Corrective Action Plans

Finding 388426 (2023-005)

Significant Deficiency 2023

State of Hawaii, Department of Accounting and General Services

HI

Procurement, Suspension & Debarment § 200.214

Finding No. 2023‐005 – Suspension and Debarment (Significant Deficiency) State Department of Land and Natural Resources AL Number: 15.615 Program Title: Cooperative Endangered Species Conservation Fund Condition The auditing firm tested a non‐statistical sample of two subawards and found no evidence...

Finding No. 2023‐005 – Suspension and Debarment (Significant Deficiency) State Department of Land and Natural Resources AL Number: 15.615 Program Title: Cooperative Endangered Species Conservation Fund Condition The auditing firm tested a non‐statistical sample of two subawards and found no evidence indicating that program personnel verified whether any of the contractors were federally suspended or debarred. Current Status of Corrective Action Plan Concur. DLNR Division of Forestry and Wildlife (DLNR DOFAW) has implemented procedures to ensure that a SAM.gov verification is performed for all subrecipients, and that documentation is printed out from SAM.gov and retained with the subrecipient file folder. Person Responsible Cynthia C. Gomez, Fiscal Management Officer David Smith, DOFAW Administrator Anticipated Date of Completion Completed.

View Audit 300162

Finding 388425 (2023-001)

Material Weakness 2023

Christus Health

TX

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles

Finding 2023-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: ...

Finding 2023-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: July 1, 2020 to June 30, 2023 Corrective Action Planned: Management agrees that certain expenses to the COVID department were not reviewed and approved at the order entry level in specific cases. Although evidence of review was not retained for every charge to the COVID department, we believe the appropriateness of the charge was reasonable. Additionally, based on monthly review of departmental expenses and full-time equivalent (FTE) analysis at the facility level, we believe that these expenditures are subject to the appropriate level of review to identify unexpected variances. As it relates to the COVID Activity Code, this code was created as a means to track certain COVID hours worked, but was not configured to calculate the amounts associated with those hours, resulting in the need to make reasonable estimates. Even using the base pay rate at the time the hours were incurred would not have been accurate since it would omit adjustments for shift differentials, weekend hours, and overtime. We performed internal analyses and reviewed the results of samples selected by the auditors and concluded that the risk of a material overcharge to the program was minimal. Further, we have almost $40 million of unused lost revenues after our final PRF submission for Period 5, such that any questioned costs would easily be covered by other eligible uses of PRF funds. We have reviewed our processes related to the retention of expense documentation to improve audit evidence should this program ever be awarded in future periods. Responsible party: Lee Sonne, Vice President of Finance and Controller Implementation Date: Procedures were reviewed and analysis completed along with the Period 5 portal filing in September 2023.

View Audit 300159 Questioned Costs: $1

Finding 388424 (2023-002)

Significant Deficiency 2023

Catholic Community Services of Southern Arizona, Inc.

AZ

Subrecipient Monitoring Significant Deficiency Matching / Level of Effort / Earmarking

Secondary Review of Billings (Significant Deficiency) Federal Agency: U.S. Department of Health and Human Services Program Title: Child Care and Development Block Grant Assistance Listing Number: 93.575 Federal Award Source: Pass-Through Funding Pass-Through Entity: Arizona Department of Economic S...

Secondary Review of Billings (Significant Deficiency) Federal Agency: U.S. Department of Health and Human Services Program Title: Child Care and Development Block Grant Assistance Listing Number: 93.575 Federal Award Source: Pass-Through Funding Pass-Through Entity: Arizona Department of Economic Security Pass-Through Identifying Number: SX222367 Criteria – Section §200.303 of the Uniform Guidance states that a 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. Condition and Context – During our audit of allowable activities, we noted the Organization did not conduct a secondary internal supervisory review of the monthly billings for this program prior to submission to the funding source. Cause and Effect – Due to a shortage in staff, all 12 monthly billings for this program were prepared by one individual and were not reviewed and approved by secondary supervisory personnel. Questioned Costs – None identified. Recommendation – We recommend that the Organization improve its internal controls over the preparation of billings for this program to ensure all billings are reviewed and approved by secondary supervisory personnel. View of Responsible Officials: We agree with the finding. We have implemented procedures to ensure secondary reviews of all billings. See our Corrective Action Plan for the fiscal year ended June 30, 2023 for additional detail. Corrective Action Plan: CCS will improve its internal controls over the preparation of all billings. Effective April 1, 2024, Tammy Gallegos, CCS Accounting Manager, will make certain all billings are reviewed and approved by a secondary supervisor. The Accounting Manager will check off and sign off on a listing of all billings in an effort to ensure and document that 1) the billings were reviewed by a secondary supervisor, 2) the billings were submitted to the payers, and 3) the billings were submitted on a timely manner.

View Audit 300150

Finding 388423 (2023-001)

Significant Deficiency 2023

Catholic Community Services of Southern Arizona, Inc.

AZ

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring

Procurement (Significant Deficiency) and Compliance Federal Agency: U.S. Department of Homeland Security Program Title: Emergency Food & Shelter National Board Program (“EFSP”) Assistance Listing Number: 97.024 Federal Award Source: Pass-Through Funding Pass-Through Entity: Pima County Pass-Through...

Procurement (Significant Deficiency) and Compliance Federal Agency: U.S. Department of Homeland Security Program Title: Emergency Food & Shelter National Board Program (“EFSP”) Assistance Listing Number: 97.024 Federal Award Source: Pass-Through Funding Pass-Through Entity: Pima County Pass-Through Identifying Number: CT-GMI-21-452 Criteria – Section §200.320 of the Uniform Guidance requires that when the value of the procurement for property or services under a Federal financial assistance award exceeds the Simplified Acquisition Threshold, a formal procurement method is required, such as a sealed bid or proposal. In addition, these formal procurement methods require public advertising. Condition – During our audit of the procurement requirements for the EFSP program, we noted the Organization utilized a vendor who in total was paid more than the Simplified Acquisition Threshold; however, the Organization did not utilize a formal procurement method in selecting this vendor as required by their policies and the Uniform Guidance. Cause – The finding appears to be the result of an immediate need to obtain services and an oversight to subsequently conduct a formal procurement method. Effect and Context – By not adhering to a formal procurement method, the Organization may or may not have chosen the best vendor to provide the services. There was only one vendor whose payments exceeded the Simplified Acquisition Threshold during the audit period. Our sample was a statistically valid sample. Questioned Costs – None identified. Recommendation – We recommend the Organization provide periodic training to its program staff regarding procurement requirements per the Uniform Guidance and consider modifying its procurement related internal controls to ensure all staff follow the Organization’s procurement policies. View of Responsible Officials: We are in agreement with the finding and are in the process of updating our procedures to mitigate issues in the future. See our Corrective Action Plan for the fiscal year ended June 30, 2023 for additional detail. Corrective Action Plan: CCS has updated its purchasing policy as of March 22, 2024. The purchasing policy will be included as part of the program staff’s required 2024 annual training effective April 1, 2024. The Relias Learning platform will be the mechanism used for this training. Staff will be given a deadline of April 30, 2024 to complete this training. In addition, Tammy Gallegos, the CCS Accounting Manager will monitor large purchases by vendor on a monthly basis. This is to ensure that vendors providing goods or services to CCS that meet or exceed the Single Acquisition Threshold per federal regulations follow a formal procurement method, such as soliciting bids. Bids will be kept with the vendors’ file in the CCS Business Office.

View Audit 300150

Finding 388415 (2023-102)

Material Weakness 2023

Santa Cruz County

AZ

Reporting Subrecipient Monitoring Cash Management § 200.303

Assistance Listings number and program name: 97.067 Homeland Security Grant Program Contact Person(s): Augustin Huerta Jr., Commander Anticipated completion date: April 30, 2024 Due to unexpected staff turnover, including the retirement of the office manager responsible for submitting H...

Assistance Listings number and program name: 97.067 Homeland Security Grant Program Contact Person(s): Augustin Huerta Jr., Commander Anticipated completion date: April 30, 2024 Due to unexpected staff turnover, including the retirement of the office manager responsible for submitting Homeland Security Grant Program quarterly reports, the Sheriff’s Office ultimately relied on staff that was not properly trained nor have sufficient time to prepare the reports. The Sheriff’s Office has since improved the understanding of grant administration and submission process. The Sheriff's Office is working collaboratively to ensure accurate and timely submission of required documents to the grantor. Subsequent to June 30, 2023, the Sheriff's Office implemented calendar reminders of deadlines, statistic and financial reports are generated one week in advance of the due date, and quarterly reports are completed by the 13th day of each month. The Sheriff's Office will work with County finance staff to develop and implement written policies and procedures.

View Audit 300146

Finding 388413 (2023-103)

Material Weakness 2023

Santa Cruz County

AZ

Reporting Internal Control / Segregation of Duties § 200.303

Assistance Listings number and program name: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Contact Person(s): Mauricio A. Chavez, Deputy County Manager/CFO Anticipated completion date: April 30, 2024 The County’s finance department reported the entirety of the allo...

Assistance Listings number and program name: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Contact Person(s): Mauricio A. Chavez, Deputy County Manager/CFO Anticipated completion date: April 30, 2024 The County’s finance department reported the entirety of the allocation based on County’s interpretation of the final rule and multiple subsequent reporting guidelines. The County will revise and resubmit reports to the Treasury Department and will work with staff to correct any deficiencies for future reports. The County will meet with staff to assess all present and future grant reporting guidelines.

View Audit 300146

Finding 388410 (2023-101)

Material Weakness 2023

Santa Cruz County

AZ

Questioned Costs Matching / Level of Effort / Earmarking § 200.303

Assistance Listings number and program name: 17.259 WIOA Youth Activities Contact Person(s): Irasema Olvera, WIOA Director Anticipated completion date: June 30, 2025 To assist the County, meet the WIOA 75% earmarking requirement for out-of-school youth program, the County continues to d...

Assistance Listings number and program name: 17.259 WIOA Youth Activities Contact Person(s): Irasema Olvera, WIOA Director Anticipated completion date: June 30, 2025 To assist the County, meet the WIOA 75% earmarking requirement for out-of-school youth program, the County continues to develop written policies and procedures for its WIOA Youth Activities program. The County continues to provide eligible out-of-school youth the opportunity of paid work experiences (WEX). The County will also work with the pass-through grantor to develop an effective strategy to recruit and retain eligible out-of-school youth. Through the pass-thru grantor, the County requested a waiver of the of the 75% out-of-school youth program earmark ultimately seeking a more balanced 50% for the out-of-school youth program and 50% for the in-school youth program distribution. The County will continue to monitor the out-of-school services spending throughout the fiscal year and award period.

View Audit 300146 Questioned Costs: $1

Finding 388409 (2023-002)

Significant Deficiency 2023

Community Youth Advance

MD

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking

Planned Corrective Actions: The Community Youth Advance Interim Executive Director will make updates to the Employee Handbook and create a Standard Operating Procedures manual that outlines key responsibilities with regard to record keeping and reporting that will ensure continuity and stability dur...

Planned Corrective Actions: The Community Youth Advance Interim Executive Director will make updates to the Employee Handbook and create a Standard Operating Procedures manual that outlines key responsibilities with regard to record keeping and reporting that will ensure continuity and stability during times of leadership and staff transition. This will be reviewed with staff and our accounting firm to ensure it is comprehensive and addresses the organization’s needs and the recommendations of this audit. The Board of Directors will then review and give final approval of these documents. Name of the contact Person responsible for corrective action: Danielle Middlebrooks, Interim Executive Director, Community Youth Advance Board of Directors (Cassius Priestly, Chair) and Goldin Group CPAs Planned completion date for corrective action plan: The Standard Operating Procedures Manual and the Updated Community Youth Advance Employee Handbook will be completed and approved by June 30, 2024, to take effect July 1, 2024.

View Audit 300144

Finding 388408 (2023-004)

Material Weakness 2023

City of Atlanta

GA

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties

Name of Contact Person Responsible for Corrective Action Plan: Jerry Deloach, Chief Risk Officer - Enterprise Risk Management Corrective Action Plan: The City of Atlanta’s Department of Enterprise Risk Management (ERM) is now calendaring the quarterly reports due dates and immediately following the ...

Name of Contact Person Responsible for Corrective Action Plan: Jerry Deloach, Chief Risk Officer - Enterprise Risk Management Corrective Action Plan: The City of Atlanta’s Department of Enterprise Risk Management (ERM) is now calendaring the quarterly reports due dates and immediately following the timely filing before transmitting a copy of the report to the City of Atlanta’s Grants Accounting area. Anticipated Completion Date: Fiscal year 2024

View Audit 300142

Finding 388403 (2023-002)

Significant Deficiency 2023

Heidelberg University

OH

Student Financial Aid Matching / Level of Effort / Earmarking Special Tests & Provisions

Due to turnover in the financial aid office, verification was performed incorrectly prior to the employment of the current Director of Financial Aid. Since a new Director of Financial Aid has been employed, the verification tracking group of each student selected is reviewed prior to completing the ...

Due to turnover in the financial aid office, verification was performed incorrectly prior to the employment of the current Director of Financial Aid. Since a new Director of Financial Aid has been employed, the verification tracking group of each student selected is reviewed prior to completing the verification process to ensure each student is verified in accordance with the CPS assigned tracking group.

View Audit 300140

Finding 388399 (2023-001)

Significant Deficiency 2023

Heidelberg University

OH

Questioned Costs Student Financial Aid Special Tests & Provisions

The academic calendar used for return of funds calculations will be reviewed by a separate individual in the Financial Aid Office. We will review each calculation as it is completed to verify that the number of days in the semester have been reported correctly for each student.

View Audit 300140 Questioned Costs: $1

Finding 388398 (2023-001)

Significant Deficiency 2023

Colgate University

NY

Cash Management Student Financial Aid § 200.516

COLGATE UNIVERSITY. Corrective Action Plan – Finding 2023-001. Responsible Official – Kyle Dombrowski, Director of Tax and Financial Reporting. We will perform and document a review of reimbursement submissions before they are processed to ensure that reimbursement requests are not in excess of fund...

COLGATE UNIVERSITY. Corrective Action Plan – Finding 2023-001. Responsible Official – Kyle Dombrowski, Director of Tax and Financial Reporting. We will perform and document a review of reimbursement submissions before they are processed to ensure that reimbursement requests are not in excess of funds disbursed for the period. After the error in the Federal Direct Loan reimbursement for November 2022 was identified, we implemented a new requirement that the Director of Tax and Financial Reporting or the AVP/Controller must review the reimbursement request calculated by the Assistant Controller/Director of Grant Accounting before it can be processed. As of June 30, 2023, this review was fully implemented. Anticipated Completion Date: 3/27/2024.

View Audit 300136

Finding 388394 (2023-006)

Material Weakness 2023

County of Los Angeles

CA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.317 § 200.318 § 200.319 § 200.320

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH agrees with this finding and recommendation and will discuss, and document sensitive legal matters funded by federal funds with respective grantors to obtain guidance and direction on addressing audit reque...

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH agrees with this finding and recommendation and will discuss, and document sensitive legal matters funded by federal funds with respective grantors to obtain guidance and direction on addressing audit requests. DPH will implement a protocol wherein the program executing any contract using federal funds will collect and maintain sufficient records which detail the history of the procurement. The program will also verify that compliance with procurement requirements is maintained for all federally funded contracts, including sufficient documentation to demonstrate compliance with suspension or debarment. To confirm this, the program will check the SAM exclusions prior to entering into a contract and will maintain documentation of that verification. These will ensure DPH’s ability to provide documentation when requested by auditors. 3. Anticipated implementation date: July 1, 2024

View Audit 300135

Finding 388380 (2023-003)

Material Weakness 2023

County of Los Angeles

CA

Subrecipient Monitoring Reporting Material Weakness § 200.303

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Acute Communicable Disease Controls (ACDC) agrees with the finding and recommendation. ACDC staff will monitor subawards and submit the required FFATA reports in the FFATA system upon execution date of the ...

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Acute Communicable Disease Controls (ACDC) agrees with the finding and recommendation. ACDC staff will monitor subawards and submit the required FFATA reports in the FFATA system upon execution date of the amendment, but no later than the following month it was executed. This includes keeping monitoring logs of all contract amendments and modifications that are subject to FFATA reporting requirements. 3. Anticipated implementation date: March 1, 2024

View Audit 300135

Finding 388378 (2023-004)

Material Weakness 2023

County of Los Angeles

CA

Subrecipient Monitoring Reporting Material Weakness § 200.303

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Emergency Preparedness Response Program (EPRD) agrees with the finding and recommendation. EPRD staff will send the subrecipient/contractor the FFATA reporting notice, which includes a request for the fiv...

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Emergency Preparedness Response Program (EPRD) agrees with the finding and recommendation. EPRD staff will send the subrecipient/contractor the FFATA reporting notice, which includes a request for the five most highly compensated officers at the same time the contract is sent to the subrecipient/contractor for signature. This will assist EPRD with tracking the reporting notice because once the subrecipient/contractor returns the signed contract, they will also return the FFATA reporting notice. Once staff receives the executed contract from DPH’s Contracts and Grants, the FFATA reporting system will be updated accordingly and a screenshot showing the date/time the report was submitted will be kept on file. 3. Anticipated implementation date: July 1, 2024

View Audit 300135

Finding 388363 (2023-010)

Material Weakness 2023

County of Los Angeles

CA

Questioned Costs Period of Performance Allowable Costs / Cost Principles § 200.1 § 200.211 § 200.403

1. Person responsible: Division Chief, Auditor-Controller Accounting Division 2. Corrective action plan: The County agrees with the finding and recommendation. The County will review CSLFRF claims and verify that all claimed payroll expenditures were incurred or obligated on or after March 3, 202...

1. Person responsible: Division Chief, Auditor-Controller Accounting Division 2. Corrective action plan: The County agrees with the finding and recommendation. The County will review CSLFRF claims and verify that all claimed payroll expenditures were incurred or obligated on or after March 3, 2021. Payroll expenditures that were incurred or obligated before March 3, 2021, will be removed from the CSLFRF claims. 3. Anticipated implementation date: June 28, 2024

View Audit 300135 Questioned Costs: $1

Finding 388362 (2023-009)

Material Weakness 2023

County of Los Angeles

CA

Subrecipient Monitoring § 200.1 § 200.332 § 200.414 § 200.501

1. Person responsible: Division Chief, Auditor-Controller Accounting Division 2. Corrective action plan: The County agrees with the finding and recommendation. In September 2022, the County issued the Notice of Federal Subaward Information template, which contains the 14 reporting elements requir...

1. Person responsible: Division Chief, Auditor-Controller Accounting Division 2. Corrective action plan: The County agrees with the finding and recommendation. In September 2022, the County issued the Notice of Federal Subaward Information template, which contains the 14 reporting elements required by 2 CFR §200.332(a) that must be provided to subrecipients at the time of the subaward. The County will issue written correspondence reminding departments to complete the Notice of Federal Subaward Information template and provide a completed copy to the subrecipient at the time of the subaward. The County will also remind departments to provide all the required elements from 2 CFR §200.332(a) via letter or amended agreement to existing subrecipients that were not initially provided all the requirements. In the same correspondence, the County will remind departments to monitor their Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) subrecipients, maintain sufficient records of the monitoring, and utilize the Subrecipient Monitoring Guide issued in June 2023. 3. Anticipated implementation date: June 28, 2024

View Audit 300135

Finding 388361 (2023-002)

Significant Deficiency 2023

County of Los Angeles

CA

Reporting Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.502 § 200.510

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Finance agrees with this finding and recommendation. DPH will ensure to report Federal expenditures in the SEFA under the correct ALN based on Time Studies received. 3. Anticipated implementation date: Mar...

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Finance agrees with this finding and recommendation. DPH will ensure to report Federal expenditures in the SEFA under the correct ALN based on Time Studies received. 3. Anticipated implementation date: March 7, 2024

View Audit 300135

Finding 388358 (2023-005)

Material Weakness 2023

County of Los Angeles

CA

Subrecipient Monitoring Reporting Material Weakness § 200.303

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Division of HIV and STD Programs (DHSP) agrees with the finding and recommendation. DHSP will institute a new procedure that 1) notifies subaward recipients within 30 days of the effective date of the sub...

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Division of HIV and STD Programs (DHSP) agrees with the finding and recommendation. DHSP will institute a new procedure that 1) notifies subaward recipients within 30 days of the effective date of the subaward execution or modification of relevant federal award information and 2) uploads federal subaward information to FFATA within 30 days of the effective date of the subaward execution or modification of relevant federal award information. These notifications will happen for all subawards that meet the threshold for FFATA reporting. DHSP understands that these notifications may precede the full execution of a new contract or subaward. 3. Anticipated implementation date: July 1, 2024

View Audit 300135

Finding 388357 (2023-007)

Material Weakness 2023

County of Los Angeles

CA

Procurement, Suspension & Debarment Subrecipient Monitoring

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Center for Health Equity agrees with the finding and recommendation. Moving forward staff will check the SAM exclusions before entering into any contracts and maintain documentation of that verification to...

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Center for Health Equity agrees with the finding and recommendation. Moving forward staff will check the SAM exclusions before entering into any contracts and maintain documentation of that verification to provide upon request. 3. Anticipated implementation date: July 1, 2024

View Audit 300135

Finding 388355 (2023-001)

Significant Deficiency 2023

County of Los Angeles

CA

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.502 § 200.510

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Finance agrees with finding and recommendation. Finance will take the following corrective action: • Initiate direct, written communication with the Auditor-Controller to seek precise instructions and guida...

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Finance agrees with finding and recommendation. Finance will take the following corrective action: • Initiate direct, written communication with the Auditor-Controller to seek precise instructions and guidance on the inclusion of accruals in our reporting. • Proactively review and document accrual procedures, ensuring alignment with regulatory requirements. • Prospectively include and implement accrual reporting in the Single Audit. • Establish a communication protocol with the Auditor-Controller to address any future uncertainties promptly. Through these measures, DPH aims to address the audit finding, establish clear guidelines for accrual reporting, and ensure compliance with reporting requirements while maintaining transparency and accuracy in our financial reporting practices. 3. Anticipated implementation date: April 1, 2024

View Audit 300135

Finding 388354 (2023-008)

Material Weakness 2023

County of Los Angeles

CA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.317 § 200.318 § 200.319 § 200.320

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Acute Communicable Disease Control (ACDC) agrees with the finding and recommendation. Before entering into contract, DPH will check for SAM exclusions with date indicating verification before contract exe...

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Acute Communicable Disease Control (ACDC) agrees with the finding and recommendation. Before entering into contract, DPH will check for SAM exclusions with date indicating verification before contract execution and keep this documentation on file. DPH, Administrative Services Division (ASD) - Procurement agrees with the finding and recommendation. DPH’s Administrative Services Division Manager will email Procurement staff to remind staff/manager to ensure SAM.GOV verification documents are included in all federally funded purchases before finalizing/approving those transactions. 3. Anticipated implementation date: March 11, 2024 and April 30, 2024

View Audit 300135

Finding 388352 (2023-002)

None 2023

Thiel College

PA

Subrecipient Monitoring Reporting

Federal Program: COVID-19 - Education Stabilization Fund - Higher Education Emergency Relief Fund - Student and Institutional Aid Federal Agency: U.S. Department of Education Pass-Through Entity: Not applicable Assistance Listing Number: 84.425E, 84.425F Federal Award Year: June 30, 2023 Criterion:...

Federal Program: COVID-19 - Education Stabilization Fund - Higher Education Emergency Relief Fund - Student and Institutional Aid Federal Agency: U.S. Department of Education Pass-Through Entity: Not applicable Assistance Listing Number: 84.425E, 84.425F Federal Award Year: June 30, 2023 Criterion: The U.S. Department of Education (the Department) has issued guidance for the Education Stabilization Funds (ESF) Higher Education Emergency Relief Funds (HEERF) for quarterly reporting for all Sections (a)(1), (a)(2), (a)(3) and (a)(4) that requires that institutions to prepare a report for each quarter for funds that are drawn down and disbursed/spent. The reports are to be posted on the institution’s website within 10 days of the calendar quarter end. Additionally, institutions are required to prepare an annual report and submit to the Department summarizing the uses of the HEERF funds for the calendar year. Condition While all reports in question were submitted on time to the DOE, there was no evidence maintained of timely reporting on the College website for the student or institutional reports for the quarter ending June 30, 2023; or for the annual period ending December 31, 2022. Corrective Action Plan All reports will be resubmitted to the College website in chronological order. Responsible Person Connie Jablonski—Associate Vice President of Finance and Administration Anticipated Completion Date The final report (quarter ended December 2023) was submitted in a timely manner to the Department of Education. The chronological submission of all HEERF related reports to the College website is anticipated to begin in early February. A review will be a part of Thiel’s Audit Process for Fiscal 2023 – 2024.

View Audit 300134

Finding 388351 (2023-001)

None 2023

Thiel College

PA

Student Financial Aid Matching / Level of Effort / Earmarking Subrecipient Monitoring

Federal Program: Student Financial Assistance Cluster - Federal Direct Student Loan Program Federal Agency: U.S. Department of Education Pass-Through Entity: Not applicable Assistance Listing Number: 84.268 Federal Award Year: June 30, 2023 Criterion: Title IV regulations (34 CFR 685.309b) require t...

Federal Program: Student Financial Assistance Cluster - Federal Direct Student Loan Program Federal Agency: U.S. Department of Education Pass-Through Entity: Not applicable Assistance Listing Number: 84.268 Federal Award Year: June 30, 2023 Criterion: Title IV regulations (34 CFR 685.309b) require that upon receipt of an enrollment report from the Secretary, Institutions must update all information included in the report and return the report to the Secretary; (i) in the manner and format prescribed by the Secretary; and (ii) within the timeframe prescribed by the Secretary. Unless it expects to submit its next updated enrollment report to the Secretary within the next 60 days, an Institution must notify the Secretary within 30 days after the date the Institution discover that: (i) a loan under Title IV of the Act was made to or on behalf of a student who was enrolled or accepted for enrollment at the Institution and the student has ceased to be enrolled on at least a half-time basis or failed to enroll on at least a half-time basis for the period for which the loan was intended; or (ii) a student who is enrolled at the Institution and who received a loan under Title IV of the Act has changed his or her permanent address. Condition and Context: For one student out of 25 selected for testing, the College did not notify the NSLDS in a timely matter for a change in enrollment status. Cause and Effect: The College failed to follow its procedures for reporting student status changes. The accuracy of Title IV student loan records depends heavily on the accuracy of the enrollment information reported by schools. If an institution does not review, update, and verify student enrollment statuses, effective dates of the enrollment status, and the anticipated completion dates, then the Title IV student loan records will be inaccurate in NSLDS. Recommendation: The College should implement a process and related to verify with NSLDS that all enrollment status information for all students is updated accurately and timely. Recommendation: The College should implement a process and related to verify with NSLDS that all enrollment status information for all students is updated accurately and timely. Corrective Action Plan The College will continue to work with the NSC Audit Response Team, Office of the Registrar, and Office of Information Technology to resolve the data reporting issues we are currently experiencing. Denise Owens, Student Loan Specialist and Debra Schreiber, Registrar will work together to provide manual data reporting to NSLDS in an accurate and timely manner. Responsible Persons Michelle Work, Director of Financial Aid Denise Owens, Student Loan Specialist Dr. Laura Pickens, Associate Dean for Academic Programs and Records Debra Schreiber, Registrar Anticipated Completion Date This is an ongoing process and will begin immediately.

View Audit 300134

Finding 388350 (2023-001)

Significant Deficiency 2023

Peace River Center for Personal Development, Inc.

FL

Procurement, Suspension & Debarment

Record Keeping Recommendation: We recommend Peace River Center implement an internal review process which includes adequate record keeping of the approval process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:...

Record Keeping Recommendation: We recommend Peace River Center implement an internal review process which includes adequate record keeping of the approval process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: An internal review process has been updated to include documented signoff by responsible staff. Names of the contact persons responsible for corrective action: David Tournade. Planned completion date for corrective action plan: April 1, 2024. If the U.S. Department of Treasury or Florida Department of Children and Families has questions regarding this plan, please call David Tournade at 863-519-0575, extension 6005.

View Audit 300129

Corrective Action Plans

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