviews is maintained on a google shared drive. Clinical time for federal grants will be supported by a completed timesheet signed by a supervisor or PI. Timesheets will be completed monthly.Person Responsible: Research Ops Managers; Tomas Cortez, Grant Accounting ManagerExpected Completion: September 2022

REFERENCE: 2022-009 ? Activities Allowed or UnallowedResearch and Development Cluster (Multiple)Federal Grantor: U.S. Department of DefenseU.S. Department of Health and Human ServicesFacility: St. Joseph?s Hospital and Medical CenterFinding: At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Corrective Action Plan: Indirect expense calculation is reviewed and compared to grant agreement by Grant Accounting Manager prior to month end close.Person Responsible: Tomas Cortez, Grant Accounting ManagerCompletion: January 2022

Finding Number 2022-208: State Opioid Response program performance progress reports did not have documentation to support completion of a review for accuracy and compliance prior to submission.Federal Program: 93.788 - Opioid STRRelated to Prior Finding: N/AAgency?s view: The Department agrees with this finding.The contract manager attests that she did, in fact, review, edit, re-review and ultimately approve the 5 program performance reports to the grantor. The reports were either emailed to the Program Manager or uploaded in Teams for her review/approval. The auditor was provided documentation of these reviewed documents, including editing notes by that manager. Additionally, one-on-one supervision notes between the person submitting the reports and the contract manager validate that these reports were, in fact, reviewed and approved prior to submission to the grantor. The federal funder does not require this type of documentation of review/approval and the program was not aware of this CFR requirement. The program does, however, agree, that review and approval of these reports was not documented and that a corrective action plan is warranted.Corrective Action: Beginning April 1, 2023, all required federal reports will include thefollowing statement, which will be signed and dated electronically by the approving reviewerbefore the report is submitted:? I, _______________________, have reviewed and approved this report prior tosubmission.Name, titleA copy of the approved and signed report will be retained in DBH?s electronic grant fundingrecords.Anticipated Corrective Action Date: April 1, 2023Responsible for Corrective Action: Kelly Combs, Bureau Chief, Compliancekelly.combs@dhw.idaho.gov 208-334-5814

Finding Number 2022-211: The Schedule of Expenditures of Federal Awards (SEFA) closing package originally submitted to the Office of the State Controller did not properly identify COVID-19 Emergency Acts expenditures for multiple programs.Federal Programs:93.391 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises10.551 - Supplemental Nutrition Assistance Program (Snap)84.181 - Special Education - Grants for Infants and Families93.497 - Family Violence Prevention and Services/ Sexual Assault/Rape Crisis Services and Supports93.590 - Community-Based Child Abuse Prevention Grants93.958 - Block Grants for Community Mental Health Services93.977 - Sexually Transmitted Diseases (STD) Prevention and Control Grants10.557 - WIC Special Supplemental Nutrition Program for Women, Infants, And Children10.561 - State Administrative Matching Grants for The Supplemental Nutrition Assistance ProgramRelated to Prior Finding: 2021-206Agency?s view: The Department agrees with this finding.The Department agrees with this finding but it is important to highlight that our internal controls and review processes are designed to detect and correct material inaccuracies or omissions of required information within the annual SEFA. As this does not constitute a material error, but rather a significant deficiency, the Department?s controls for this process worked as intended.This was a new requirement and Department personnel failed to identify a significant risk related to it and enhance the review procedures accordingly. This requirement will be monitored while we spend down the remaining COVID-19 emergency funding we have already been awarded.Corrective Action: This corrective action plan is complete. Effective immediately, we willmonitor awards for any new COVID-19 funding, but we don?t believe that there will be any newCOVID-19 awards. All existing awards have been confirmed as being reported as COVID-19funding.Anticipated Corrective Action Date: Corrective action has been taken as of April 2023Responsible for Corrective Action: Kelly Combs, Bureau Chief, Compliancekelly.combs@dhw.idaho.gov 208-334-5814

Finding Number 2022-202: The Commission did not complete required reports for the Federal Funding Accountability and Transparency Act (FFATA).Federal Programs: 93.044, 93.045, 93.053 ? Aging ClusterRelated to Prior Finding: N/AAgency?s view: The Commission agrees with this finding.Corrective Action: Federal Funding Accountability and Transparency Act (FFATA) reporting for federal fiscal years 2021, and 2022 have been completed as of March 27, 2023. The agency will complete FFATA reporting as awards are administered to sub-awardees going forward.Anticipated Corrective Action Date: March 27, 2023Responsible for Corrective Action: Joe Zaher, Senior Financial SpecialistJoe.zaher@aging.idaho.gov 208-577-2864

Finding Number 2022-201: The Commission did not complete the required Federal Financial SF-425 Report for the Aging Cluster Grant program in a timely manner.Federal Programs: 93.044, 93.045, 93.053 ? Aging ClusterRelated to Prior Finding: N/AAgency?s view: The Commission agrees with this finding.Corrective Action: Actions have been taken to complete SF-425 reports as they come due for each grant. A reporting workbook has been created to track awards and reporting dates. Reporting period end dates and due dates will be added to fiscal staff calendars. We will continue to keep our federal partners appraised of our progress through completion.Anticipated Corrective Action Date: 'A soft target date for completion of all past due reports is set for September 30, 2023, and a hard target date of December 31, 2023.Responsible for Corrective Action: Joe Zaher, Senior Financial SpecialistJoe.zaher@aging.idaho.gov 208-577-2864

Finding Number 2022-206: The Department did not complete required subrecipient monitoring of the Elementary and Secondary School Emergency Relief (ESSER) Fund of the Education Stabilization Fund.Federal Programs:84.425U - Education Stabilization Fund ? ARPA ESSER III84.425D - Education Stabilization Fund - Elementary and Secondary School Emergency Relief Fund84.425W - Education Stabilization Fund - ARPA ESSER - Homeless Children and Youth84.425R - Education Stabilization Fund - Emergency Assistance for Non-Public SchoolsRelated to Prior Finding: 2021-204Agency?s view: The Department agrees with this finding.Corrective Action: It was not until the end of the 2022 legislative session that spending authority was given to the State Department of Education to use ARP ESSER Sincerely, administrative funds to hire additional staff to meet the robust requirements identified by the U.S. Department of Education. Up to that point, only one full-time person was handling all of the needs associated with ESSER funds. Since then, two positions have been hired. The ESSER Data and Reporting Coordinator began in April 2022, and the ESSER Monitoring Coordinator began in June 2022. While developing the monitoring procedures began in July 2022, it was after the audit timeframe. The Department now has in place all ESSER monitoring policies and procedures and will complete year one monitoring before May 5, 2023.Anticipated Corrective Action Date: May 2023Responsible for Corrective Action: Gideon Tolman, Chief Financial Officergtolman@sde.idaho.gov 208-332-6874

Finding Number 2022-210: The Department did not review subrecipient application information for Coronavirus State and Local Fiscal Recovery Funds at a sufficient level to identify missing information from required documentation.Federal Program: 21.027 - Coronavirus State and Local Fiscal Recovery FundsRelated to Prior Finding: N/AAgency?s view: The Department agrees with this finding.In the rush to respond to emergency needs during the pandemic and the non-traditional format these funds were distributed, the Department neglected to properly review and hold incomplete attestation applications. The attestation application process was specifically developed under the pandemic, was a new process for staff, and was during the time period of transitioning from DUNS to Unique Identifier. Additionally, staff not typically involved in the subrecipient process approved the applications for payment and did not know to hold payments if the unique identifier field was blank. Finally, attestation documents did not route through the traditional internal processes where controls would have identified the gap. After funds were distributed and the misstep was realized, the Department verified Unique Identifiers through SAMS registration or by reaching out directly to the hospitals for documented proof. At the time of the audit, we did not have documentation of a unique identifier for two (2) hospitals out of the forty-three (43) awarded, but that information has subsequently been obtained.The attestation process has since been discontinued. Internal controls are in place as the Department procurement policy; staff are trained to check SAM.gov on all subrecipients. Additionally, internal forms needed to execute a subrecipient agreement require documentation of the Unique Identifier. If the Unique Identifier field is left blank, the Department Contracts and Procurement Unit will not process the agreement request. This finding was a result of a new process and untrained staff pulled into the rapid dispersal of COVID funds.Corrective Action: Corrective action is complete. Internal controls are in place as the Department procurement policy; staff are trained to check SAM.gov on all subrecipients. Additionally, internal forms needed to execute a subrecipient agreement require documentation of the Unique Identifier. If the Unique Identifier field is left blank, the Department Contracts and Procurement Unit will not process the agreement request. This finding was a result of a new process and untrained staff pulled into the rapid dispersal of COVID funds.Anticipated Corrective Action Date: Corrective action has been taken as of April 2023Responsible for Corrective Action: Kelly Combs, Bureau Chief, Compliancekelly.combs@dhw.idaho.gov 208-334-5814

Finding Number 2022-209: An annual physical inventory was not completed for all storage facilities used by sub-distributing agencies for the Emergency Food Assistance Program as required by federal guidance.Federal Program: 10.568 - Emergency Food Assistance ProgramRelated to Prior Finding: N/AAgency?s view: The Department agrees with this finding.Corrective Action: The Department questioned and relied upon an opinion from the National Office of USDA Food and Nutrition Service (FNS), which administers TEFAP, affirming the Department?s interpretation of the regulations for this program. Dixon, R. (2023) Email to Cho Heide, March 23. In that opinion the Department asserted and FNS agreed that the requirements for an annual physical review of food inventories only applies to storage facilities used by the state distributing agency or sub-distributing agencies (as defined in 7 CFR 250.2). The Department has always considered the organizations with which we have subgrant agreements for TEFAP to be eligible recipient agencies (as defined in 7 CFR 251.3), not sub-distributing agencies. The Department provided this information to LSO auditors but on review with them as relates to the compliance supplement for this program, it became clear that the guidance from FNS was not authoritative and therefore, did not supersede the compliance supplement. With this knowledge, the Department will work with FNS to clarify requirements within the compliance supplement, revising our control process in this program accordingly.Anticipated Corrective Action Date: July 2023Responsible for Corrective Action: Kelly Combs, Bureau Chief, Compliancekelly.combs@dhw.idaho.gov 208-334-5814

Finding Number 2022-212: The Department did not maintain consistent operation of controls and compliance with Electronic Benefit Transfer (EBT) Card Security procedures for the Supplemental Nutrition Assistance Program (SNAP).Federal Programs:10.551 - Supplemental Nutrition Assistance Program (SNAP)10.561 - State Administrative Matching Grants for the Supplemental Nutrition Assistance ProgramRelated to Prior Finding: 2021-210Agency?s view: The Department agrees with this finding.Corrective Action: Immediately upon receiving the audit finding in March 2022, staffreviewed and revised procedures and fully implemented a corrective action plan by June 30, 2022. The entire EBT team was trained on the bulk card ordering and issuing process and modified security procedures to mitigate the risk of non-compliance in the future. The bulk card managers in the field offices review and reconcile card issuances monthly. Also, the EBT Supervisor documents the review of the previous quarter?s electronic card audits for accuracy and completeness.Anticipated Corrective Action Date: See corrective action above.Responsible for Corrective Action: Kelly Combs, Bureau Chief, Compliancekelly.combs@dhw.idaho.gov 208-334-5814

LockHaven: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: The University will review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately. The University will put necessary controls in place to ensure reports are posted within ten days of the end of the quarter. Documentation of report review and approval will be in writing and saved to ensure documentation is available to support review and approval of report submissions.Name(s) of the contact person(s) responsible for corrective action: Michael Hall, Director of Financial Aid.Planned completion date for corrective action plan: April 30, 2023Clarion: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: This finding resulted from a combination of staff turnover and the complexity of integration. All grant-related reporting requirements will be reviewed to ensure that they are properly documented and scheduled for completion and review when required by the granting authority.Name(s) of the contact person(s) responsible for corrective action: Sean Bliley, Controller, 814-732-1304Planned completion date for corrective action plan: June 30, 2023Bloomsburg: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: We have reviewed the reporting requirements published by the federal government to ensure compliance with all procedures. In addition, we have established review procedures so that each document is reviewed prior to publishing on our website.Name(s) of the contact person(s) responsible for corrective action: : Amanda Kishbaugh at (570) 389-4497.Planned completion date for corrective action plan: April 30, 2023Edinboro: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: All grant-related reporting requirements will be reviewed to ensure that they are properly documented and scheduled for completion and review when required by the granting authority.Name(s) of the contact person(s) responsible for corrective action: Sean Bliley, Controller, 814-732-1304. Planned completion date for corrective action plan: 06/30/2023California: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: This finding resulted from a combination of staff turnover and the complexity of integration. All grant-related reporting requirements will be reviewed to ensure that they are properly documented and scheduled for completion and review when required by the granting authority.Name(s) of the contact person(s) responsible for corrective action: Sean Bliley, Controller, 814-732-1304Planned completion date for corrective action plan: June 30, 2023 Mansfield: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: The University will review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately. Documentation of report review and approval will be in writing and saved to ensure documentation is available to support review and approval of report submissions.Name(s) of the contact person(s) responsible for corrective action: Colleen Jackson, Assistant Controller, Pam Kathcart, Director of Financial AidPlanned completion date for corrective action plan: April 30, 2023 Millersville: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: The finding related to the institutional report not being displayed on the website refers to reporting of December 31st, 2021 (due to be posted on website by January 10th, 2022). The university was alerted to the issue of approval requirements during the last single audit process, which was after the December 31st report was posted. All reports posted to the website after the finding in last year?s audit were completed with Finance and Administration Vice President or Associate Vice President approvals prior to posting.Name(s) of the contact person(s) responsible for corrective action: Tammy Aument-Martin, Director of Accounting & Budget at 717-871-4091 and Emi Alvarez, Director of Financial Aid at 717-871-5100.Planned completion date for corrective action plan: 06/30/2022 (all HEERF funds were drawn down and recorded) Cheyney: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: Additional policies and procedures were implemented to mitigate errors in the future.Planned completion date for corrective action plan: 9/30/2023Name(s) of the contact person(s) responsible for corrective action: Victoria Atkins at (610) 399-2097.