Corrective Action Plans

Finding 58686 (2022-001)

Material Weakness 2022

AL

Questioned Costs Procurement, Suspension & Debarment § 200.303 § 200.320

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED SEPTEMBER 30, 2022 The Jefferson County Department of Health submits the following corrective action plan for the year ended September 30, 2022: FINDINGS ? FEDERAL AWARDS: Audit Finding Reference 2022-001 Procurement Corrective Action Plan Rate quotes will...

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED SEPTEMBER 30, 2022 The Jefferson County Department of Health submits the following corrective action plan for the year ended September 30, 2022: FINDINGS ? FEDERAL AWARDS: Audit Finding Reference 2022-001 Procurement Corrective Action Plan Rate quotes will be obtained from at least three (3) law firms as required for ?small purchases? by 2 C.F.R. 200.320. Person Responsible Rodney Holmes, Finance Director Estimated Completion Date May 31, 2023

View Audit 53878 Questioned Costs: $1

Finding 58628 (2022-002)

Material Weakness 2022

University of the Incarnate Word

TX

Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.319

Finding 2022-002 ? Procurement, Suspension, and Debarment Contact Person: Michael R. Castilleja, Director of Procurement & Other Support Services Current Status: Correction of this finding is in-progress. Anticipated Completion Date: December 31, 2023 Condition: The University did not main...

Finding 2022-002 ? Procurement, Suspension, and Debarment Contact Person: Michael R. Castilleja, Director of Procurement & Other Support Services Current Status: Correction of this finding is in-progress. Anticipated Completion Date: December 31, 2023 Condition: The University did not maintain records for procurements sufficient to detail the history of procurement, including the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Additionally, as required by the University?s Procurement and Bid Policy, the University did not maintain and provide documentation of the performance of an annual pricing review in order to assess whether preferred vendors continue to provide comparable pricing to other vendors. Identification of repeat finding: N/A UIW is committed to complying with the Procurement, Suspension, and Debarment regulations as indicated in the Uniform Guidance Procurement Standards (2 CFR ? 200.317 through 200.327). The University?s practice to maintain records for procurements which include the rationale for the method of procurement, selection of contract type, price analysis (including bidding process) and justification of vendor selection are currently being followed. Due to the urgency and state of emergency the University was under, it hindered our efforts of documenting our procurement practices. An oversight of the Procurement Standards has been reviewed and we are confident that our policies and procedures are sufficient to satisfy the requirements of the regulations. In addition, the University will implement a Sole Source/Preferred Vendor Form that will require justification and evidence of a vendor meeting the requirements of the purchase within a reasonable, allowable and consistent manner. ? Sole Source Vendors will be identified by department needs and may be requested at time of purchase requisition. Determination will be based on vendor availability of products and needs. ? Preferred Vendors will be maintained for the year and must be requested for market pricing review to include date of request, vendor category and price for like items. The Preferred Vendors list will be maintained in the Procurement Department and may be requested for review by initiator of purchase requisitions. All Sole Source/Preferred Vendor request should be reviewed/signed by requestor, a Procurement Officer, and the CFO & VP for Finance and Administration.

View Audit 56368

Finding 58625 (2022-001)

Material Weakness 2022

University of the Incarnate Word

TX

Student Financial Aid Eligibility Reporting § 200.303

Finding 2022-001 ? Special Tests and Provisions ? Enrollment Reporting (Student Financial Assistance Cluster) Contact Persons: Diana Dimas, Registrar?s Office Cristen Alecia, Office of Financial Assistance Current Status: Correction of this finding is in-progress. Anticipated Completion D...

Finding 2022-001 ? Special Tests and Provisions ? Enrollment Reporting (Student Financial Assistance Cluster) Contact Persons: Diana Dimas, Registrar?s Office Cristen Alecia, Office of Financial Assistance Current Status: Correction of this finding is in-progress. Anticipated Completion Date: December 31, 2023 Condition: The University of the Incarnate Word did not accurately or timely report student status changes to the NSLDS for 6 out of 60 students selected for testing. Identification of Repeat Finding: 2021-001, 2020-001, 2019-002 While the condition reported above is considered a repeat finding, it is important to note that the errors are different this year and that these findings are not a reflection of the university ignoring previous findings or failing to make changes, but rather a reflection of the complexity of enrollment reporting. There were no inaccurate or untimely attendance level changes, and the official withdrawals were reported accurately and timely. In this year?s errors, we had a student who graduated outside of a normal conferral date, causing them not to be reported during our normal degree conferral report to NSC. The Registrar?s Office is putting changes in place to either eliminate out-of-cycle conferrals, or increase the number of conferral and reporting dates to effectively capture all graduates. We know that only 6 students were caught up in this out-of-cycle graduation, as it was a specific exception for the School of Osteopathic Medicine, and is not a wide-spread issue. We had two unofficial withdrawals reported later than 60 days ? at 69 and 70 days. While the withdrawal and the changes were processed timely, the timing of the roster from NSLDS compared to the submission to NSC caused the report not to be acknowledged until after the 60 days had passed. The Office of Financial Assistance is researching the option of manually reporting unofficial withdrawals outside of the monthly reporting cycle in order to eliminate this problem. The Registrar?s Office will review the roster and NSC submission schedules to see if changes need to be made in order to better align reporting dates. We had three students inaccurately reported as withdrawn for the summer semester. These students were at least half-time in the preceding Spring and the following Fall, and therefore were not required to be reported as withdrawn. The Office of Financial Assistance and the Registrar?s Office will work together to research options in Banner and with NSC. It may be necessary to create a separate withdrawal code to identify summer withdrawals that should not be reported as withdrawn, and create a report to monitor the fall enrollment for these students in case they later withdraw from Fall and transition to a withdrawal which must be reported. The Banner system alone does not allow for the complicated logic mandated for summer reporting in the NSLDS Enrollment Reporting Guide. Our offices will continue to work in partnership to resolve these enrollment reporting issues. Cristen Alicea Director Office of Financial Assistance 210.805.1238 gimenez@uiwtx.ed www.uiw.edu/finaid Diana Dimas Associate Registrar Registration and Technology Office of the Registrar 210.832.5484 dimasd@uiwtx.edu www.uiw.edu

View Audit 56368

Finding 58620 (2022-004)

Material Weakness 2022

Tippecanoe School Corporation

IN

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

FINDING 2022-004 Contact Person Responsible for Corrective Action: Amanda M. Brackett, Chief Financial Officer Contact Phone Number: (765) 269-8218 Views of Responsible Official: We agree with the findings identified. Description of Corrective Action Plan: In order to mitigate future findings regard...

FINDING 2022-004 Contact Person Responsible for Corrective Action: Amanda M. Brackett, Chief Financial Officer Contact Phone Number: (765) 269-8218 Views of Responsible Official: We agree with the findings identified. Description of Corrective Action Plan: In order to mitigate future findings regarding earmarking within the Greater Lafayette Area Special Services cooperative, the TSC will implement procedures to ensure better internal controls which includes monitoring. The Chief Financial Officer will monitor the progress of the Corrective Action Plan to ensure that we fulfill our requirements of the CAP. Anticipated Completion Date: Summer 2023.

View Audit 56365

Finding 58619 (2022-003)

Material Weakness 2022

Tippecanoe School Corporation

IN

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

FINDING 2022-003 Contact Person Responsible for Corrective Action: Amanda M. Brackett, Chief Financial Officer Contact Phone Number: (765) 269-8218 Views of Responsible Official: We agree with the findings identified. Description of Corrective Action Plan: In order to mitigate future findings regard...

FINDING 2022-003 Contact Person Responsible for Corrective Action: Amanda M. Brackett, Chief Financial Officer Contact Phone Number: (765) 269-8218 Views of Responsible Official: We agree with the findings identified. Description of Corrective Action Plan: In order to mitigate future findings regarding suspension and debarment within the Greater Lafayette Area Special Services cooperative, the TSC will implement procedures to ensure better internal controls which includes monitoring. The Chief Financial Officer will monitor the progress of the Corrective Action Plan to ensure that we fulfill our requirements of the CAP. Anticipated Completion Date: July 2021. Completion of this has been remedied an only affected year 1 of the audit period.

View Audit 56365

Finding 58618 (2022-002)

Material Weakness 2022

Tippecanoe School Corporation

IN

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

FINDING 2022-002 Contact Person Responsible for Corrective Action: Amanda M. Brackett, Chief Financial Officer Contact Phone Number: (765) 269-8218 Views of Responsible Official: We agree with the findings identified. Description of Corrective Action Plan: In order to mitigate future findings regard...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Amanda M. Brackett, Chief Financial Officer Contact Phone Number: (765) 269-8218 Views of Responsible Official: We agree with the findings identified. Description of Corrective Action Plan: In order to mitigate future findings regarding activities allowed and allowable costs within the Greater Lafayette Area Special Services cooperative, the TSC will implement procedures to ensure better internal controls which includes monitoring. The Chief Financial Officer will monitor the progress of the Corrective Action Plan to ensure that we fulfill our requirements of the CAP. Anticipated Completion Date: July 2021. Completion of this has been remedied an only affected year 1 of the audit period.

View Audit 56365

Finding 58547 (2022-003)

Material Weakness 2022

Sicangu Oyate Ho, INC

SD

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

2022-003 Payroll (Material Weakness) New Finding This Year Recommendation: Management should restrict payroll module access to those with a logical need for such access. Action Taken: St. Francis Indian School has checks and balances in place when changes need to be made in the payroll module. The o...

2022-003 Payroll (Material Weakness) New Finding This Year Recommendation: Management should restrict payroll module access to those with a logical need for such access. Action Taken: St. Francis Indian School has checks and balances in place when changes need to be made in the payroll module. The only employees who have access are those who need to input data and make changes such as Human Resources and of course Payroll.

View Audit 55377

Finding 58540 (2022-002)

Material Weakness 2022

Frankton Lapel Community School Corporation

IN

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

FINDING 2022-002 Contact Person Responsible for Corrective Action: Candace McDonald Contact Phone Number: 765-734-1261 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Going forward, Frankton-Lapel Schools will no longer plan on entering into a ...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Candace McDonald Contact Phone Number: 765-734-1261 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Going forward, Frankton-Lapel Schools will no longer plan on entering into a construction project through the Education Stabilization Fund. Anticipated Completion Date: Already completed.

View Audit 50226

Finding 58486 (2022-007)

Material Weakness 2022

Regional West Health Services

NE

Reporting Internal Control / Segregation of Duties § 200.303

Material Weakness: 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 feder...

Material Weakness: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: RWHS selected option I to calculate lost revenue for its subsidiary, which consists of reporting quarterly net revenue by payor during the period of availability. Net revenue was determined by projecting payor deductions instead of using actual deductions as required by the terms and conditions of the award. Planned Corrective Action: Management will refine processes to more diligently review the lost revenue calculation to ensure such amounts are in accordance with the terms and conditions of the federal award. Contact Person: Alan Townsend, CFO Anticipated Completion Date: Ongoing

View Audit 54656

Finding 58485 (2022-006)

Material Weakness 2022

Regional West Health Services

NE

Reporting Internal Control / Segregation of Duties § 200.303

Material Weakness: 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 feder...

Material Weakness: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: RWHS selected option II to calculate lost revenue for its subsidiary, which consists of a comparison of actual results during the period of availability to the approved budget in 2020 and 2021. The budget was required to be approved by March 27, 2020. The budget used for 2021 and 2022 was not approved by the required date. Planned Corrective Action: Management will refine processes to more diligently review the lost revenue calculation to ensure such amounts are in accordance with the terms and conditions of the federal award. Contact Person: Alan Townsend, CFO Anticipated Completion Date: Ongoing

View Audit 54656

Finding 58476 (2022-003)

Significant Deficiency 2022

Mt. Graham Regional Medical Center, Inc.

AZ

Allowable Costs / Cost Principles Significant Deficiency § 200.303

Finding 2022-003 Federal Agency Name Department of Health and Human Services Program Name: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution/Federal Financial Assistance Listing #93.498 Finding Summary: The Medical Center's eligible expenses listing had errors when agre...

Finding 2022-003 Federal Agency Name Department of Health and Human Services Program Name: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution/Federal Financial Assistance Listing #93.498 Finding Summary: The Medical Center's eligible expenses listing had errors when agreed to underlying supporting documentation. Responsible Individuals: Kathleen Williams, Chief Financial Officer Corrective Action Plan: We will implement new control process which ensures amounts reported are reviewed and accurately reported. Anticipated Completion Date: September 27, 2023

View Audit 55247

Finding 58453 (2022-003)

Material Weakness 2022

North Spencer County School Corporation

IN

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.328 § 200.329 § 200.334

FINDING 2022-003 Contact Person Responsible for Corrective Action: Gerri Ford Contact Phone Number: 812-937-2400 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Corporation Treasurer will prepare the annual reports and ensure the amounts agree t...

FINDING 2022-003 Contact Person Responsible for Corrective Action: Gerri Ford Contact Phone Number: 812-937-2400 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Corporation Treasurer will prepare the annual reports and ensure the amounts agree to the accounting records. The annual reports prepared by the Corporation Treasurer will be provided to the Director of Learning who oversees the Elementary and Secondary School Emergency Relief (ESSER) grant to review and approve the amounts reported are accurate. After review and approval from the Director of Learning, the annual reports will be submitted by the Corporation Treasurer. Anticipated Completion Date: May 2023

View Audit 54408

Finding 58451 (2022-002)

Material Weakness 2022

North Spencer County School Corporation

IN

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

FINDING 2022-002 Contact Person Responsible for Corrective Action: Dan Scherry Contact Phone Number: (812) 937-2400 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: At each Co-Op Board Meeting, the Superintendent will request a copy of the reimbursem...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Dan Scherry Contact Phone Number: (812) 937-2400 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: At each Co-Op Board Meeting, the Superintendent will request a copy of the reimbursement requests submitted indicating the amount in North Spencer?s non-public expenditures along with the supporting documentation (timesheets showing time spent with non-public students). Superintendent will make sure the two (requests and timesheets) agree in order to ensure a percentage is not used for the reimbursement requests. Anticipated Completion Date: March 15, 2023

View Audit 54408

Finding 58448 (2022-002)

Significant Deficiency 2022

Cleveland Area Hospital Trust

OK

Allowable Costs / Cost Principles Cash Management Reporting § 200.303

Consideration of Amounts Reimbursed from Other Sources Finding 2022-002 Federal Agency Name Department of Health and Human Services Program Name: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution/Federal Financial Assistance Listing #93.498 Finding Summary: The expenses re...

Consideration of Amounts Reimbursed from Other Sources Finding 2022-002 Federal Agency Name Department of Health and Human Services Program Name: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution/Federal Financial Assistance Listing #93.498 Finding Summary: The expenses reported as eligible for the American Rescue Plan (ARP) Rural Distribution were overstated. The error related to not identifying expenses that were reimbursement from other sources. Responsible Individuals: Ray Moss CFO Corrective Action Plan: We will implement an additional layer of review as part of the response of the findings above. Anticipated Completion Date: September 27, 2023

View Audit 55720

Finding 58441 (2022-101)

Significant Deficiency 2022

B J Enterprises, Inc.

AZ

Procurement, Suspension & Debarment Cash Management Eligibility § 200.303

B J ENTERPRISES, INC. CORRECTIVE ACTION PLAN SEPTEMBER 30, 2022 REFERENCE: 2022-101 REPEAT FINDING REFERENCE: 2021-001 CFDA NUMBER: 10.558 ? CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2022 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBE...

B J ENTERPRISES, INC. CORRECTIVE ACTION PLAN SEPTEMBER 30, 2022 REFERENCE: 2022-101 REPEAT FINDING REFERENCE: 2021-001 CFDA NUMBER: 10.558 ? CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2022 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBER 6AZ300003 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur with the condition. 1. Name of the contact person responsible for corrective action: Katie O'Neill, Director 2. Corrective action planned: a. For 2 of 40 providers files tested, menus were clerically inaccurate and did not support the meals claimed. The Area Coordinators will be retrained to double check their meal counting on their menus at least once before they submit their meal counts and one time after they submit their meal counts. See BJ Enterprises Procedures for Reading Menus, Section D, #6. b. For 1 of 40 provider files tested, meals were claimed for the provider's own child, when the provider was not eligible for free/reduced price meals. The menu reader must use the most current "Claiming Own" report while they are menu reading. The income applications have to be approved by the Assistant Director or Director prior to the menus being read. The menu reader will use this list, as well as the Master List when reading the menus. The Area Coordinators will be retrained to ensure that the provider who is claiming their own children qualify to do so. See BJ Enterprises Procedures for Reading Menus, Section C, #5. c. For 2 of 40 provider files tested meals were claimed when the provider's children were the only children present. This occurred when the day care children were disallowed. The Area Coordinators will be re-trained to disallow the day care providers own children when meals are disallowed for all of the day care children. See BJ Enterprises Procedures for Reading Menus, Section C, #5. d. For 1 of 40 provider files tested, meals were claimed outside of the current claim month. The Area Coordinators will be re-trained to disallow meals on the front end or the back end of the month. See BJ Enterprises Procedures for Reading Menus, Section B, #2. e. For 1 of 40 provider files tested, meals were claimed when the child was not indicated as being present for the meal. The times in and out were not on the day that was claimed. The Area Coordinators will be re-trained to disallow meals when the time in and outs are not written on the menu. See 8 J Enterprises Procedures for Reading Menus, Section C, #4. f. For 1 of 40 provider files tested, meals were claimed when no menu components were listed on the menu. The Area Coordinators will be re-trained to disallow meals when thy have no components listed on the menu. See BJ Enterprises Procedures for Reading Menus, Section B, #3. All of the menu mistakes were on paper menus. We are encouraging everyone to start claiming on computerized menus (KidKare) because there are less or no mistakes on those menus. 3. Anticipated completion date: June 30, 2023

View Audit 55181

Finding 58424 (2022-001)

Significant Deficiency 2022

Carroll Community College

MD

Eligibility Reporting Matching / Level of Effort / Earmarking § 200.303

Action taken in response to finding: After management was re-notified of the reporting errors in the HEERF reports on the college website, management has decided to completely reorganize the college webpage for HEERF reports. This will allow management and the reader to better understand the spendin...

Action taken in response to finding: After management was re-notified of the reporting errors in the HEERF reports on the college website, management has decided to completely reorganize the college webpage for HEERF reports. This will allow management and the reader to better understand the spending history of institutional and student portions of these grants. When the website is reorganized, quarterly reports will be reviewed and verified that student data is verified and reported correctly in the narrative of the reports. Name(s) of the contact person(s) responsible for corrective action: Ms. Karen Pelton, Mr. Timothy League and Mr. John Gay. Planned completion date for corrective action plan: Adjustments to the website and the review and correction of these reports, if needed, is currently in process and is expected to be completed no later than January 31, 2023.

View Audit 56029

Finding 58321 (2022-001)

Significant Deficiency 2022

Herzing University, Ltd.

WI

Student Financial Aid Matching / Level of Effort / Earmarking Reporting § 200.303

FY 2022 SFA Audit Corrective Action Plan Audit Firm: RSM US LLP 30 S Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 1/1/2022 ? 12/31/2022 Comments on Findings and Recommendations: Finding 2022-001 ? Error in Reporting for NSLDS Finding: Herzing University did not properly report the studen...

FY 2022 SFA Audit Corrective Action Plan Audit Firm: RSM US LLP 30 S Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 1/1/2022 ? 12/31/2022 Comments on Findings and Recommendations: Finding 2022-001 ? Error in Reporting for NSLDS Finding: Herzing University did not properly report the student enrollment change for a student who received federal student aid to the National Student Loan Data System (NSLDS). Condition: The University did not report a student?s Program-Level or Campus-Level enrollment status change to NSLDS. Out of the 60 students tested, we noted 1 student (1.7%) whose status change at the Program-Level and Campus-Level was not reported to NSLDS. Action Taken: In this instance, the student identified was withdrawn from the University and was correctly reported to NSLDS as such through our standard enrollment reporting processes. The student then subsequently re-enrolled at the University in the subsequent academic period becoming an Active student, and then withdrew again prior to our next standard enrollment reporting process occurring (one month after the previously reported withdrawn status). At the point of the second standard enrollment reporting timeframe, the student status was once again withdrawn, therefore an update did not occur to their enrollment status. Our process did not have a mechanism to identify the student changing statuses in between those reporting periods so that the active enrollment status was reported and then changed back to withdrawn versus simply staying at a withdrawn status. In August 2022, Herzing University updated our enrollment reporting policy to send in enrollment reporting biweekly instead of monthly. This was done to ensure that each student?s enrollment status was accurately reported as soon as possible and to prevent issues that occur from delays in proper enrollment statuses being reported to NSLDS. This update inherently decreased the likelihood that status timing issues would occur given the condensed timeframe for reporting. In addition, as of May 1st, 2023 Herzing University has developed and implemented an exception reporting process that will identify any student that has status updates that occur but reverts back to the original status within the timeframe of the two enrollment reporting periods. Using the student identified in this finding as an example, if the student is at a withdrawn status at the first enrollment reporting period, then moves to an active status immediately after that but then withdraws again within that 2 week window and therefore goes back to a withdrawn status in the subsequent enrollment reporting period, while our standard reporting would still show the student withdrawn for both standard enrollment reporting timeframes, the exception report will flag that student for review since a status change occurred in between the two withdrawn statuses being reported out. Upon review of the exception report, all relevant status progressions will be correctly reported to NSLDS. The required corrective action for Finding 2022-001 listed in the SFA audit for the period 1/1/2022 ? 12/31/2022 was completed on 5/1/2023. The person responsible for completion of the corrective action was Kevin McShane, Vice President of Financial Aid & Compliance.

View Audit 55185

Finding 58295 (2022-001)

Significant Deficiency 2022

Saint Leo University, INC

FL

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

2022-001 HEERF Reporting Recommendation: We recommend that the University review their reporting policies and procedures to ensure accurate reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Immediate act...

2022-001 HEERF Reporting Recommendation: We recommend that the University review their reporting policies and procedures to ensure accurate reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Immediate action was taken to update the quarterly report and post the updated report to our university?s website. Error was made due to data file showing category under other uses in previous quarterly reports. When new quarterly report was prepared the amount was reported on proper lost revenue line but was not deducted from the other uses total. This resulted in an overstatement of expenditures. An additional step was implemented to confirm total balance with data spreadsheet balance of expenditures. Name(s) of the contact person(s) responsible for corrective action: Jennifer Martell, Controller Planned completion date for corrective action plan: This was immediately corrected when brought to our attention on 5/26/22 for the quarterly report ending 3/31/22 which was originally posted to our website on 4/10/22.

View Audit 60987

Finding 58233 (2022-003)

Significant Deficiency 2022

City of Omro

WI

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

Finding 2022-003 Condition One of the two reports selected for testing were not independently reviewed before submission. The sample is not statistically valid. Corrective Action Plan Corrective Action Planned: The City does not currently have sufficient staffing to provide segregation of duties...

Finding 2022-003 Condition One of the two reports selected for testing were not independently reviewed before submission. The sample is not statistically valid. Corrective Action Plan Corrective Action Planned: The City does not currently have sufficient staffing to provide segregation of duties in all areas. Upon start of employment of a new City Administrator/Treasurer on October 9, 2023, that position employee will be reviewing such reports and financial documents on a regular basis as part of his job duties. Name of Contact Person Responsible for Corrective Action: Barbara J. Van Clake, City Clerk/Deputy Treasurer. Anticipated Completion Date: October 2023.

View Audit 50354

Finding 58120 (2022-006)

Material Weakness 2022

County of San Joaquin

CA

Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.319 § 200.320 § 200.323

Program: COVID-19 ? Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) CFDA No.: 93.323 Federal Agency: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award Year: 2021-2022 Compliance Requirement: Procurement and Suspension and De...

Program: COVID-19 ? Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) CFDA No.: 93.323 Federal Agency: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award Year: 2021-2022 Compliance Requirement: Procurement and Suspension and Debarment Grant Award Number: COVID-19 ELC39 and COVID-19 ELC97 Type of Finding: Material Noncompliance and Material Weakness in Internal Control over Compliance Repeat Finding from Prior Year: Yes, prior year finding 2021-09. Management?s or Department?s Response: We Concur. Views of Responsible Officials and Corrective Action: Procedures have been developed and implemented to comply with the County?s policies over procurement and suspension and debarment. Name of Responsible Person: Bruce Cosby Name of Department Contact: Bruce Cosby Projected Implementation Date: July 1, 2023

View Audit 53495

Finding 58085 (2022-010)

Material Weakness 2022

County of San Joaquin

CA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.303

Program: Community Development Block Grants/Entitlement Grants (CDBG)/Entitlement Grants Cluster CFDA No.: 14.218 Federal Agency: U.S. Department of Housing and Urban Development Pass-through: N/A Award Year: 2021-2022 Compliance Requirement: Reporting Grant Award Number: All Type of Finding: Instan...

Program: Community Development Block Grants/Entitlement Grants (CDBG)/Entitlement Grants Cluster CFDA No.: 14.218 Federal Agency: U.S. Department of Housing and Urban Development Pass-through: N/A Award Year: 2021-2022 Compliance Requirement: Reporting Grant Award Number: All Type of Finding: Instances of Noncompliance and Material Weakness in Internal Control over Compliance Repeat Finding from Prior Year: Yes, prior year finding 2021-012. Management?s or Department?s Response: We concur. Views of Responsible Officials and Corrective Action: The County has implemented policies and procedures to ensure compliance with the program?s special FFATA reporting requirements. Segregation of duties between report preparers and reviewers will be applied to the preparation and review of the FFATA reports. Evidence of documentation will be retained. Name of Responsible Person: Chris Becerra, Management Analyst III Name of Department Contact: Chris Becerra, Management Analyst III Projected Implementation Date: July 1, 2023

View Audit 53495

Finding 58081 (2022-012)

Significant Deficiency 2022

County of San Joaquin

CA

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Program: COVID-19 ? Emergency Rental Assistance Program, (ERAP) CFDA No.: 21.023 Federal Agency: U.S. Department of the Treasury Pass-through: N/A Award Year: 2021-2022 Compliance Requirement: Reporting Grant Award Number: Applies to all awards with findings and no specific grant award Type of Findi...

Program: COVID-19 ? Emergency Rental Assistance Program, (ERAP) CFDA No.: 21.023 Federal Agency: U.S. Department of the Treasury Pass-through: N/A Award Year: 2021-2022 Compliance Requirement: Reporting Grant Award Number: Applies to all awards with findings and no specific grant award Type of Finding: Instance of Noncompliance, Significant Deficiency in Internal Control over Compliance Repeat Finding from Prior Year: No Management?s or Department?s Response: Concurred. Views of Responsible Officials and Corrective Action: During the fiscal year, the County had routed the second tranche of funding to the State as the County did not have the capacity to continue the program. Name of Responsible Person: Connie Hart, Deputy County Administrator Name of Department Contact: Connie Hart, Deputy County Administrator Projected Implementation Date: June 30, 2023

View Audit 53495

Finding 58042 (2022-006)

Significant Deficiency 2022

State of Missouri

MO

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

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2022 State Agency: Department of Social Services (DSS) ? Division of Finance and Administrative Services (DFAS) Audit Finding Number: 2022 -006 ? DSS Federal Funding Accountability and Transparency Act (FFATA) R...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2022 State Agency: Department of Social Services (DSS) ? Division of Finance and Administrative Services (DFAS) Audit Finding Number: 2022 -006 ? DSS Federal Funding Accountability and Transparency Act (FFATA) Reporting Name of the contact person responsible for corrective action: Sheena Frazer Anticipated completion date for corrective action: N/A Recommendation: The DSS through the DFAS strengthen internal controls related to FFATA reporting by having supervisors maintain documentation of reviews performed of the information reported to the FSRS. In addition, the DFAS should timely complete FFATA reporting in accordance with the applicable requirements. DSS Response: The DSS partially agrees with this finding. The DSS does not agree that documentation of supervisory reviews directly correlates to strong internal controls. The DSS adheres to formalized procedures for FFATA reporting which includes managerial oversight and contends documented reviews may be preferred but are not required by regulation. The DSS experienced a transition of staff during the timeframe in question and the FSRS system does not permit users to access and compliance data or reports uploaded in the system by an alternate user. The FFATA does not impose a deadline on federal awarding agencies to report federal award information in FSRS. Additionally, the FFATA does not impose a deadline on direct recipients to report the subaward of secondary federal awards issued beyond the month following the original obligation date. Therefore, the timeliness of DSS? FFATA reports is also dependent on the date the federal awarding agency makes the federal award information available in FSRS. These circumstances allowed for exceptions identified. The DSS has or will upload reports for all exception items to ensure the information is available in USA Spending. Corrective action planned is as follows: The DSS will continue to adhere to written procedures and maintain strong internal controls to maintain FFATA reporting compliance based on available guidance.

View Audit 56478

Finding 58033 (2022-009)

Significant Deficiency 2022

State of Missouri

MO

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

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2022 State Agency: Department of Elementary and Secondary Education (DESE) Audit Finding Number: 2022-009 DESE FFATA Reporting Name of the contact person responsible for corrective action: Shelley Woods, Chief Op...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2022 State Agency: Department of Elementary and Secondary Education (DESE) Audit Finding Number: 2022-009 DESE FFATA Reporting Name of the contact person responsible for corrective action: Shelley Woods, Chief Operations Officer Anticipated completion date for corrective action: June 30, 2024 Corrective action planned is as follows: All previous reports have been corrected and are ready to submit. However, DESE is unable to submit due to a previous open report that the Federal Government has to close and then delete to prevent duplicate reporting. DESE has tried to submit the report multiple times without success. DESE has reached out to FSRS for assistance in resolving this issue, and continues to communicate with the FSRS team. DESE is unable to resolve the reporting issue until the Federal Government takes action on our help tickets. DESE has reviewed, strengthened, and is enforcing policies and procedures regarding accurate and timely report submission.

View Audit 56478

Finding 58032 (2022-005)

Significant Deficiency 2022

State of Missouri

MO

Questioned Costs School Nutrition Programs Matching / Level of Effort / Earmarking § 200.303

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2022 State Agency: Department of Social Services (DSS) ? Family Support Division (FSD) Audit Finding Number: 2022-005 ? Pandemic Electronic Benefit Transfer Food Benefits Name of the contact person responsible ...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2022 State Agency: Department of Social Services (DSS) ? Family Support Division (FSD) Audit Finding Number: 2022-005 ? Pandemic Electronic Benefit Transfer Food Benefits Name of the contact person responsible for corrective action: Elizabeth Roberts-Smith Anticipated completion date for corrective action: Completed Recommendation: The DSS through the FSD strengthen internal controls to ensure P-EBT program benefit issuances are in accordance with the state plan, and review and correct the overpayments for the children identified in this finding. DSS Response: The DSS agrees with this finding. The DSS agrees that the two children identified in the report were incorrectly issued benefits. Recognizing the complexity for families seeking to appropriately access the benefit, the process by which school children are determined eligible and issued P-EBT benefits was modified in the state plan submitted by the State of Missouri to the Food and Nutrition Service (FNS) for the 2021-2022 school year. The P-EBT state plan for the 2021-2022 school year was approved by FNS on June 6, 2022. Eligibility for P-EBT is now determined at the individual child level based on COVID-related absences and qualification for federal free and reduced lunch benefits. For the 2021-2022 school year, local education authorities (LEA?s) submit lists of students determined eligible to the Missouri Department of Elementary and Secondary Education (DESE). DESE then submits the approved eligibility file to DSS with the name of each eligible child and the amount of benefit to be issued on a P-EBT card. DSS then issues the benefit. Corrective Action is as follows: DSS has reviewed the overpayments and referred the children identified in this finding to the Missouri Program Integrity Unit (PIU) for claims processing, if the funds can be recovered. This is outlined in the FNS approved Missouri P-EBT state plan.

View Audit 56478 Questioned Costs: $1

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