Corrective Action Plans

Finding 398543 (2023-002)

None 2023

City of Haverhill

MA

Reporting Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Elementary and Secondary Education The City of Haverhill, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: ...

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Elementary and Secondary Education The City of Haverhill, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Powers & Sullivan, LLC 100 Quannapowitt Parkway, Suite 101 Wakefield, MA 01880 Audit period: July 1, 2022 through June 30, 2023 The finding from the June 30, 2023, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. DEPARTMENT OF TREASURY COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Assistance Listing Number 21.027 2023-002: Reporting to the Federal Government Compliance Requirement: Reporting Type of Finding: Compliance and Internal Control over Compliance – Other Matter Criteria or Specific Requirement: Grantees must comply with reporting requirements established by the U.S. Treasury that includes reporting the total grant expenditures incurred for the reporting period. Since the City is a Metropolitan City with a population below 250,000 residents that was allocated more than $10.0 million in funding, the City is required to submit, to the U.S. Department of Treasury, a project and expenditure report 30 days after the end of each quarter. Condition: The City submitted the appropriate quarterly report timely, however the report submitted through June 30, 2023, did not reconcile into the City’s accounting ledgers by approximately $787,000. Questioned Costs: None Reported. Context: The City filed the required project and expenditure report in a timely manner, however the report submitted to the U.S. Treasury’s Portal was $787,000 less than the expenditures reported to the City’s accounting ledgers. A large majority of the missing expenditures related to year end warrants processed. In compiling the information for reporting purposes, the City did not extract the expenditure information correctly from the general ledger and omitted some of the City’s year end warrants. Effect: The expenditures reported on the City’s project and expenditure report did not match the accounting records. Cause: The City did not set the report parameters in the City’s accounting software to generate all 2023 expenditures incurred. Recommendation: Management should correct the report in the next reporting submission. Views of Responsible Officials and Planned Corrective Actions: Management made a good faith effort to correctly report its expenditures to the U.S. Treasury Department on an accurate and timely basis. The accounting ledgers require specific parameters to be set when the underlying data to compile the reports is generated. There was a clerical error in running these reports, and Management expects to correct this on the subsequent period’s reporting in fiscal 2024. If the Oversight Agency has questions regarding this plan, please call Angel Perkins, Chief Financial Officer & City Auditor at (978)-374-2306.

View Audit 307261

Finding 398515 (2023-001)

Significant Deficiency 2023

City of Haverhill

MA

Allowable Costs / Cost Principles Subrecipient Monitoring Reporting

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Education The City of Haverhill, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Powers & Sullivan, LLC 10...

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Education The City of Haverhill, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Powers & Sullivan, LLC 100 Quannapowitt Parkway, Suite 101 Wakefield, MA 01880 Audit period: July 1, 2022 through June 30, 2023 The finding from the June 30, 2023, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. DEPARTMENT OF EDUCATION Passed through the Massachusetts Department of Elementary and Secondary Education Title I Grants to Local Educational Agencies Title I Grants to Local Educational Agencies Federal Assistance Listing No. 84.010 Special Education Cluster Special Education Grants to States and Special Education Preschool Grants Federal Assistance Listing Numbers, 84.027 and 84.173. COVID-19 Education Stabilization COVID-19 Education Stabilization Federal Assistance Listing Numbers, 84.425, 84.425C, 84.425D, 84.425U, and 84.425W Twenty-First Century Community Learning Centers Twenty-First Century Community Learning Centers Federal Assistance Listing Numbers, 84.287 and 84.287C 2023-001: Controls for Monitoring Payroll Charged to the Grant Compliance Requirement: Allowable Costs/Cost Principles Type of Finding: Compliance and Significant Deficiency in Internal Control over Compliance Criteria or Specific Requirement: Grantees must provide reasonable assurance that Federal awards are expended only for allowable activities and that the costs of goods and services charged to Federal awards are allowable and in accordance with the applicable cost principles. Condition: Management has not established written guidelines and procedures outlining the time and effort reporting and documentation requirements that department heads must adhere with to ensure compliance with federal and state time and effort reporting requirements. Such guidelines and procedures should indicate under what circumstances semi-annual certifications and personnel activity reports (PARS) are required and should indicate due dates for when this information must be provided to the school business office. Management also has not adopted and implemented standardized forms for semi-annual certifications and PARS that include all data required by federal and state guidelines. Questioned Costs: None reported. Context: Payroll expenditures charged to the programs are required to be supported with documentation substantiating that the employees are eligible to be charged to the grant and that the payroll charged relates to time spent accomplishing grant objectives. This supporting documentation should be standardized and should include all required elements in accordance with Title 2 U.S. Code of Federal Regulations Part 225 Cost Principals for State, Local, and Indian Tribal Governments. The City did not have an adequate system of internal controls in place to provide sufficient documentation to demonstrate compliance with federal and state time and effort reporting requirements in accordance with the provisions of Title 2 U.S. Code of Federal Regulations Part 225 Cost Principals for State, Local, and Indian Tribal Governments. Effect: The City has not complied with the federal and state time and effort reporting requirements. Cause: Lack of documented policies, procedures and guidelines in place to ensure compliance with time and effort reporting requirements. Repeat Finding: This matter was reported as a finding for the Title I major program and special education cluster grants in the previous year as finding 2022-001. Recommendation: Management should establish written guidelines and procedures outlining the time and effort reporting and documentation requirements that department heads must adhere with to ensure compliance with federal and state time and effort reporting requirements. Such guidelines and procedures should indicate under what circumstances semi-annual certifications and personnel activity reports (PARS) are required and should indicate due dates for when this information must be provided to the school business office. Management should also adopt and implement standardized forms for semi-annual certifications and PARS that include all data required by federal and state guidelines. Once the written guidelines and procedures have been established, training should be provided to ensure that the program managers fully understand the time and effort reporting requirements. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will establish written guidelines and procedures outlining the time and effort reporting and documentation requirements that department heads must adhere with to ensure compliance with federal and state time and effort reporting requirements. Such guidelines and procedures will indicate under what circumstances semi-annual certifications and personnel activity reports (PARS) are required and will indicate due dates for when this information must be provided to the school business office. Management will also adopt and implement standardized forms for semi-annual certifications and PARS that include all data required by federal and state guidelines. Once the written guidelines and procedures have been established, training will be provided to ensure that the program managers fully understand the time and effort reporting requirements. Management intends to implement these procedures in fiscal 2024. If the Oversight Agency has questions regarding this plan, please call Michael Pfifferling, Assistant Superintendent of Finance and Operations at 978-374-3400. Sincerely yours, Michael Pfifferling Assistant Superintendent of Finance and Operations City of Haverhill

View Audit 307261

Finding 398514 (2023-001)

Material Weakness 2023

Seattle School District No. 1

WA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

The District does not concur with the audit finding or the $858,725 of questioned costs. This finding is the same as reported in the 21/22 audit. The District still contends that the costs were allowable. The issues regarding internal controls and reporting were not brought to the District’s attenti...

The District does not concur with the audit finding or the $858,725 of questioned costs. This finding is the same as reported in the 21/22 audit. The District still contends that the costs were allowable. The issues regarding internal controls and reporting were not brought to the District’s attention until 10 months into the 22/23 audit period, leaving no time for discussion or changes in interpretation and process. The audit’s condition states that our internal controls were ineffective for ensuring we requested reimbursement only for students and staff with a documented unmet need and that our internal controls were ineffective for demonstrating per location and per user limitations. Based on guidance from the Federal Communications Commission (excerpted below), the District contends we have spent all funds for allowable costs, that those costs were reasonable and necessary, and for students and staff with unmet needs. Districts were able to determine whether students and staff had unmet needs. For our district this meant addressing instances where students may have shared a home device with other siblings; student or staff devices were too old or slow to function properly when running multiple required applications; and / or student owned devices did not have the appropriate security in place to protect students during remote learning (especially from unauthorized websites). Home drives, where all educational digital resources were stored, couldn’t be accessed unless using a district issued device. Additionally, the district’s technical support could not access personally owned devices to provide for thousands of trouble tickets and support issues students faced during remote learning. Based on these factors, unmet need was defined broadly, but within allowed parameters and inventory records were kept, albeit, not perfectly. Devices for remote learning could also be used at school. During the pandemic in Washington State we experienced times when classrooms, schools and or districts were closed by the health department and state regulations because of outbreaks. Districts had to be prepared to support remote learning each day with constantly changing guidance on who was allowed to be in person. Seattle Public Schools followed guidance from the Federal Communications Commission outlined in a document titled: . “Emergency Connectivity Fund Common Misconceptions”, “Misconception #2: If schools have returned to in-class instruction for the upcoming school year, they are not eligible to participate. Answer: This is false. Equipment and services provided to students or school staff who would otherwise lack sufficient access to connected devices, and/or broadband internet access connection while off campus is eligible for Emergency Connectivity Fund Support.” Additionally, from the Federal Communications Commission Order FCC-CIRC21-93-043021, question 77: “We think schools are in the best position to determine whether their students and staff have devices and broadband services sufficient to meet their remote learning needs, and we recognize that they are making such decisions in the midst of a pandemic. We, therefore, will not impose any specific metrics or process requirements on those determinations.” And from question 51: “…we are sensitive to the need to provide some flexibility during this uncertain time. If those connected devices were purchased for the purpose of providing students…with devices for off-campus use consistent with the rules we adopt today, we will not prohibit such on-campus use.” Finally, SAO did not apply any reasonable measure to reduce questioned costs but did state they know that at least some of the equipment addressed unmet needs, while still choosing to question all costs. That is clearly out of alignment with the FCC guidance. There are no corrective actions to take at this time as the funding source has been exhausted and the timeline has passed.

View Audit 307259 Questioned Costs: $1

Finding 398507 (2023-003)

Material Weakness 2023

Brush Hill Development Corporation

MA

Management should review its process and implement additional controls to ensure that an appropriate month and year-end reconciliation and closing process is in place. If appropriate processes are in place then the Organization should be able to file timely.

View Audit 307255

Finding 398506 (2023-002)

Material Weakness 2023

Brush Hill Development Corporation

MA

Management understands the importance of timely and effective reconciliations and reviews to ensure the accuracy and timeliness of financial reporting. Management is committed to implementing timely reconciliations and review procedures for key accounts to support quality, timely and compliant finan...

Management understands the importance of timely and effective reconciliations and reviews to ensure the accuracy and timeliness of financial reporting. Management is committed to implementing timely reconciliations and review procedures for key accounts to support quality, timely and compliant financial reporting.

View Audit 307255

Finding 398505 (2023-001)

Material Weakness 2023

Brush Hill Development Corporation

MA

Management understands the importance of timely and effective reconciliations and reviews to ensure the accuracy and timeliness of financial reporting. Management is committed to implementing timely reconciliations and review procedures for key accounts to support quality and timely financial report...

Management understands the importance of timely and effective reconciliations and reviews to ensure the accuracy and timeliness of financial reporting. Management is committed to implementing timely reconciliations and review procedures for key accounts to support quality and timely financial reporting.

View Audit 307255

Finding 398503 (2023-009)

Significant Deficiency 2023

Penasco Independent School District

NM

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Significant Deficiency

Recommendation We recommend that the District follow the guidance in NM PED’s PSAB Supplement 13, Purchasing. Management Response Corrective Action: We will work with the District staff to plan and obtain purchase orders before receiving items and/or placing orders. Due Date of Completion: June...

Recommendation We recommend that the District follow the guidance in NM PED’s PSAB Supplement 13, Purchasing. Management Response Corrective Action: We will work with the District staff to plan and obtain purchase orders before receiving items and/or placing orders. Due Date of Completion: June 30, 2024 Responsible Party(ies): Business Manager

View Audit 307246

Finding 398502 (2023-001)

Significant Deficiency 2023

The Women's Home

TX

Subrecipient Monitoring Cash Management Reporting

Corrective Action Plan: We have held recent discussions with the City of Houston regarding the Fiscal Report. As a result, it has been agreed that we will submit the Fiscal Report within the required timeframe. The Home will develop a process to ensure that once the Board of Directors has approve...

Corrective Action Plan: We have held recent discussions with the City of Houston regarding the Fiscal Report. As a result, it has been agreed that we will submit the Fiscal Report within the required timeframe. The Home will develop a process to ensure that once the Board of Directors has approved the quarterly financial information, the previously submitted Fiscal Reports will be reviewed for consistency. If differences exist, The Home will submit an amended Fiscal Report to the City of Houston for the applicable quarter. Contact Person Responsible for Corrective Action: Ms. Anna Coffey, Chief Executive Officer. Anticipated Completion Date: This was completed in conjunction with the filing of the Fiscal Report for March 31, 2024.

View Audit 307245

Finding 398497 (2023-002)

Material Weakness 2023

Kalamazoo Youth Development Network

MI

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness § 200.212 § 200.318

Condition: During testing we noted the Organization did not retain support showing they had searched if an entity was debarred, suspended or otherwise excluded. Planned corrective action: KYD Network and the American Rescue Plan Act (ARPA) Compliance Contractor will conduct a search to ensure all A...

Condition: During testing we noted the Organization did not retain support showing they had searched if an entity was debarred, suspended or otherwise excluded. Planned corrective action: KYD Network and the American Rescue Plan Act (ARPA) Compliance Contractor will conduct a search to ensure all ARPA funded organizations have not been debarred, suspended, or otherwise excluded from receiving federal funds prior to receiving ARPA summer program funds. The results of the search will be included in the ARPA spreadsheet. Responsible Person: Viridiana Carvajal, Co-Executive Director, and American Rescue Plan Act (ARPA) Compliance Contractor Anticipated completion date: May 10, 2024. This action already has been implemented for the 2024 ARPA summer program.

View Audit 307230

Finding 398496 (2023-001)

Material Weakness 2023

Pomona Valley Hospital Medical Center

CA

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Period of Performance

Finding 2023-001 – Internal Control Deficiency Over Activities Allowed or Unallowed and Activities Allowed/Allowable Costs Federal Grantor: Department of Homeland Security; Federal Emergency Management Agency (FEMA) Assistance Listing No.: 97.036, Disaster Grants – Public Assistance (Presidentia...

Finding 2023-001 – Internal Control Deficiency Over Activities Allowed or Unallowed and Activities Allowed/Allowable Costs Federal Grantor: Department of Homeland Security; Federal Emergency Management Agency (FEMA) Assistance Listing No.: 97.036, Disaster Grants – Public Assistance (Presidentially Declared Disasters) Award Period of Performance: January 20, 2020 – May 11, 2023 Finding: Management did not consistently retain documentation evidencing the performance of controls to ensure allowable COVID-19 expenses were charged to the program. Corrective Action Plan: All of these deficiencies were related to the selections being more than 36 months old, which is past the current documentation retention policy of PVHMC for non-controlled substances and non-patient records. In order to ensure that documentation is retained for future audits, all FEMA related documentation that is still retained will be kept indefinitely to ensure compliance in future years. Person Responsible: Juli Hester, Chief Financial Officer Estimated Completion Date: May 31, 2024

View Audit 307226

Finding 398492 (2023-001)

Material Weakness 2023

Charlotte Center for Legal Advocacy

NC

The Organization has contracted with Ascend Nonprofit Solutions to assist with their accounting oversight.

View Audit 307211

Finding 398483 (2023-002)

Significant Deficiency 2023

Crazy Horse School

SD

Internal Control / Segregation of Duties HUD Housing Programs Reporting

2023-002 FINDING: Internal Controls over Financial Reporting Question Cost: None noted. Not considered a material weakness Response: Crazy Horse School Business Office staff will follow auditor’s recommendation. The Business Manager will determine the financial statements, schedule of expenditures o...

2023-002 FINDING: Internal Controls over Financial Reporting Question Cost: None noted. Not considered a material weakness Response: Crazy Horse School Business Office staff will follow auditor’s recommendation. The Business Manager will determine the financial statements, schedule of expenditures of federal awards and related footnotes are free of material misstatement and the audit package is filed timely. The most effective controls lie in the management and the Board of Education’s knowledge of the School’s financial operations. Supervision and review functions will be done continually during all phases of the accounting cycle. Cross training with the Business Office staff will continue to be done. The Business Manager will continue to assist with disclosure information and approve any adjusting entries to the trial balance. She reviews and approves all draft and final copies of the financial statements including disclosures. In light of the guidance of SAS 115, the Business Manager will continue additional and continuing training for herself as well as the designated staff. The goal is still to provide training in government financial reporting and current reporting standards to enable management to continue to take the responsibility for the statements and disclosures. The school will continue their implantation of their new financial policies and take steps to ensure they are being followed. All expenditures will continue be reviewed to ensure they are properly documented, coded, and the expenditures are allowable for grant. Review of paychecks will continue to include recalculation of hours on timesheets and leave accrual calculation. With the continue Covid, Flu Seasons, Weather closures, Funeral closures, and my illness this past year has made it very difficult at times to get things done in a timely manner. We will continue to improve and hope to have a better year. This School’s financial stability is better than it has been for years with a clean opinion and no question costs. We will continue to improve, with our outstanding Business Office Staff, and we will continue to make sure we are on top of the internal controls daily. We are not perfect and there is always room to get better and better! ANTICIPATED COMPLETION DATE: June 30, 2025 PERSON(S) RESPONSIBLE: Leslie Cuny, Business Manager

View Audit 307206

Finding 398482 (2023-001)

Material Weakness 2023

Crazy Horse School

SD

Subrecipient Monitoring Cash Management Matching / Level of Effort / Earmarking

2023-001 FINDING: Deficit Fund Balances Questioned Costs: None noted. Recommendation: We recommend the School continue to implement their plan to liquidate all remaining debt from the general fund. We also recommend they continue a vigilant oversight of all budgets of the School. Response: The curre...

2023-001 FINDING: Deficit Fund Balances Questioned Costs: None noted. Recommendation: We recommend the School continue to implement their plan to liquidate all remaining debt from the general fund. We also recommend they continue a vigilant oversight of all budgets of the School. Response: The current Business Manager is enforcing the CHS Policies that do not permit expenditures in excess of the approved budget without Board approval. In addition, the current Business Manager does not include any carryover from prior budgets in the existing budget until the audit is completed and the financial statements are reconciled. The Business Manager has restricted use of General Fund revenues to remedy the deficit, including income received by the School that is non-program income, and the School Board is responsible for monitoring expenditures monthly. ANTICIPATED COMPLETION DATE: June 30, 2025 PERSON(S) RESPONSIBLE: Leslie Cuny, Business Manager

View Audit 307206

Finding 398481 (2023-004)

Significant Deficiency 2023

Anchorage Community Mental Health Services, Inc.

AK

Cash Management § 200.305

Finding 2023-004: 2023-004 - Significant Deficiency in Internal Control over Compliance and Noncompliance – Cash Management Contact: Michael Bailey, Chief Financial Officer Corrective Action Plan: The Accounting department at Alaska Behavioral Health has stabilized staffing in accounting personnel,...

Finding 2023-004: 2023-004 - Significant Deficiency in Internal Control over Compliance and Noncompliance – Cash Management Contact: Michael Bailey, Chief Financial Officer Corrective Action Plan: The Accounting department at Alaska Behavioral Health has stabilized staffing in accounting personnel, including the replacement of the Chief Financial Officer. The CFO will develop and maintain a Master Grants tracking system that identifies cumulative allowable expenditures, determining the maximum cash drawdown of Federal Funds for the appropriate reporting time period and assuring that drawdowns are made in a timely manner. Proposed Completion Date: 09/30/2024

View Audit 307202

Finding 398480 (2023-003)

Significant Deficiency 2023

Anchorage Community Mental Health Services, Inc.

AK

Allowable Costs / Cost Principles Significant Deficiency § 200.403

Finding 2023-003: 2023-003 - Significant Deficiency in Internal Control over Compliance and Noncompliance – Allowable Costs/Cost Principles Contact: Michael Bailey, Chief Financial Officer Corrective Action Plan: The Accounting department at Alaska Behavioral Health has stabilized staffing in accoun...

Finding 2023-003: 2023-003 - Significant Deficiency in Internal Control over Compliance and Noncompliance – Allowable Costs/Cost Principles Contact: Michael Bailey, Chief Financial Officer Corrective Action Plan: The Accounting department at Alaska Behavioral Health has stabilized staffing in accounting personnel, including the replacement of the Chief Financial Officer. Prior to submission of financial reports, the CFO will review and verify that personnel related expenditures are supported by payroll allocation records, and other direct expenditures have adequate documentation associated with the allowable expenditure. Proposed Completion Date: 06/30/2024

View Audit 307202

Finding 398464 (2023-001)

Significant Deficiency 2023

Dickinson-Iron Community Service Agency

MI

Eligibility

Conduct physical review of each client application (and/or scanned and emailed applications). Increase training on procedural regulations to front-line and supervisory staff in counties outside Dickinson and Iron. Implement quality control verification checks regularly at counties outside of Dickins...

Conduct physical review of each client application (and/or scanned and emailed applications). Increase training on procedural regulations to front-line and supervisory staff in counties outside Dickinson and Iron. Implement quality control verification checks regularly at counties outside of Dickinson and Iron. Person(s) Responsible: Christina Ureta, CSFP/TEFAP Director Timing for Implementation: Immediately

View Audit 307189

Finding 398463 (2023-001)

Significant Deficiency 2023

YWCA of Southern Arizona

AZ

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.318 § 200.326

Program Name/Assistance Listing Title: COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Contact Person: Melissa M. Tomlinson, CPA, CGFM, Director of Finance Anticipated Completion Date: May 2024 Planned Corrective Action: The YWCA will develop and implemen...

Program Name/Assistance Listing Title: COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Contact Person: Melissa M. Tomlinson, CPA, CGFM, Director of Finance Anticipated Completion Date: May 2024 Planned Corrective Action: The YWCA will develop and implement formal procurement procedures aligned with federal regulations, including thresholds for prior‐purchase authorization and vendor checks for suspension and debarment. Staff training will be conducted to ensure competency, and oversight mechanisms will be strengthened through regular monitoring and integration of SAM verification processes. Comprehensive documentation and record‐keeping practices will be established, with periodic reviews to facilitate continuous improvement. Through these actions, the YWCA aims to enhance compliance with federal procurement standards and ensure transparent and accountable procurement practices.

View Audit 307188

Finding 398461 (2023-002)

Significant Deficiency 2023

Texas Council on Family Violence, INC

TX

Subrecipient Monitoring § 200.332

Policies and procedures will reflect the Program lead prepares sub-grants and CFO will review to ensure correct fund source/CFDA is noted. This approach creates a check and balance. A committee involving program staff and finance staff will review all documentation including application, and post aw...

Policies and procedures will reflect the Program lead prepares sub-grants and CFO will review to ensure correct fund source/CFDA is noted. This approach creates a check and balance. A committee involving program staff and finance staff will review all documentation including application, and post award documentation.

View Audit 307186

Finding 398460 (2023-001)

Material Weakness 2023

Mount Vernon School District No. 320

WA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs, equipment and restricted purpose requirements. Name, address, and telephone of District contact person: Tim Papendorf, Information Services ...

Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs, equipment and restricted purpose requirements. Name, address, and telephone of District contact person: Tim Papendorf, Information Services Supervisor 124 E. Lawrence Street, Mount Vernon, WA 98273 360-428-6110 Corrective action the auditee plans to take in response to the finding: Concern: The district failed to maintain sufficient documentation proving that the equipment provided to students matched their actual unmet needs. Reimbursement was sought based on estimated unmet needs rather than documented, actual unmet needs. Response: The Mount Vernon School District mandates that students use districtassigned devices for remote learning. According to grant training provided to the district, if students are required to use district-owned devices for remote learning, Chromebooks could be distributed to any student who did not have a district-assigned device that meets hardware standards. The standards used to assess the hardware included Chromebooks that were older than four years, unable to support the necessary software and digital learning tools, and devices at their end-of-life stage, meaning they no longer received automatic updates from Google. We assessed our inventory and supplied new Chromebooks to students based on our understanding of their needs. Chromebooks were only provided to students who lacked a device that met our hardware standards. Resolution: During this audit, the district learned that its understanding was inaccurate. However, we are confident our need exceeded our request. In May 2020, Page 71Office of the Washington State Auditor sao.wa.gov as directed by OSPI, the district conducted a survey which revealed that only 38% of our families had access to a device at home suitable for online learning. Given our students in poverty population was 4,365 during the 2022-23 school year, the 1,869 devices for which funding was requested only partially met our overall device needs. This audit has improved our understanding of the requirements related to verifying unmet needs. Moving forward, we will directly contact families and collect signatures to confirm their needs. These records will be attached to student profiles within our asset management system (Destiny) before ECF funded Chromebooks are assigned to them. Concern: Inventory records were incomplete, missing the names of 273 students assigned laptops funded by the ECF, thus failing to fully meet FCC documentation requirements. Response: The district acknowledges challenges related to student device assignment. Staff reductions and changes in our inventory and check-out processes necessitate updates and training, which is ongoing. We are committed to ensuring accurate and timely updates to our records. Resolution: A list of inventory discrepancies has been distributed, and action is being taken to update our records. To strengthen our existing systems, we will implement additional biannual training sessions with our inventory managers. These trainings will cover best practices for record keeping and emphasize the importance of maintaining accurate inventory records. We will conduct monthly audits of our records, and correction requests will be sent to individual sites to promptly address any information inaccuracies. Concern: MVSD lacked documentation to show that it only provided one device per student or location, leading to possible over-issuance of equipment. Response: While the district acknowledges the need to improve its student assignment inventory within Destiny, we have confirmed that only one device is assigned per student through the use of our additional inventory system (Google Workspace). Resolution: The district will enhance its inventory practices and explore additional redundancies to ensure effective contingencies if future data issues arise. Anticipated date to complete the corrective action: ● Unmet Needs Documentation: May 31, 2024 ● Inventory Update: June 20th, 2024 ● Staff Training: June 20th, 2024 (Ongoing)

View Audit 307176 Questioned Costs: $1

Finding 398457 (2023-006)

Material Weakness 2023

Pana Community Unit School District 8

IL

Reporting Internal Control / Segregation of Duties

03-011-0080-26 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2023 Corrective Action Plan Finding No.: 2023-_ 006_ Condition: Expenditure functions and objects used to record grant expenditures in the general ledger are not consistent with the expenditure function...

03-011-0080-26 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2023 Corrective Action Plan Finding No.: 2023-_ 006_ Condition: Expenditure functions and objects used to record grant expenditures in the general ledger are not consistent with the expenditure functions and objects used for grant reporting. In addition, general ledger support for each expenditure report submitted is not complete and readily available. Plan: Grant expenditures will be recorded in the same general ledger expenditure functions as are used for grant reporting and supporting general ledger reports will be maintained in District files for all expenditure reports filed. The employees assigned to code grant expenditures and prepare grant expenditure reports will work together to accomplish this. Anticipated Date of Completion: 06/30/2024 Name of Contact Person: Jason Bauer Management Response: Management will implement the auditor's recommendation for the year ended June 30, 2024.

View Audit 307162

Finding 398456 (2023-001)

None 2023

Pomperaug Senior Housing, Inc. (grace Meadows III & Iv)

CT

Questioned Costs HUD Housing Programs

MANAGEMENT AGREES WITH THE FINDING. HUD APPROVAL WAS NOT GRANTED FOR A DISBURSEMENT FROM A RESTRICTED ACCOUNT. THE DISBURSEMENT WAS MADE TO GRACE MEADOWS IN ERROR AND WAS REPAID ON JANUARY 25, 2024.

View Audit 307153 Questioned Costs: $1

Finding 398453 (2023-001)

Material Weakness 2023

Driscoll Children's Hospital and Subsidiaries

TX

Allowable Costs / Cost Principles

Federal Agencies: U.S. Department of Homeland Security Assistance Listing No.: 97.036 COVID-19 Disaster Grants – Public Assistance Award Period of Performance: March 25, 2020 to July 01, 2022 Corrective Action Planned: Management agrees that evidence of our internal determination that certain expen...

Federal Agencies: U.S. Department of Homeland Security Assistance Listing No.: 97.036 COVID-19 Disaster Grants – Public Assistance Award Period of Performance: March 25, 2020 to July 01, 2022 Corrective Action Planned: Management agrees that evidence of our internal determination that certain expenses incurred for the Medline Spot Buy program was not fully documented. The Medline Spot Buy program was used as a guarantee of delivery of Personal Protection Equipment (PPE) which was in short supply during the initial stages of the Covid pandemic. These purchases were subsequently charged to the FEMA COVID grant, reviewed, and properly reimbursed to Driscoll through that grant by FEMA. Although evidence of review was not retained for the purchases through this program, management believes that adequate review was conducted in the decision to charge these costs to the grant. As it relates to the Medline Spot Buy program, Driscoll Children’s Hospital took part in the program to ensure that the Hospital was adequately stocked with necessary PPE during the COVID pandemic. This program allowed for rapid purchasing and delivery of PPE. Orders were submitted for the program by uploading a spreadsheet to Medline. This ordering process resulted in these purchases bypassing the normal purchase order approval structure. These expenses were correctly charged to the FEMA grant and their appropriateness is not in question. We have reviewed our processes related to the retention of evidence of expense review to improve audit evidence should this program ever be awarded in future periods. We will keep minutes of meetings documenting committee approval for these invoices and/or other documentation that clearly shows our internal review and decision tree. Responsible party: Steve King, CFO Implementation Date: Procedures were reviewed along with the finalization of the FY23 Uniform Guidance audit in May 2024.

View Audit 307140

Finding 398452 (2023-001)

Significant Deficiency 2023

Northeast Texas Public Health District

TX

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring

The Northeast Texas Public Health District (NET Health) will take steps to ensure overall effective grant monitoring and to increase communications between NET Health Grant Managers and the Chief Financial Officer and Chief Executive Officer. The NET Health Leadership Team will discuss any issues du...

The Northeast Texas Public Health District (NET Health) will take steps to ensure overall effective grant monitoring and to increase communications between NET Health Grant Managers and the Chief Financial Officer and Chief Executive Officer. The NET Health Leadership Team will discuss any issues during our weekly Leadership Team meetings to ensure compliance. These weekly meetings will address costs expended within the grant parameters and ensure grant funds will be more evenly expended during the year as appropriate. NET Heatlh will continue to develop effective methods of grant oversight as it finds weaknesses in its processes. To ensure compliance with the period of performance requirements, NET Health will change its processes effectively immediately. Going forward checks will only be prepared, dated, signed, and mailed to vendors after work is completed or items are received. There will be enhanced internal controls by establishing procedures to monitor and ensure timely payment of accrued expenditures, such as regularly accounting for any outstanding checks and actively communicating with vendors on performance requirements. In addition, we will enhance communication and coordination among relevant departments to expedite the payment process while maintaining compliance with grant regulations. George T. Roberts, CEO, and Lawanda Owens, CFO, are the persons responsible for this action plan going forward. NET Health is expected to have this action plan implemented by May 1, 2024.

View Audit 307138 Questioned Costs: $1

Finding 398450 (2023-005)

Significant Deficiency 2023

Nassau Community College

NY

Student Financial Aid Cash Management Reporting

NCC conducted staff training to reinforce requirements for the return of funds within 240 days for all federal award checks returned uncashed. Effective November 2023, we implemented an automated process to assist with identifying federal funds that need to be returned.

View Audit 307129

Finding 398448 (2023-004)

Significant Deficiency 2023

Nassau Community College

NY

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

The HEERF reports are being updated, approved and uploaded to our website.

View Audit 307129

Corrective Action Plans

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