Corrective Action Plans

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Proposed Completion Date: Immediately
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View Audit 310251 Questioned Costs: $1
The Settlement agrees with the finding. The Assistant Controller prepares the form SF-425 reports and the Controller reviews and approves them for submission. These forms and supporting documentation are saved and retained in SharePoint. SF-425 due date reminders are posted in preparer’s calendar an...
The Settlement agrees with the finding. The Assistant Controller prepares the form SF-425 reports and the Controller reviews and approves them for submission. These forms and supporting documentation are saved and retained in SharePoint. SF-425 due date reminders are posted in preparer’s calendar and adherence to the due dates is monitored by the Controller. Implementation began July 2022. Responsible parties: Assistant Controllers, Controller Completion date: 7/1/2022
The Settlement agrees with the finding. Fiscal and program staff will update CACFP Policies and Procedures to ensure that all CACFP records are retained for a minimum of three years. CACFP eligibility will be clearly documented and retained for three years by program staff. Fiscal and program staff ...
The Settlement agrees with the finding. Fiscal and program staff will update CACFP Policies and Procedures to ensure that all CACFP records are retained for a minimum of three years. CACFP eligibility will be clearly documented and retained for three years by program staff. Fiscal and program staff will update CACFP Policies and Procedures to reflect subrecipient eligibility and related paperwork. Staff will be trained on completing and maintaining CACFP enrollment and eligibility paperwork via CACFP online workshops. Managers will complete management KidKare training to optimize electronic record-keeping of CACP documentation. The Compliance Director will complete an unannounced monitoring review of enrollment paperwork quarterly. Policies and Procedures will be edited to reflect rules and regulations for enrollment and eligibility paperwork. Implementation began October 2023. Responsible parties: Fiscal and Program staff, Compliance Director Completion date: 10/1/2023
The University concurs with the finding. The SNAP-Ed office experienced significant staff turnover during fiscal year 2022, and records could not be located. The University has established workflows and policies to ensure compliance and documentation currently and in the future.
The University concurs with the finding. The SNAP-Ed office experienced significant staff turnover during fiscal year 2022, and records could not be located. The University has established workflows and policies to ensure compliance and documentation currently and in the future.
The University concurs with the finding and has taken proactive measures to ensure compliance. Specifically, the University has established a digital folder dedicated to maintaining all records pertaining to HEERF funding and lost revenue calculations.
The University concurs with the finding and has taken proactive measures to ensure compliance. Specifically, the University has established a digital folder dedicated to maintaining all records pertaining to HEERF funding and lost revenue calculations.
Finding: 2022-006: Significant Deficiency in Internal Controls over Compliance – Cash Management Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Corrective Action: Controller reviews and corrects billings received which includes backup by...
Finding: 2022-006: Significant Deficiency in Internal Controls over Compliance – Cash Management Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Corrective Action: Controller reviews and corrects billings received which includes backup by AR, then CFO reviews prior to submission to payment management system. Proposed Completion Date: 6/30/23
FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT Finding: 2022-003: Significant Deficiency in Internal Controls over Compliance – Reporting Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Controller reviews and corre...
FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT Finding: 2022-003: Significant Deficiency in Internal Controls over Compliance – Reporting Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Controller reviews and corrects reports received which includes backup by the Staff Accountant, then CFO reviews reports created by Controller prior to submission. Proposed Completion Date: 6/30/23
US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable ...
US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable to be recreated. The organization was lacking appropriate internal controls to ensure records were retained for the required period of time. Responsible Individual: Dawn Helmowski, Finance Director Corrective Action Plan: Subsequent to the audit period under review, the affiliated entity of Luther Social Services of North Dakota has been replaced with Beyond Shelter, Inc. Upon this change, the new LSS Jamestown Housing, Inc. Board of Directors, implemented a Document Retention and Destruction Policy that includes retention or required documents for the required time periods that will ensure documents are retained. This policy was put into place on April 19, 2023. Anticipated Completion Date: April 2023
Community Partners acknowledges that documentation to support expenditures was not consistently kept across all federal grants. Current leadership has addressed this issue by implementing documentation standards across all federal grants. Furthermore, through the implementation of NetSuite, expendit...
Community Partners acknowledges that documentation to support expenditures was not consistently kept across all federal grants. Current leadership has addressed this issue by implementing documentation standards across all federal grants. Furthermore, through the implementation of NetSuite, expenditures will be fully supported and approved by staff before posting. The person responsible for the corrective action detailed above will be Joyce Williams, Chief Financial and Operations Officer, (213) 346‐3202. We anticipate corrective action will be completed by June 30, 2024.
View Audit 296891 Questioned Costs: $1
FINDING 2023-002 (Auditor Assigned Reference Number) Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: The School Corporation had not properly designed or implemented a system of internal control, which, would include appropriate segregation of duties, that would likely be e...
FINDING 2023-002 (Auditor Assigned Reference Number) Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: The School Corporation had not properly designed or implemented a system of internal control, which, would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting noncompliance related to the eligibility determination of a child receiving meals. Any child enrolled in a participating school or summer camp, who meets the applicable program’s definition of “child”, may receive meals under applicable programs. A child belonging to households meeting nationwide income eligibility requirements may receive meals at no charge or at a reduced price. Children that have been determined ineligible for free or reduced-price meals pay the fun price for their meals. A child’s eligibility for free and reduced-priced meals under a Child Nutrition Cluster program may be established by the submission of an annual application or statement which furnished such information as family income and family size. The School Corporation determines eligibility by comparing the data reported by the child’s household to published income eligibility guidelines. Annual eligibility determinations may also be based on the child’s household receiving benefits under SNAP, FDPIR, the Head Start Program, or, under most circumstances, the TANF program. A household may furnish documentation if its participation in one of those programs, or the School Corporation may obtaine the information directly from the State or local agency that administers those programs. Certain foster, runaway, homeless, and migrant children are categorically eligible for free school lunches and breakfasts. Direct Certified households do not need to complete an application. The School Corporation’s child nutrition program software company, Skyward, automatically imported the eligibility parameters into the system., There was no evidence of an oversight, review, or approval process to ensure that the eligibility parameters entered into the Skyward system were accurate and that eligibility statuses were being correctly determined. A Sample of students receiving free or reduced lunches as selected for testing. The following issues were noted with the first students tested: 1.) Six of the 14 students were determined to be processed at the incorrect eligibility. Errors noted were: a. Three students had an eligibility determination of free; however, their eligibility determination should have been reduced. b. One student had an eligibility determination of reduced; however, the eligibility determination should have been paid. c. Two students were determined to be reduced; however, their eligibility determination should have been free. 2.) One of the 14 students did not have a completed application on file; thus, a determination of eligibility could not be made. 3.) Two students were direct certified; however, the School Corporation did not retain the monthly direct certification reports ran to support this determination, nor could the reports be recreated. Due to the number and magnitude of exceptions, per auditor judgement, we concluded it would not be appropriate to examine the remaining 26 students. The lack of internal controls and noncompliance were isolated to the 2022-2023 school year. We recommended that the School Corporation's management establish a proper system of internal controls and develop policies and procedures to ensure student eligibility for free or reduced price lunches is accurately determined and that all documentation is retained. Contact Person Responsible for Corrective Action: Contact Phone Number and Email Address: Stefanie Grandstaff, Director of Business Services stefanie.grandstaff@epulaski.k12.in.us Views of Responsible Officials: We concur with the finding . Description of Corrective Action Plan: The Food Service Director has been in contact with Skyward to find which reports can help with the Eligibility compliance requirements. The corporation has found a few more reports that can be of assistance with this finding. The Director of Business Services has also reached out to other Skyward users who use the food service module to ask for suggestions on what reports should be pulled and how to locate supporting documentation of students that received free or reduced-priced meals. At the end of each year when the corporation completes the roll-over process, all the reports are saved to a Google Drive folder. The Direct Certified Reports will be kept upon processing for future use and documentation purposes. An additional review of the applications will be performed to verify that the system is calculating properly. The Food Service Director and Director of Business Services are going to continue to reach out to other Skyward food service users and ask if any other reports should be saved, printed or kept for future audits. Anticipated Completion Date: Projected completion date of major tasks for the planned corrective actions is June 30, 2024
Views of Responsible Officials and Planned Corrective Actions: MARR will retain a CPA consultant to implement a document retention policy that is consistent with federal document retention requirements.
Views of Responsible Officials and Planned Corrective Actions: MARR will retain a CPA consultant to implement a document retention policy that is consistent with federal document retention requirements.
FINDING 2022-003 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: An effective internal control system was not designed, nor implemented at the School Corporation to ensure compliance with requirements related to the grant agreement and the Reporting complianc...
FINDING 2022-003 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: An effective internal control system was not designed, nor implemented at the School Corporation to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. The annual Elementary and Secondary School Emergency Relief (ESSER) Data Collection reports were complied, prepared and submitted by three different staff members; however, this process was not properly designed or implemented to prevent, or detect and correct, errors. The School Corporation completed and submitted three annual Data Collection reports (Reports) for the ESSER grants. For two of the three reports tested, the report was not supported by the unit’s records. The financial information provided did not agree to the data submitted in the Reports, therefore we could not determine their accuracy. The lack of internal controls and noncompliance were systemic issues throughout the audit period. Contact Person Responsible for Corrective Action: Matthew Miles, CFO Contact Phone Number and Email Address: 317-423-8380 mattmiles@msdlt.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The School District will work to ensure the ESSER report amounts tie to the accounting records and will improved record keeping of supporting documentation. If the amounts do not match, District will document support for all claims. Anticipated Completion Date: The School District will implement changes described in the Corrective Action Plan in February 2024.
FINDING 2022-007 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: Finding: No oversight of reports and supporting documentation did not agrees to report submitted Recommendation: Provide oversight of reports submitted and retain supporting documentation that a...
FINDING 2022-007 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: Finding: No oversight of reports and supporting documentation did not agrees to report submitted Recommendation: Provide oversight of reports submitted and retain supporting documentation that agrees to reports submitted Contact Person Responsible for Corrective Action: Kareemah Fowler, Assistant Superintendent of Business and Finance Deb Martin, Director of Student Learning & Title I Contact Phone Number and Email Address: Kareemah Fowler (574) 393-6088; kfowler@sbcsc.k12.in.us Deb Martin (574) 393-6053; dmartin@sbcsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: All reports and supporting documentation, which supports each report submitted, will be reviewed/approved by the program director. All supporting documentation will be retained for future audits. Anticipated Completion Date: December 8, 2024
FINDING 2022-006 Finding Subject: COVID-19 - Education Stabilization Fund - Allowable Costs/Cost Principles Summary of Finding: Finding: Documentation for 3 employees was not available to verify the contract amounts. Recommendation: Documents be retained to support amounts paid. Contact Person Respo...
FINDING 2022-006 Finding Subject: COVID-19 - Education Stabilization Fund - Allowable Costs/Cost Principles Summary of Finding: Finding: Documentation for 3 employees was not available to verify the contract amounts. Recommendation: Documents be retained to support amounts paid. Contact Person Responsible for Corrective Action: Kareemah Fowler, Assistant Superintendent of Business and Finance Contact Phone Number and Email Address: (574) 393-6088; kfowler@sbcsc.k12.in.us Views of Responsible Officials: We disagree with the finding. Explanation and Reasons for Disagreement: While we agree that the single source document used by the State to validate a teacher’s contract was not available for 3 employees. We provided sufficient alternate documents that would allow the State to validate the contract amount being paid, and whether the proper employees were paid from or should have been paid from the Education Stabilization Funds. The documents provided sufficient data to support the questioned cost of $26,207 outlined in the finding. We will be working with our software vendor to rectify the glitch that prevented us from providing the documentation requested by the State for future audit. Description of Corrective Action Plan: We will be working with our software vendor to rectify the glitch that prevented us from providing the documentation requested by the State. Anticipated Completion Date: January 2024
View Audit 289747 Questioned Costs: $1
FINDING 2022-004 Finding Subject: Title I Grants to Local Educational Agencies - Reporting Summary of Finding: Finding: Detail data on the Form 9 and Reimbursement Request was not provided to knowledgeable individuals for review. Recommendation: Design control that provides sufficient data to knowle...
FINDING 2022-004 Finding Subject: Title I Grants to Local Educational Agencies - Reporting Summary of Finding: Finding: Detail data on the Form 9 and Reimbursement Request was not provided to knowledgeable individuals for review. Recommendation: Design control that provides sufficient data to knowledgeable individuals for review. Contact Person Responsible for Corrective Action: Kareemah Fowler, Assistant Superintendent of Business and Finance Contact Phone Number and Email Address: (574) 393-6088; kfowler@sbcsc.k12.in.us Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: Form 9 Data The Human Resources Department has added a second review to verify all employee distribution codes are correct when recording/updating employee requisitions. Additionally, detailed expense reports and payroll distribution reports that support each reimbursement request are being provided to knowledgeable employees to review. Anticipated Completion Date: Completed December 8, 2023, and May 2023 Reimbursement Requests Summary level payroll data is no longer being used to support reimbursement requests. Detailed expense reports and payroll distribution reports that support each reimbursement request are being provided to knowledgeable employees to review. Anticipated Completion Date: Completed May 2023.
FINDING 2022-003 Finding Subject: Title I Grants to Local Educational Agencies - Allowable Costs/Cost Principles Summary of Finding: Finding: Documentation for 10 employees was not available to verify the contract amounts. Recommendation: Documents be retained to support amounts paid. Contact Person...
FINDING 2022-003 Finding Subject: Title I Grants to Local Educational Agencies - Allowable Costs/Cost Principles Summary of Finding: Finding: Documentation for 10 employees was not available to verify the contract amounts. Recommendation: Documents be retained to support amounts paid. Contact Person Responsible for Corrective Action: Kareemah Fowler, Assistant Superintendent of Business and Finance Contact Phone Number and Email Address: (574) 393-6088; kfowler@sbcsc.k12.in.us Views of Responsible Officials: We disagree with the finding. Explanation and Reasons for Disagreement: While we agree that the single source document used by the State to validate a teacher’s contract was not available for 10 employees. We provided sufficient alternate documents that would allow the State to validate the contract's amount being paid, and whether the proper employees were paid from or should have been paid from the Title I funds. The documents provided sufficient data to support the questioned cost of $203,488 outlined in the finding. We will be working with our software vendor to rectify the glitch that prevented us from providing the documentation requested by the State for future audit. Description of Corrective Action Plan: We will be working with our software vendor to rectify the glitch that prevented us from providing the documentation requested by the State. Anticipated Completion Date: January 2024
View Audit 289747 Questioned Costs: $1
Finding 286696 (2022-063)
Significant Deficiency 2022
In December 2022, the Office of Financial Aid strengthened its internal control over the reporting requirements for the Higher Education Emergency Relief Fund (HEERF), by adding the report due dates to the internal operational calendar. Additional level reviews were also added to the submission proc...
In December 2022, the Office of Financial Aid strengthened its internal control over the reporting requirements for the Higher Education Emergency Relief Fund (HEERF), by adding the report due dates to the internal operational calendar. Additional level reviews were also added to the submission process before the required reports will be sent to the Department of Education and posted on the financial aid website.
Condition: Administrative costs are submitted to the state monthly for reimbursement on the Record of Expenditures under the TEFAP Financial Assistance form ("FD-32D"). The State reimburses the Organization for administrative costs as determined by the state on a monthly basis. Typically, the monthl...
Condition: Administrative costs are submitted to the state monthly for reimbursement on the Record of Expenditures under the TEFAP Financial Assistance form ("FD-32D"). The State reimburses the Organization for administrative costs as determined by the state on a monthly basis. Typically, the monthly reimbursement amount is significantly less than the actual amount of allowed administrative expenses incurred by the Organization. During our procedures, we noted that certain expenditures, amounting to approximately $3,290, which were included on the FD-32D of which supporting documentation the Organization is required to retain under 2 CFR part 200 was lacking. As such, we could verify these costs related to activities allowed for reimbursement under 2 CFR part 200. Views of Responsible Officials and Corrective Actions: We agree with the auditor's comments and the following action will be taken to improve this situation. The Finance and Administration Manager and the Director of Logistics, who prepare the FD-32D, will work together to ensure that all supporting documentation is retained for all allowable expenses monthly. The corrective actions will be implemented by July 1, 2023.
FINDING 2022-016 Contact Person Responsible for Corrective Action: Casey Brewster Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: The approved grant budgets for all federal grants will be input into the financial man...
FINDING 2022-016 Contact Person Responsible for Corrective Action: Casey Brewster Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: The approved grant budgets for all federal grants will be input into the financial management system and with all expenditures reported monthly from the Treasurer to the Director overseeing the federal grant for review and final approval. The Director shall be one of the approvers within the approval chain of federal grant funds the Director oversees. The Director shall be responsible for reviewing and utilizing actual expenditure reports to complete the annual reports, or any other reports, prior to another documented review by the Treasurer or CFO. All documentation related to the reports shall be maintained for future audit purposes. Anticipated Completion Date: April 2023.
FINDING 2022-007 Contact Person Responsible for Corrective Action: Kristin Nass Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: In addition to on-going training and support of the Director of Grants/Programs who ove...
FINDING 2022-007 Contact Person Responsible for Corrective Action: Kristin Nass Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: In addition to on-going training and support of the Director of Grants/Programs who oversees Title I, a comprehensive checklist which includes required documentation and actions (including the verified data from non-pub school) is being developed and will be implemented in the spring of 2023. Checklist completion and reviewed data will be signed off by the CFO. Anticipated Completion Date: May 2023
FINDING 2022-006 Contact Person Responsible for Corrective Action: Casey Brewster Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. INDIANA STATE BOARD OF ACCOUNTS 67 Description of Corrective Action Plan: Additional training related to grant budgets enter...
FINDING 2022-006 Contact Person Responsible for Corrective Action: Casey Brewster Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. INDIANA STATE BOARD OF ACCOUNTS 67 Description of Corrective Action Plan: Additional training related to grant budgets entered into and monitored within the financial software will occur, as will the new practice of having the program directors initiating monthly reimbursement requests informed by the accurate reports from the software (ledger), with documented review by the Treasurer or CFO. Additional training over the reporting requirements is taking place with the Treasurer, CFO and Directors overseeing federal funds provide accurate reporting. Anticipated Completion Date: June 2023
FINDING 2022-005 Contact Person Responsible for Corrective Action: Casey Brewster Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Instead of utilizing journal entries for corrections or adjustments in generic form, ...
FINDING 2022-005 Contact Person Responsible for Corrective Action: Casey Brewster Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Instead of utilizing journal entries for corrections or adjustments in generic form, corrections to large or for multiple disbursements or receipts should be completed by reversing the action within the financial software and then correctly processing the disbursements or receipts. The on-going training and the related corrective actions which ensure more frequent and more in-depth reviews of reports on a monthly basis will also reduce the need for corrections in general. However, in the event there must be journal entries for corrections, documentation supporting and related to any journal entry will be input into the financial management software, as will any related notes, and any journal entry will have documented approval contained in that software, all completed by separate people ? the Treasurer and CFO. Additional, related training will also be sought to ensure related processes and controls are understood and followed. Anticipated Completion Date: May 2023
View Audit 90090 Questioned Costs: $1
FINDING 2022-011 Contact Person Responsible for Corrective Action: Casey Brewster Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Additional training related to grant budgets entered into and monitored within the fi...
FINDING 2022-011 Contact Person Responsible for Corrective Action: Casey Brewster Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Additional training related to grant budgets entered into and monitored within the financial software will occur, as will the new practice of having the program directors initiating monthly reimbursement requests informed by the accurate reports from the software (ledger), with documented review by the Treasurer or CFO. Additional training over the reporting requirements is taking place with the Treasurer, CFO and Directors overseeing federal funds provide accurate reporting. Anticipated Completion Date: June 2023
FINDING 2022-010 Contact Person Responsible for Corrective Action: Casey Brewster Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Instead of utilizing journal entries for corrections or adjustments in generic form, ...
FINDING 2022-010 Contact Person Responsible for Corrective Action: Casey Brewster Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Instead of utilizing journal entries for corrections or adjustments in generic form, corrections to large or for multiple disbursements or receipts should be completed by reversing the action within the financial software and then correctly processing the disbursements or receipts. The on-going training and the related corrective actions which ensure more frequent and more in-depth reviews of reports on a monthly basis will also reduce the need for corrections in general. However, in the event there must be journal entries for corrections, documentation supporting and related to any journal entry will be input into the financial management software, as will any related notes, and any journal entry will have documented approval contained in that software, all completed by separate people ? the Treasurer and CFO. Additional, related training will also be sought to ensure related processes and controls are understood and followed. Anticipated Completion Date: June 2023
View Audit 90090 Questioned Costs: $1
Program: Immunization Cooperative Agreements Federal Financial Assistance Listing Number: 93.268 Federal Grantor: U.S. Department of Health and Human Services Passed-Through: California Department of Public Health Award No. and Year: 17-10336 A02 and 2021 Compliance Requirements: Reporting Type of ...
Program: Immunization Cooperative Agreements Federal Financial Assistance Listing Number: 93.268 Federal Grantor: U.S. Department of Health and Human Services Passed-Through: California Department of Public Health Award No. and Year: 17-10336 A02 and 2021 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control and Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 2 CFR Section 200.334, Retention requirements for records, states that financial records, supporting documents, statistical records, and all other non-Federal entity records pertinent to a federal award must be retained for a period of three years from the date of submission of the final expenditure report, or, for Federal awards that are renewed quarterly or annually, from the date of submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient. Condition: During our testing of the HCA?s provisions for reporting requirements, we noted the following instances for two (2) out of two (2) reports: ? The performance reports were not reviewed or approved prior to submission to the State. ? The department did not retain any supporting documents for the performance reports. Cause: The HCA department personnel prepared program required performance reports and submitted to the State without retaining evidence that the reports were reviewed and approved by a separate individual prior to submission. The HCA department did not retain any supporting documents for the performance reports submitted. Effect: The County?s control was not consistently followed, which requires reports to be reviewed and approved by a separate individual prior to submission to the State. Additionally, the HCA department did not adhere to their policies and procedures in place requiring record retention of supporting documentation. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: The entire population of two (2) performance reports were selected for report testing for the Immunization Cooperative Agreements program. Repeat Finding from Prior Years: No. Recommendation: We recommend the HCA adhere to their policies and ensure the review and approval of reports are clearly documented prior to the report?s submission and adhere to their policies of record retention of supporting documents for the performance reports submitted to the State. Management Response and Corrective Action: Health Care Agency: 1. Person Responsible: Joshua Jacobs, HCA Public Health Services - Communicable Disease Control Division Director 2. Corrective action plan: HCA Public Health Services Communicable Disease Control Division will ensure retention of proper documentation supporting the performance reports and substantiating the review/approval prior to report submission to the State for the Immunization Cooperative Agreement. 3. Anticipated Implementation date: March 27, 2023
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