Corrective Action Plans

Finding 21500 (2022-002)

Material Weakness 2022

IN

Procurement, Suspension & Debarment School Nutrition Programs § 200.303 § 200.318 § 200.320

FINDING 2022-002 Contact Person Responsible for Corrective Action: Food Service Director Billie Jo Russell Contact Phone Number: 812-755-4872 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: Procurement ? The School Corporation has established internal...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Food Service Director Billie Jo Russell Contact Phone Number: 812-755-4872 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: Procurement ? The School Corporation has established internal controls to ensure compliance with the grant agreement and the Procurement and Suspension and Debarment requirement. The Food Service Director will obtain information from the Wilson Service Center for any necessary documentation pertaining to this requirement. The School Corporation has procured any food and supply purchases that exceed $150,000 and will maintain documentation for procurement procedures for purchases under $150,000. Suspension/Debarment ? Procedures will be implemented to ensure our procurement agent is an approved procurement agent. Anticipated Completion Date: Immediately

View Audit 24080

Finding 21486 (2022-001)

Significant Deficiency 2022

Rfe/rl, Inc.

DC

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

Views of Responsible Officials: RFE/RL?s Finance management team understands the importance of accurate and timely account reconciliations. Asset and liability account reconciliations are prioritized, prepared, and reviewed on a schedule in line with the level of activity in the account and in accor...

Views of Responsible Officials: RFE/RL?s Finance management team understands the importance of accurate and timely account reconciliations. Asset and liability account reconciliations are prioritized, prepared, and reviewed on a schedule in line with the level of activity in the account and in accordance with the best use of limited staff resources. Accounts with a large quantity of monthly transactions or significant dollar amounts are reconciled monthly; those with little activity may be reviewed quarterly or annually. An accounting close and reconciliation management tool that will create more accountability and insight into account analysis across locations is being implemented in FY23. Staff will be trained to ensure their reconciliation provides clear information to any outside finance professional as to the items that make up the balance in the account and amounts are to be easily traceable to support documentation that they can provide upon request. Auditors will have access via the software to all account reconciliations upon demand.

View Audit 19732

Finding 21444 (2022-003)

Significant Deficiency 2022

Solano Community College District

CA

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking § 200.303

U.S. Department of Education 2022-003: Student Financial Aid Cluster ? Student Eligibility and Awarding ? Assistance Listing Number: Various Recommendation: We recommend that the College implements a process that will ensure all Title IV funds are awarded at proper amounts. Action taken in response ...

U.S. Department of Education 2022-003: Student Financial Aid Cluster ? Student Eligibility and Awarding ? Assistance Listing Number: Various Recommendation: We recommend that the College implements a process that will ensure all Title IV funds are awarded at proper amounts. Action taken in response to finding: This student was awarded an incorrect amount because a subsequent ISIR transaction was received but the Pell was not recalculated on the basis of the new information. After this discovery, we have taken the following actions in response: ? We examined our ISIR import process to make sure that our means of communicating locked transactions was functioning correctly. We found that our system for monitoring new transactions was deficient; if a set of conditions were aligned, a new transaction could slip by our notice. Implemented by August 2022. ? We added another layer of review wherein the output of both the messages we receive from our third-party verification partner and our internal reports associated with importing ISIRS are examined on a regular basis. New transactions on students with a current locked transaction are reported to staff members for further review. Implemented by August 2022. ? We wrote an ad hoc report that allows us to identify subsequent ISIR transactions and will run it regularly to reduce the likelihood of this issue occurring again. Implemented by August 2022. Name(s) of the contact person(s) responsible for corrective action: Alysa Borelli, Dean of Enrollment and Student Services. Planned completion date for corrective action plan: The corrective action plan was implemented by August of 2022.

View Audit 62600 Questioned Costs: $1

Finding 21442 (2022-004)

Significant Deficiency 2022

Solano Community College District

CA

Questioned Costs Student Financial Aid Subrecipient Monitoring § 200.303

U.S. Department of Education 2022-004: Student Financial Assistance Cluster ? 240 Days Outstanding Check ? Assistance Listing Number: Various Recommendation: We recommend the College to update its procedures and procedures for processing and monitoring refund checks to ensure compliance with the Tit...

U.S. Department of Education 2022-004: Student Financial Assistance Cluster ? 240 Days Outstanding Check ? Assistance Listing Number: Various Recommendation: We recommend the College to update its procedures and procedures for processing and monitoring refund checks to ensure compliance with the Title IV requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the 2021-22 aid year, the financial aid and fiscal services departments have been working hard together to clean up and streamline the process by which we handle stale-dated ?financial aid checks? (Title-IV funds processed through BankMobile) as well as ?student refund checks? (non-Title IV funds processed through our district office). In our review, we found that three students had Title IV aid incorrectly processed as ?student refund checks? whose initial disbursement date was more than 240 days before the date of discovery. As a result, we reported those checks to the auditors when asked for outstanding Title IV checks. We have taken the following actions in response to this item: ? We have developed a ?Time Out / Reversal? workgroup that includes members of both the financial aid and fiscal services department to ensure that reissuance of checks does not occur automatically (pre-existing, but this workgroup allows us to address this issue). ? We have trained the workgroup members specifically on the importance of the 240 day limit. Implemented by September 2022. ? We continue to improve the communication between the financial aid and fiscal services. department. We currently hold meetings every two weeks to bring up any common issues and solve problems related to the administration. Implemented by September 2022. Name(s) of the contact person(s) responsible for corrective action: Alysa Borelli, Dean of Enrollment and Student Services. Planned completion date for corrective action plan: The corrective action plan was implemented by August of 2022.

View Audit 62600 Questioned Costs: $1

Finding 21441 (2022-001)

Significant Deficiency 2022

Solano Community College District

CA

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

U.S. Department of Education 2022-001: Student Financial Assistance Cluster ? NSLDS Enrollment Reporting ? Assistance Listing Number: 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the District review its report procedures to ensure that the enrollment and program information is accurat...

U.S. Department of Education 2022-001: Student Financial Assistance Cluster ? NSLDS Enrollment Reporting ? Assistance Listing Number: 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the District review its report procedures to ensure that the enrollment and program information is accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Repeat finding was unavoidable as we were unaware we were out of compliance until we were over half-way through the current year (21-22). Alysa Borelli, Dean of Enrollment Services contacted the National Student Clearinghouse (NSC) for guidance on what was causing our NSDLS errors and since has restructured when Solano is supposed to report to NSC. Solano has not been reporting in the correct part of the month for the NSDLS roster to pick up an accurate enrollment snapshot, which is the root cause of all of the findings under this header. Solano has received updated training for all staff who are responsible for submitting to NSC. Additionally, the staff member that used to submit who was not submitting at the correct time as removed from this task and replaced. Solano will be following the new protocols starting with Spring 2023 semester and does not expect this to be a repeat finding. It was known that 2nd year findings were unavoidable. Name(s) of the contact person(s) responsible for corrective action: Alysa Borelli, Dean of Enrollment and Student Services. Planned completion date for corrective action plan: All training and adjustments to our processes was completed in December 2022.

View Audit 62600

Finding 21364 (2022-001)

Significant Deficiency 2022

Los Lunas Schools

NM

School Nutrition Programs Eligibility Reporting § 200.303

Corrective Action: We will be creating universal tick sheets for the elementary and secondary schools. The internal control will be more manageable when we make this change. The tick sheets will be on separate sheets for breakfast and lunch and there will be a signature line on each sheet in orde...

Corrective Action: We will be creating universal tick sheets for the elementary and secondary schools. The internal control will be more manageable when we make this change. The tick sheets will be on separate sheets for breakfast and lunch and there will be a signature line on each sheet in order to identify the employee that ticked during the meal. All Student Nutrition employees will be instructed to use the standardized tick sheet and will be advised not to make any change to the form. Due Date of Completion: December 31, 2022 Responsible Party: Director of Student Nutrition

View Audit 21727

Finding 21354 (2022-001)

Material Weakness 2022

Alton School District

NH

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

The district has hired an additional person to help with grant reporting. Part of the job is to keep track of the grant funded employees making sure we are receiving either timecards, PARS, or Semi-certifications for the employee's time worked in the grant. Name of Contact Person and Completion Date...

The district has hired an additional person to help with grant reporting. Part of the job is to keep track of the grant funded employees making sure we are receiving either timecards, PARS, or Semi-certifications for the employee's time worked in the grant. Name of Contact Person and Completion Date: Name 1: Heidi Duford Anticipated Completion Date - 6/30/2024

View Audit 18760 Questioned Costs: $1

Finding 21321 (2022-003)

Significant Deficiency 2022

Argentum

VA

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

SIGNIFICANT DEFICIENCY ? INTERNAL CONTROL OVER COMPLIANCE U.S. Department of Labor 2022-003 Reporting Recommendation: We recommend that Argentum update its policies and procedures to ensure adequate review and approval over quarterly financial reports. Procedures must also be implemented to main...

SIGNIFICANT DEFICIENCY ? INTERNAL CONTROL OVER COMPLIANCE U.S. Department of Labor 2022-003 Reporting Recommendation: We recommend that Argentum update its policies and procedures to ensure adequate review and approval over quarterly financial reports. Procedures must also be implemented to maintain documentation supporting such procedures and submit the required report in timely manner. Explanation of disagreement with audit finding: There is no disagreement with audit finding. Action taken in response to finding: Argentum experienced high staff turnover in 2021 through midyear 2022 which impacted the implementation of corrective actions for this finding during the first half of 2022. Argentum established a documented review process for financial reports for the last two quarters in 2022 prepared by the Grants Manager and approved by Staff Accountant. Argentum will develop an internal documented process for review and approval of performance reports separately from ETA WIPS review and approval process. Performance reports will be prepared by the Program Director and approved by VP of Workforce Development. Name of the contact person responsible for corrective action: Janet Andrews Program Director and Ashante Abubakar Vice President Workforce Development Planned completion date for corrective action plan: September 30, 2023

View Audit 24347

Finding 21319 (2022-001)

Significant Deficiency 2022

Argentum

VA

Allowable Costs / Cost Principles Significant Deficiency § 200.303

SIGNIFICANT DEFICIENCY ? INTERNAL CONTROL OVER COMPLIANCE U.S. Department of Labor 2022-001 Allowable Costs Recommendation: We recommend that Argentum establish policies and procedures to support a system of internal control that requires the review and approval of employee time spent on a time...

SIGNIFICANT DEFICIENCY ? INTERNAL CONTROL OVER COMPLIANCE U.S. Department of Labor 2022-001 Allowable Costs Recommendation: We recommend that Argentum establish policies and procedures to support a system of internal control that requires the review and approval of employee time spent on a timely basis to ensure charges made to Federal awards for salaries and benefits are accurate, allowable, and properly allocated. Explanation of disagreement with audit finding: There is no disagreement with audit finding. Action taken in response to finding: Argentum experienced high staff turnover in 2021 through midyear 2022 which created challenges in ensuring consistent application of internal controls for employee time review and approvals. Since April 2022, Argentum has implemented corrective actions and a dedicated staff has been ensuring procedures for review and approval of employee time spend on the federal award are followed. Name of the contact person responsible for corrective action: Saara Dillard Grants Manager and Ashante Abubakar Vice President of Workforce Development Planned completion date for corrective action plan: September 30, 2023

View Audit 24347

Finding 21235 (2022-001)

Significant Deficiency 2022

Southwestern Illinois College Community College District #522

IL

Cash Management Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

2022-001 Higher Education Emergency Relief Fund ? CFDA No. 84.425E; 84.425F Recommendation: We recommend that the College implement controls related to cash management that designates a different reviewer and signer of drawdowns that occur within a given year. Explanation of disagreement with audi...

2022-001 Higher Education Emergency Relief Fund ? CFDA No. 84.425E; 84.425F Recommendation: We recommend that the College implement controls related to cash management that designates a different reviewer and signer of drawdowns that occur within a given year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As a result of audit finding and 2022-001, the College implemented a process that includes formalized review and approval of drawdowns of federal awards. Name(s) of the contact person(s) responsible for corrective action: Jacob Wheeler Planned completion date for corrective action plan: 6/30/23

View Audit 23196

Finding 21231 (2022-003)

Material Weakness 2022

Purdue University

IN

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

2022-003 Federal Agency: Department of Education Federal Program: COVID-19 Education Stabilization Fund Assistance Listing Number: 84.425F Condition The University did not properly design or implement an effective internal control system to ensure HEERF reports were properly completed and posted....

2022-003 Federal Agency: Department of Education Federal Program: COVID-19 Education Stabilization Fund Assistance Listing Number: 84.425F Condition The University did not properly design or implement an effective internal control system to ensure HEERF reports were properly completed and posted. Views of Responsible Officials and Planned Corrective Actions PFW Contact Person Responsible for Corrective Action: Ron Herrell, Director of Financial Aid Contact Phone Number: 260-481-6242 The PFW Office of Financial Aid Director will complete the quarterly reports and a dual review process will be implemented to ensure accuracy. The quarterly report will be updated on the HEERF site and sent to the Assistant Director of Enrollment and Institutional Scholarships to post. The information posted will be compared to the reports submitted quarterly. Anticipated Completion Date: February 2023 Once the Corrective Action Plan is completed, Purdue Internal Audit will conduct a follow-up review to ensure the corrective action plan is fully implemented and being followed consistently. PNW Contact Person Responsible for Corrective Action: Michael Biel, Executive Director of Financial Aid Contact Phone Number: 219-989-2510 PNW acknowledges that, while it had the appropriate Institutional HERF reporting completed, they missed updating the required student portion questions and answers that get posted to the reporting webpage. Once that was discovered, it was corrected in April 2022. PNW has ensured that the process now identifies looking at both the combined (updated) reporting PDF and the questions and answers that are required to be posted to the reporting webpage. PNW has spent all of its HEERF funding and no further reporting except the final annual report should be required. Completion Date: April 2022 Once the Corrective Action Plan is completed, Purdue Internal Audit will conduct a follow-up review to ensure the corrective action plan is fully implemented and being followed consistently.

View Audit 18358

Finding 21230 (2022-002)

Significant Deficiency 2022

Purdue University

IN

Procurement, Suspension & Debarment Reporting Significant Deficiency § 200.303

2022-002 Federal Agency: Department of Education Federal Program: COVID-19 Education Stabilization Fund Assistance Listing Number: 84.425F Condition The Purdue Fort Wayne campus did not have adequate controls in place to ensure invoices related to technology services were properly recorded in acc...

2022-002 Federal Agency: Department of Education Federal Program: COVID-19 Education Stabilization Fund Assistance Listing Number: 84.425F Condition The Purdue Fort Wayne campus did not have adequate controls in place to ensure invoices related to technology services were properly recorded in accordance with GAAP. Views of Responsible Officials and Planned Corrective Actions Contact Person Responsible for Corrective Action: Glen Nakata, Vice Chancellor for Financial and Administrative Affairs Contact Phone Number: 260-481-4199 The University system, including the Purdue Fort Wayne (PFW) Campus, has internal controls and training in place related to non-catalog purchases and the review of Goods Receipt/Invoice Receipt (GRIR) discrepancies. In the case of these two purchase orders, it appears these were isolated instances where established controls were not fully implemented as designed. These processes will be covered in staff meetings on all campuses and Procurement Services will review and update non-catalog order instructions and GRIR report documentation to ensure clear guidance is given. Anticipated Completion: March 2023 Once the Corrective Action Plan is completed, Purdue Internal Audit will conduct a follow-up review to ensure the corrective action plan is fully implemented and being followed consistently.

View Audit 18358

Finding 21222 (2022-003)

Significant Deficiency 2022

Hamilton Community Schools

IN

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

FINDING 2022-003 Subject: Special Education Cluster - Earmarking Audit Finding: Significant Deficiency Condition: The School Corporation is a member of the Northeast Indiana Special Education Cooperative (Cooperative). The School Corporation did not have adequate internal controls in place to e...

FINDING 2022-003 Subject: Special Education Cluster - Earmarking Audit Finding: Significant Deficiency Condition: The School Corporation is a member of the Northeast Indiana Special Education Cooperative (Cooperative). The School Corporation did not have adequate internal controls in place to ensure that the Cooperative complied with the earmarking requirements. Context: The School Corporation is a member of the Northeast Indiana Special Education Cooperative (Cooperative). During fiscal year 2021-2022, the Cooperative operated the special education programs and spent the federal money on behalf of all its members. As the grant agreements were between the Indiana Department of Education (IDOE) and each member school, the School Corporation was responsible for ensuring and providing oversight of the Cooperative. However, there was inadequate oversight performed by the School Corporation in order to ensure compliance with the Matching, Level of Effort, Earmarking compliance requirement. The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the earmarking requirements. The Cooperative did not have adequate procedures in place to ensure that the required level of expenditures for non-public students with disabilities was met for each member school. The Cooperative did not have effective internal controls to ensure non-public school expenditures were appropriately identified and reported. The Non-Public Proportionate Share expenditures for 19611-042-PN01 and 20611-042-PN01 grant awards could not be verified for the individual schools to verify the minimum amount per the grant awards was expended and properly reported to IDOE as required. The School Corporation?s minimum earmarking requirements for the 19611-042-PN01 and 20611-042-PN01 grant awards were $1,095 and $1,791, respectively. The lack of internal controls and noncompliance were isolated to the 19611-042-PN01 and 20611-042-PN01 grant awards. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Hamilton Community Schools will work with the Northeast Indiana Special Education Cooperative to ensure proper oversight and internal controls are maintained of awarded monies. Responsible Party and Timeline for Completion: Brittany Taylor, Business Manager Completion Date: 6/30/2023

View Audit 57985

Finding 21209 (2022-003)

Significant Deficiency 2022

Career and Recovery Resources, Inc.

TX

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.302 § 200.303

2022-003 Compliance and Internal Controls over Allowable Costs and Earmarking (Significant Deficiency) Assistance Listing Number 64.033 VA Supportive Services for Veteran Families, A Supportive Services for Veteran Families ? Shallow Subsidy, and COVID ? 19 VA Supportive Services for Veteran Famili...

2022-003 Compliance and Internal Controls over Allowable Costs and Earmarking (Significant Deficiency) Assistance Listing Number 64.033 VA Supportive Services for Veteran Families, A Supportive Services for Veteran Families ? Shallow Subsidy, and COVID ? 19 VA Supportive Services for Veteran Families 2020-2021 and 2021-2022 Funding U.S. Department of Veteran Affairs Recommendation: The Agency should establish and follow an allowable indirect allocation policy based on identifiable measures. The indirect costs charged to the grant can be substantiated by actual costs incurred. Corrective Action: Management will ensure the indirect allocation policy is correct, and actual and allowable costs will substantiate the indirect charge to grants. Responsible Party: Controller and Chief Operating Officer Date Expected to be Corrected: Immediately

View Audit 23531 Questioned Costs: $1

Finding 21202 (2022-003)

Significant Deficiency 2022

Feeding South Dakota

SD

Internal Control / Segregation of Duties Eligibility Significant Deficiency § 200.303

Finding 2022-003 Federal Agency Name: Department of Agriculture Passed through State of South Dakota Department of Education Program Name: Emergency Food Assistance Program (TEFAP) CFDA # 10.569 Finding Summary: One instance in which Emergency Food Assistance Program (TEFAP) food commodities wer...

Finding 2022-003 Federal Agency Name: Department of Agriculture Passed through State of South Dakota Department of Education Program Name: Emergency Food Assistance Program (TEFAP) CFDA # 10.569 Finding Summary: One instance in which Emergency Food Assistance Program (TEFAP) food commodities were distributed to a non-approved TEFAP agency. There was no agency agreement signed on file at that time. Responsible Individuals: Matthew Burn, Chief Operations Officer Corrective Action Plan: Internal controls have been revised to include validation of agency as a TEFAP certified agency while orders are picked. As well as additional training and updated standard operating procedures.

View Audit 23414

Finding 21197 (2022-002)

Significant Deficiency 2022

Feeding South Dakota

SD

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Cash Management § 200.303

Finding 2022-002 Federal Agency Name: Department of Agriculture Passed through State of South Dakota Department of Education Program Name: Emergency Food Assistance Program (TEFAP) CFDA# 10.568,10.569 Finding Summary: Emergency Food Assistance Program (TEFAP) pounds distributed to passthrough ag...

Finding 2022-002 Federal Agency Name: Department of Agriculture Passed through State of South Dakota Department of Education Program Name: Emergency Food Assistance Program (TEFAP) CFDA# 10.568,10.569 Finding Summary: Emergency Food Assistance Program (TEFAP) pounds distributed to passthrough agencies didn't agree to underlying inventory reports. This resulted in monthly draw requests to be misstated. Responsible Individuals: Christy Carr, Chief Financial Officer Corrective Action Plan: Internal controls have been revised to include additional cross referencing of distributions reporting. As well as additional training for employees involved in the process and updated standard operating procedures.

View Audit 23414

Finding 20935 (2022-002)

Significant Deficiency 2022

Corewell Health & Affiliates

MI

Matching / Level of Effort / Earmarking Cash Management Period of Performance § 200.303

Finding 2022-002 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Pass-Through Gr...

Finding 2022-002 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Pass-Through Grantor: Not applicable Pass-Through Award Number: Not applicable Pass-Through Award Period: 1/1/2020-12/31/2022 (Periods 3 and 4) Summary of finding: Management?s internal controls over the review and interpretation of instructions related to the input of lost revenue into the HRSA PRF portal were not sufficient to ensure the lost revenue recorded in the General Distribution portal ?Total Lost Revenues for the Period of Availability (January 1, 2020 to December 31, 2022)? line did not include the lost revenues that had been transferred from the Parent to subsidiaries and recorded in the portal for the subsidiaries Targeted Distributions. Corrective Action Plan: When populating the Period 4 HRSA PRF portal for Spectrum Health System, Corewell Health West management was aware that the inputs were not considering the System lost revenue attributed to the affiliates appropriately. In order to communicate to the users of the portal and other auditors, Management included an excel tracking worksheet which was uploaded on the HRSA PRF portal showing the total lost revenue used as an organization and the remaining balance left to be used. When populating the Period 5 filing, due September 30, 2023, Corewell Health West Management will correctly input the lost revenue in the Parent submission in order to reflect the lost revenue used by the individual subsidiaries. Individual responsible for the corrective action: Cindy Brink, Director, System Accounting & Reporting Timing of the Corrective Action Period 5 HRSA PRF portal filing, due September 30, 2023.

View Audit 23232

Finding 20892 (2022-003)

Material Weakness 2022

Metropolitan School District of Wayne Township

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Cash Management § 200.303 § 200.334

FINDING 2022-003 (Medical Assistance Program) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number: 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Internal controls are being updated and will be adopted by t...

FINDING 2022-003 (Medical Assistance Program) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number: 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Internal controls are being updated and will be adopted by the Board. The Township and Fire Department have worked on division of duties. Now the Fire Department will process a payment and will be approved by someone else in Fire Department. Then, the bill will be reviewed by the Township Accounting Specialist and will be paid by the outside accounting service. After the check is written, the Trustee will sign. If an invoice is over $5000 the Trustee will sign off prior to the payment. The payments received by the Medicaid program will be reviewed by the Township Accounting Specialist. After the person agrees it is then inputted in the accounting software and coded to the proper account. The accounting software is reconciled on a monthly basis to ensure all transactions are accounted for properly and accurately. Anticipated Completion Date: 9/30/23

View Audit 20160

Finding 20891 (2022-002)

Material Weakness 2022

Metropolitan School District of Wayne Township

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Cash Management § 200.303

FINDING 2022-002 (Medicaid Cluster ? Activities Allowed or Unallowed) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Federal Cost report beginning 202...

FINDING 2022-002 (Medicaid Cluster ? Activities Allowed or Unallowed) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Federal Cost report beginning 2022 will be done by a new firm. The firm is Blue & Co. They are a wellestablished CPA. The information that is supplied to the CPA firm will be maintained by Wayne Township and will be put the finished cost report. This is for the financial and other metrics that are needed for the report. The cost report will be reviewed for accuracy by the Township Office. Since the audit is just completed for 2019, this comment be repeated until we receive the funds for 2023 which will probably occur in 2026. Anticipated Completion Date: 9/30/23

View Audit 20160

Finding 20885 (2022-003)

Material Weakness 2022

Harrison County

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.1 § 200.303

FINDING 2022-003 Contact Person Responsible for Corrective Action: Chad Shireman Contact Phone Number: 812-738-8241 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The county will ensure that internal controls that are currently in place will be modi...

FINDING 2022-003 Contact Person Responsible for Corrective Action: Chad Shireman Contact Phone Number: 812-738-8241 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The county will ensure that internal controls that are currently in place will be modified in order to be effective in preventing, detecting and correcting errors. This will include making sure the county auditor and designated county commissioner are aware of all reporting deadlines and reporting periods covered. Once the county auditor enters expenditure and obligation information, the designated county commissioner will review the data and submit the necessary report(s). Anticipated Completion Date: This will be completed by September 30, 2023, allowing the county auditor to update the designated county commissioner in the Department of the Treasury?s system and inform him of all upcoming report deadlines. This will ensure the effectiveness of existing internal controls.

View Audit 20295

Finding 20883 (2022-004)

Material Weakness 2022

Harrison County

IN

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.208 § 200.303 § 200.332 § 200.513 § 200.521

FINDING 2022-004 Contact Person Responsible for Corrective Action: Chad Shireman Contact Phone Number: 812-738-8241 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The county will be retaining and periodically reviewing the grant application and awar...

FINDING 2022-004 Contact Person Responsible for Corrective Action: Chad Shireman Contact Phone Number: 812-738-8241 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The county will be retaining and periodically reviewing the grant application and award to stay current on applicable requirements of the subrecipient in order to ensure compliance. Lines of communication with the subrecipient will be established and maintained to better monitor activities, ensuring that the subaward is used for authorized purposes, complies with the terms and conditions of the subaward and achieves performance goals. Policies and procedures will be adopted and implemented to allow the county to evaluate the subrecipient?s risk of noncompliance. The county will request supporting documentation from the subrecipient when reimbursement requests are made, and this process will be documented in order to provide evidence that it is taking place. Anticipated Completion Date: The anticipated completion date will be December 31, 2023. This will allow the county and the subrecipient to work together to create the necessary policies and procedures. Once created, the remainder of the year will be used to implement them, allowing the county to evaluate all activities for the entire 2023 audit period that will be under review by SBOA in 2024.

View Audit 20295

Finding 20849 (2022-005)

Significant Deficiency 2022

Corewell Health & Affiliates

MI

Period of Performance § 200.303 § 200.308 § 200.403

Finding 2022-005 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services Assistance Listing: Various ? Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through Award Period: 1/1/2022-12/31/2022 Su...

Finding 2022-005 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services Assistance Listing: Various ? Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through Award Period: 1/1/2022-12/31/2022 Summary of finding: Management does not track expenses by budget period for Corewell East federal Research and Development (R&D) grants and is therefore unable to support that expenses are recorded in the appropriate period of performance. Corrective action plan: The hierarchy and functionality of the prior Corporate financial management system (prior to July 1, 2023) did not support separate budget periods during a single award project period. This was managed manually by the CHE Sponsored Programs Administration via a customized internal report. Effective July 1, 2023, the institution transitioned Corewell Health East onto Workday, the common financial management system already used by Corewell Health West. The Workday financial management system includes a separate grant module that has the capability to establish defined budget periods under a single award. CHE successfully transitioned to Workday beginning July 1, 2023. With the functionality now enabled by Workday, we do not anticipate any barriers to maintaining defined budget periods within an award funding cycle to assure that expenses are recorded in the appropriate period of performance. Individuals responsible for corrective action: Giacomo DeChellis, Sr. Director, Research Operations, Corewell Health East Timing of corrective action: July 1, 2023 and going forward.

View Audit 23232

Finding 20843 (2022-006)

Significant Deficiency 2022

Corewell Health & Affiliates

MI

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

Finding 2022-006 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various ? Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through ...

Finding 2022-006 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various ? Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through Award Period: 1/1/2022-12/31/2022 Summary of the finding: Management did not retain evidence to support their review over the patient data submitted to Sponsor for the per diem billings from February 1, 2022 to December 31, 2022 was complete and accurate. Corrective action plan: The current attestation memo control will be replaced as follows: There are two categories of study activity that required review and approval by the appropriate individual (i.e., Principal Investigator, Clinical Research Manager (CRM) or a delegate): (1) at the time of enrollment to assure that the study participant met sponsor-defined eligibility requirements and (2) subsequent study activities that may include but are not limited to a study visit, data collection, follow-up phone call, questionnaire completion, laboratory testing, biospecimen collection, or some combination of these. Verification of eligibility at the time of enrollment will continue to be reviewed and approved by the study PI, CRM, or appropriate delegate per sponsor requirements. Documentation is maintained in study-specific binders, per FDA audit standards and internationally-accepted Good Clinical Practice principles to assure that only patients meeting the sponsor?s defined eligibility criteria are enrolled into the study. Review of study activities subsequent to the study participant enrollment will be conducted monthly by the CRM or their delegate. Sponsored Programs Administration (SPA) will prepare and send each CRM a Transaction Report downloaded from the institutional clinical trial management system for each federally funded study, at least quarterly, that includes a listing of study visits associated with enrolled study participants that occurred within the defined period of time. The CRM/delegate will review the report detail provided and, upon approval, sign, and date the report. To assure that the information in the report is consistent with what was submitted to third parties which generates reimbursement, the CRM/delegate will conduct an audit of a sample of patients from a random selection of studies included in the Transaction Report. Each sample will be verified against documentation maintained in the study binder. Audit results affirming document review will be recorded in an audit tracking log which will be retained with the study activity report in their Clinical Trial Office (CTO) file as evidence of their review of study activity for federally funded fixed fee/per patient studies. For those federally funded fixed fee/per patient studies that do not utilize the standard institutional clinical trial management system, a similar study activity report downloaded from the clinical trial management system utilized for the study will be used for review, signed and dated upon approval and kept in the CTO files as evidence of review. Individuals responsible for corrective action: Giacomo DeChellis, Sr. Director, Research Operations, Corewell Health East Timing of corrective action: September 1, 2023 and going forward.

View Audit 23232

Finding 20840 (2022-001)

Material Weakness 2022

Corewell Health & Affiliates

MI

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

Finding 2022-001 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various ? Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through A...

Finding 2022-001 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various ? Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through Award Period: Various Federal Agency: Department of Homeland Security Assistance Listing: 97.036 ? COVID-19 Disaster Grants ? Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through Grantor: Michigan State Police Emergency Management and Homeland Security Division Pass-Through Award Number: 4494-DR-MI Pass-Through Award Period: 1/20/2020-7/1/2022 Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Pass-Through Award Period: 1/1/2020-12/31/2022 (Periods 3 and 4) Summary of finding: The draft Schedule of Expenditures of Federal Awards (the Schedule) prepared by Corewell Health and Subsidiaries (the System) was misstated. Total federal expenses included on the Schedule were $102,235,937 for the year ended December 31, 2022. Total expenses included on the final Schedule were $101,562,371 for the year ended December 31, 2022. The federal expenditures were misstated as follows: See Corrective Action Plan for chart/table. Corrective Action Plan: The enhanced Schedule process and controls implemented by Corewell Health East in 2023 will be reviewed. The misstated amounts of the R&D Cluster occurred as a result of the timing of posted expenses during the first month of the merger of Spectrum Health and Beaumont Health in February 2022. This was a one-time occurrence and we do not anticipate that this will be an issue in future years. In addition, the successful implementation and transition to Workday, a new Corporate financial management system, has improved award setup functionality that enables improved differentiation of awards, identifying which need to be included on the annual Schedule of Expenditures of Federal Awards and those that should be excluded. The understatement related to FEMA was a one-time occurrence related to the clarification of guidelines on the inclusion of a new Category Z FEMA obligation in 2022 on the SEFA. This has been corrected in 2023. The overstatement related to PRF was due to an initial inclusion of Corewell Health East funding on the Schedule as well as an adjustment related to the submitted amount of Corewell Health West funding on the Schedule. On the 2023 SEFA, a management review and sign-off of the inputs prior to submission will be implemented. Individuals responsible for corrective action: Giacomo DeChellis, Sr. Director, Research Operations, Corewell Health East and Cindy Brink, Director, System Accounting and Reporting Timing of corrective action: July 1, 2023 and going forward.

View Audit 23232

Finding 20837 (2022-004)

Material Weakness 2022

Corewell Health & Affiliates

MI

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

Finding 2022-004 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various, Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through A...

Finding 2022-004 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various, Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through Award Period: 1/1/2022-12/31/2022 Summary of finding: Corewell Health West did not have an internal control over the review and approval of the fringe rate application control from January 1 to October 31, 2022. Corrective action plan: Management will continue to perform the internal control over the fringe rate implemented in November 2022. Individuals responsible for corrective action: Joseph Fugitt, Sr. Director, Research Finance & Operations, Corewell Health West, Emily Guzman, Director, Research Finance, Corewell Health West Timing of corrective action: For calendar year 2023 and going forward.

View Audit 23232

Corrective Action Plans

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