Corrective Action Plans

Finding 61094 (2022-027)

Material Weakness 2022

NH

Cash Management Subrecipient Monitoring § 200.305

View of Responsible Officials Related to compliance with the CMIA, the Department of Energy acknowledges there were several instances where draws were not completed on a monthly basis for the prior month?s expenditures following the CMIA agreement in FY22. The Department of Energy has hired another...

View of Responsible Officials Related to compliance with the CMIA, the Department of Energy acknowledges there were several instances where draws were not completed on a monthly basis for the prior month?s expenditures following the CMIA agreement in FY22. The Department of Energy has hired another staff person to complete business office grant-related tasks and will be reviewing and adjusting our policies and procedures if and where needed in the future. This staff person is still in training, therefore the completion date is not known at this time. Related to the timing of payments to subrecipients, due to staffing issues in both the Administrative and Fiscal offices, this recommendation is acknowledged and accepted. Support staff in both offices are being recruited and trained. This will ensure that adequate supervision and compliance of sub-recipient cash advances procedures are followed. Anticipated Completion Date: Ongoing Contact Person: Jane Lemire Business Administrator IV (PT) and Eileen Smiglowski, NH LIHEAP Administrator

View Audit 49723

Finding 61093 (2022-026)

Material Weakness 2022

State of New Hampshire

NH

Reporting Subrecipient Monitoring

View of Responsible Officials The Department of Energy recognizes the FFATA reporting requirement was not met due to insufficient resources in FY22 while completing an agency merger. The Department is adjusting our internal procedures and processes where necessary to address any and all deficiencies...

View of Responsible Officials The Department of Energy recognizes the FFATA reporting requirement was not met due to insufficient resources in FY22 while completing an agency merger. The Department is adjusting our internal procedures and processes where necessary to address any and all deficiencies in our reporting requirements and we are currently training new staff on reporting regulations and processes. The corrective action to ensure that the annual Performance Report is filed timely is recognized. This was due to a lack of staffing to complete the report in a timely manner. A new associate position is being created and staffed at the NH Department of Energy to prevent this situation going forward. For the Carryover and Reallotment report, Additional support staff in both the Fiscal and Program offices for LIHEAP are being recruited and trained. This will ensure that adequate policies and procedures can be developed and implemented. For the SF-425 report, the Department of Energy disagrees with this finding. The expense was calculated at the agency?s calculated and submitted Indirect Cost Rate Proposal (30.45%) to our cognizant agency the US DHHS on December 30, 2020. Our proposal was not reviewed/approved by US DHHS until May 02, 2022 at the rate of 30.40%. Energy calculates and expenses indirect cost on a quarterly basis. At the time that the rate was calculated (after 9/30/2021) for FFY22 Q1, no response was received from US DHHS as to our proposal, therefore, per the recommendation of the Admin Services ? Comptroller?s office, the proposed rate of 30.45% was used to calculate the Indirect Cost expense for FFY22 Q1. The over reported charge was not due to ?insufficient review controls?. I did provide in our backup materials in PBC#38 the late response from US DHHS acknowledging the 30.4% rate to be approved and that acknowledgment is dated April 5, 2022 ? well beyond the time the expense was calculated for FFY22 Q1 expenses. Energy will continue to follow our established processes and procedures to ensure accurate federal grant expensing. Anticipated Completion Date: June 30, 2023 and September 30, 2023 for the Carryover and Reallotment Report Contact Person: Jane Lemire, Business Administrator (PT) and Eileen Smiglowski, NH LIHEAP Administrator

View Audit 49723

Finding 61092 (2022-025)

Material Weakness 2022

State of New Hampshire

NH

Subrecipient Monitoring § 200.251 § 200.332 § 200.414 § 200.521

View of Responsible Officials The Department of Energy recognizes the need to include all required information to be communicated to sub-recipients, and that all sub-recipients? risk assessments are thoroughly completed. In addition, uniform guidance reports need to be collected and reviewed to ens...

View of Responsible Officials The Department of Energy recognizes the need to include all required information to be communicated to sub-recipients, and that all sub-recipients? risk assessments are thoroughly completed. In addition, uniform guidance reports need to be collected and reviewed to ensure that management letters be issued within the required timeframe. Anticipated Completion Date: Ongoing Contact Person Eileen Smiglowski, NH LIHEAP Administrator

View Audit 49723

Finding 61085 (2022-024)

Material Weakness 2022

State of New Hampshire

NH

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

View of Responsible Officials We concur with the finding. Corrective Action: Condition A The Bureau of Employment Supports has been undergoing massive programmatic changes over the past 2 to 3 years. As part of those changes, there has been an updated Work Verification Plan submitted which will help...

View of Responsible Officials We concur with the finding. Corrective Action: Condition A The Bureau of Employment Supports has been undergoing massive programmatic changes over the past 2 to 3 years. As part of those changes, there has been an updated Work Verification Plan submitted which will help to address some areas where errors have occurred. Keeping in mind that for a period of close to 2 years, due to the COVID pandemic, NHEP was not holding participants accountable for not returning signed employment plans to NHEP staff. The focus for that time was to ensure that families were housed, fed and safe, therefore, services focused on their immediate needs. Participants who entered the NHEP program during that time were not held accountable to returning a signed employment plan therefore it did not become part of their routine with NHEP. While COVID restrictions have been lifted, participants seem to have needed some time to reintegrate into the NHEP program and the mandatory expectations. NHEP staff and leadership will continue to remind participants and become more diligent in ensuring that signed employment plans are on the forefront of their daily responsibilities. It should be noted that in a couple of instances, employment plans were created as part of a Service Determination Appointment and very quickly after the participant was deemed exempt from the Work Program (NHEP) so the employment plan was not necessary and became a moot point. A Director?s Memo will be sent out by the end of this week which will allow Employment Plans to be acknowledged and accepted by the participant in multiple ways (not just with a wet signature) thereby increasing the likelihood of participants returning accepted employment plans to NHEP staff. Making this shift will mitigate the difficulties that are causing participants to not return their signed employment plans to NHEP staff and will decrease instances where there is not an accepted employment plan on file. NHEP leadership will hold a state wide mandatory staff training where ways to prioritize the monitoring and obtainment of accepted employment plans will be outlined and discussed. Field Support Managers will continue to monitor their staff on a quarterly basis, however, will add a monthly check on having accepted employment plans to their responsibilities. Condition B Part of the changes that NHEP has implemented have included a new Activity Tracking form which has made tracking hours more efficient and easier for the participant as well as the Employment Counselor. We believe that this activity tracker as well as the decrease in mandatory forms will allow for more accuracy and fewer errors moving forward. Uploading documents into the e-folder was found to be error prone, therefore, on March 1, 2023, NHEP leadership provided guidance and training on a specific process of indexing and scanning documents to ensure that moving forward the Employment Counselors are checking their e-folder?s to ensure that documents are properly uploaded and visible. This process was initially sent out to the field as a suggestion in 9/2022, however, on 3/1/23 this process was sent out as an expected process moving forward. Also, through cursory investigations, we believe that this new process, combined with the new Activity Tracking form, has already shown to be effective in improving the accuracy of supporting and recording hours. NHEP leadership has also been working with the NEW HEIGHTS system to streamline the process of uploading documents to further decrease the potential for errors. A change request form was submitted approximately one year ago. Also during the time period of this audit, NHEP was requiring pay stubs from employed participants and completing ?overrides? of the number of work hours that a participant worked during the week if that number was different than what was auto-populating based on information obtained by and entered by eligibility. NHEP discontinued that practice. NHEP no longer requires pay stubs from participants as that is a function of eligibility. NHEP utilizes the number of hours worked per week based on the number of hours entered by eligibility. This change will ensure that employment hour errors no longer occur. In order to address issues of audit findings, within the next 90 days, NHEP leadership is holding a state wide mandatory staff training where more in-depth information on the audit process will be shared including audit ?tests?, ?questions? and ?corrective action plans?. Historically in NH, the audit process was not shared with the NHEP staff making them unaware of the expectations and/or findings of the audit. NHEP staff were trained to complete certain processes and enter particular data but were never able to connect that back to anything. While we have been introducing this process more and more to our staff, we intend to hold a training to help them more thoroughly understand why they are doing what they are doing and remind them that what they do is reviewed for accuracy as part of the federal audit process. We believe that this transparency will create buy-in from the staff to put systems in place for themselves and to self-monitor more. Anticipated Completion Date: December 31, 2023 Contact: Brigitte Bowmar, Program and Workforce Administrator III

View Audit 49723

Finding 61084 (2022-023)

Significant Deficiency 2022

State of New Hampshire

NH

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

View of Responsible Officials The Department partially concurs as follows: The Department?s position is that it maintains compliance with the Federal Funding Accountability and Transparency Act (FFATA) (Pub. L. No. 109-282), as amended by Section 6202 of Public Law 110-252, hereafter referred as th...

View of Responsible Officials The Department partially concurs as follows: The Department?s position is that it maintains compliance with the Federal Funding Accountability and Transparency Act (FFATA) (Pub. L. No. 109-282), as amended by Section 6202 of Public Law 110-252, hereafter referred as the ?Transparency Act? that are codified in 2 CFR Part 170, recipients (i.e., direct recipients) of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). The Department agrees that during the year ended June 30, 2022, not all of the tested FFATA reports were deemed complete and accurate due to internal control considerations. The Department will review current practices regarding the internal control of financial information included in the G&C PDF?s which are the basis of the FFATA reporting with the objective of accurately reporting the specific amounts of Federal Funding content by FAIN so as to facilitate the accurate and timely reporting of FFATA in accordance with the Act. Anticipated Completion Date: September 30, 2023 Contact Person: PJ Nadeau, Administrator

View Audit 49723

Finding 61083 (2022-022)

Material Weakness 2022

State of New Hampshire

NH

Matching / Level of Effort / Earmarking

View of Responsible Officials We do not concur. The expenditures outlined are considered verifiable costs via the Memorandum of Understanding (MOU) and the Maintenance of Effort (MOE) forms completed by the third party agency. As part of the June 30, 2018 audit a similar finding is noted which we ...

View of Responsible Officials We do not concur. The expenditures outlined are considered verifiable costs via the Memorandum of Understanding (MOU) and the Maintenance of Effort (MOE) forms completed by the third party agency. As part of the June 30, 2018 audit a similar finding is noted which we also did not concur with as part of that audit. The department has since been in contact and had meetings with the Federal Administration for Children and Families (ACF). In addition, a formal response was provided by ACF on August 31, 2022 that stated they are hoping to resolve this outstanding issue soon. We are currently awaiting the Federal Administration for Children and Families (ACF) decision concerning this finding and as such, we do not believe any corrective action is required. Anticipated Completion Date When the decision from ACF is given we will respond accordingly. Until then no corrective action is considered necessary. Contact Person: Mary Calise, Deputy Chief Financial Officer, Depart. of Health and Human Services Rejoinder The Department stated in their response that it verifies the completeness and accuracy of the third-party in-kind match through the MOU entered into and the MOE forms that the providers submit. Per review of the signed certifications (or the MOE forms), we noted the certification contains a description of the general purpose of the program, an identification of the TANF purpose the program addresses, the number of families/individuals served, the expenses incurred under the program, excluding any federal and state funds received. While we were provided with documentation to support that the third-party certifications were received, we were not provided with evidence to support the Department had performed additional procedures to verify the incurred costs were complete and accurate as required by 45 CFR section 263.2(e) and 75.306. We do not agree that a certification alone from a third party meets the definition of a verifiable cost from third -party records.

View Audit 49723

Finding 61082 (2022-021)

Material Weakness 2022

State of New Hampshire

NH

Questioned Costs Subrecipient Monitoring Procurement, Suspension & Debarment § 200.251 § 200.303 § 200.332 § 200.414 § 200.521

agreement. View of Responsible Officials A. We concur with this finding. The Department utilized an internally available copy of the Management Log, which lists vendor?s determinations. This is a copy of the log, not the original, official copy. There is a delay in updating this copy from the o...

agreement. View of Responsible Officials A. We concur with this finding. The Department utilized an internally available copy of the Management Log, which lists vendor?s determinations. This is a copy of the log, not the original, official copy. There is a delay in updating this copy from the original, and incorrect information had been initially entered. The Department is moving this log to software which allows all Department employees to view the same log, while limiting the number of individuals who have access to make changes. Implementation has been completed as of March 2023. B. We concur with this finding. However, we believe this was an isolated incident as the TANF CFDA number (93.558) used was very similar to correct CFDA number (93.778) that should have been documented. C. 200.332 requirements a. We do not concur with this finding. The contract for Mt Prospect became effective 8/4/21, prior to the 4/22 inception of the UEI. The DUNS number, as in effect at that time, is noticed in Exhibit J of the contract. b. We concur with three of the four findings. Two of the four contracts pre-date the template update requiring the notice an indirect cost rate. Indirect cost rate for federal awards (including if the de minimis rate is charged per 2 CFR section 200.414) were added to Exhibit C of the Department?s contracts in April 2020. One of the contracts did not indicate an indirect cost rate as required. One of the contracts notes the indirect cost rate in the Notes of their financial details. c. One of the two contracts pre-dates the template update requiring the notice the identification of R&D. R&D identifications for federal awards were added to Exhibit C of the Department?s contracts in April 2020 One of the two contracts did not identify whether the contract was R&D as required. D. Subrecipient Risk Assessment ? We concur with the finding. We consider the finding to be fully resolved through Department policy Department policy and Department wide implementation. However, it should be noted full compliance will not be achieved for one to two contact cycles due to timing. The Department began addressing the issue of Subrecipient Monitoring issue in June 2017 when the first Grants Administrator was hired. The Department finalized the Subrecipient Monitoring Policy, which encompasses the financial and programmatic risk assessments as well as the subrecipient monitoring, on June 1, 2018. The Department provided user training on the subject in February and September 2018, training over one hundred forty-six staff. However, only brand new procurements utilized this policy during the initial roll out of this policy. The Department hired a new Grants Administrator in May 2019. The full Subrecipient Monitoring policy rolled out to all procurements, including sole source, amendments, and renewals, effective August 1, 2020. The Contracts Unit received specialized subrecipient monitoring training on May 13 and October 28, 2020. Department wide training to all staff occurred weekly between September 8 and November 3, 2020. The Grants Office provided additional targeted training to Program staff through team meetings. Over one hundred fifty Program and Finance staff received training. Annual training will be held in September each year. Refresher training or training for new staff is available upon request from the Grants Office. The Grants Office website offers Program, Finance, and Contracts Bureau staff access to the subrecipient monitoring policy, as well as training modules, slides, and tools. The training has also been recorded and is available on this site. The Subrecipient Monitoring Policy requires Program to determine whether any vendor which receives funds in exchange for goods or services is a Contractor or Subrecipient. Determined subrecipients receive a Management Questionnaire, which includes a ten question questionnaire and requirements for submitting financial data. This information is used to populate the Risk Assessment Tool, which shows any risks pertinent to a subrecipient and the subaward. Based on the risks shown, Program chooses monitoring activities to mitigate the risks and the Contracts Bureau memorializes these choices in the contract. The Grants Office continues to work closely with the Contracts Bureau to ensure compliance with the Subrecipient Monitoring policy. C. and D. It is also important to note that between April 2020 and June 2022 the Department was involved in the State?s strategic response to the COVID-19 pandemic. During this time, New Hampshire was under a state of emergency (Executive Order 2020-04), processes were rapidly converted to fully digital overnight, the State?s standard approval processes were suspended and non-standard templates, which did not include the required notifications under 200.332, were utilized to respond to the COVID-19 pandemic. The Department worked with other State Departments and the National Guard to create a record number of amendments, contracts, and other agreements (approximately 200% more than standard). The Department is in the process of instituting a new contract life cycle management solution that will utilize conditional logic to include the required notifications for agreements involving federal funds in order to ensure compliance. Implementation is anticipated to be complete in July 2023. As the COVID-19 pandemic strategic response has wound down, the Department has not suspended its regular standard approval or subrecipient risk assessment and monitoring processes and has not used non-standard templates to award federal funding. E. We concur there was no formal documentation of any monitoring activity. Due to staff turnover a new administrator has been hired and unable to furnish the monitoring that took place during FY22. However, a program site review during FY23 was performed and financial monitoring of invoices has also taken place. Anticipated Completion Date: July, 2023 Contact Person: Melissa Kelleher, Administrator Rejoinder As documented above in Bullet B of the condition found, the Department did not properly communicate all required award information to the subrecipient. Once aware of the noncompliance, the Department should have timely communicated this information to its subrecipients.

View Audit 49723 Questioned Costs: $1

Finding 61081 (2022-020)

Significant Deficiency 2022

State of New Hampshire

NH

Questioned Costs Allowable Costs / Cost Principles Special Tests & Provisions

View of Responsible Officials Condition A We concur. The department received the notice of non-cooperation on 9/14/21 and did not enter the non-cooperation until 9/29/21, which was beyond the 10-day time frame. The case should have then been confirmed to impose the sanction on or before 9/24/21....

View of Responsible Officials Condition A We concur. The department received the notice of non-cooperation on 9/14/21 and did not enter the non-cooperation until 9/29/21, which was beyond the 10-day time frame. The case should have then been confirmed to impose the sanction on or before 9/24/21. This resulted in the client being over issued by approximately $222.37. Condition B We concur. The sanction for non-cooperation with Child Support was entered in error as Child Support did not issue a non-compliance. This resulted in the client being under issued by approximately $446.50 Follow-up We will be informing all supervisors of the specific errors found during the audit. We will also require supervisors to include these topics at their next staff meeting. In addition, individual emails will be sent to the staff involved with the errors and provide guidance. Anticipated Completion Date: N/A Contact Person: Karyl Provost

View Audit 49723 Questioned Costs: $1

Finding 61075 (2022-019)

Significant Deficiency 2022

State of New Hampshire

NH

Allowable Costs / Cost Principles Reporting Significant Deficiency

View of Responsible Officials We concur. The Department has been reviewing and second reviewing all required monthly financial reports and maintaining documentation since January 2022. We believe this current control in place allows us to remain in compliance with all requirements. Anticipated C...

View of Responsible Officials We concur. The Department has been reviewing and second reviewing all required monthly financial reports and maintaining documentation since January 2022. We believe this current control in place allows us to remain in compliance with all requirements. Anticipated Completion Date: March 2, 2023 Contact Person: Shelley Swanson, DPHS Finance Director

View Audit 49723

Finding 61074 (2022-018)

Material Weakness 2022

State of New Hampshire

NH

Subrecipient Monitoring § 200.332 § 200.501 § 200.521

View of Responsible Officials The Department will review its Sub-recipient Monitoring Policy and assess compliance across the Department. It is important to note that between April 2020 and June 2022 the Department was involved in the State?s strategic response to the COVID-19 pandemic. During th...

View of Responsible Officials The Department will review its Sub-recipient Monitoring Policy and assess compliance across the Department. It is important to note that between April 2020 and June 2022 the Department was involved in the State?s strategic response to the COVID-19 pandemic. During this time, New Hampshire was under a state of emergency (Executive Order 2020-04), processes were rapidly converted to fully digital overnight, the State?s standard approval processes were suspended and non-standard templates were utilized to respond to the COVID-19 pandemic. The Department worked with other State Departments and the National Guard to create a record number of amendments, contracts, and other agreements (approximately 200% more than standard). The Department is in the process of instituting a new contract life cycle management solution that will utilize conditional logic to include the required notifications for agreements involving federal funds in order to ensure compliance. Implementation is anticipated to be complete in July 2023. As the COVID-19 pandemic strategic response has wound down, the Department has not suspended its regular standard approval or subrecipient risk assessment and monitoring processes and has not used non-standard templates to award federal funding. The Financial Compliance Unit (FCU) will continue to work with the Business System Analyst of the Cost Allocation Unit in determining the amount of Federal payments made to the vendors. The FCU receives a vendor payment list on a quarterly basis that includes the total amount of Federal funds that were paid to all contracted agencies. We will continue to closely monitor the FAC to obtain all copies of the Single Audits pertaining to the DHHS agencies. In addition, we will devise a spreadsheet that will list all contracts that have been awarded Federal funds and cross check these agencies to vendor payment list. The DHHS updated the policy on risk assessment on November 16, 2020 to ensure that all contracts have a risk assessment performed regardless of funding source. We also have added verbiage in the contracts effective for contracts that begin after November 2021. It states any Contractor that receives an amount equal to or greater than $250,000 from the Department during a single fiscal year, regardless of the funding source, may be required, at a minimum, to submit annual financial audits performed by an independent CPA if the Department?s risk assessment determination indicates the Contractor is high-risk. Finally, effective for any new procurement subsequent to March 2022, all back-up documentation must accompany the invoices and be submitted on a monthly basis. Anticipated Completion Date: July 2023 Contact Person: Melissa Kelleher, Grants Administrator, Ann Driscoll, Financial Compliance Unit

View Audit 49723

Finding 61073 (2022-017)

Material Weakness 2022

State of New Hampshire

NH

Procurement, Suspension & Debarment Subrecipient Monitoring

View of Responsible Officials The Department will review existing internal controls to assess whether they are sufficient to provide management with reasonable assurance the Department complies with the 2 CFR section 180.300. It is important to note that between April 2020 and June 2022 the Depart...

View of Responsible Officials The Department will review existing internal controls to assess whether they are sufficient to provide management with reasonable assurance the Department complies with the 2 CFR section 180.300. It is important to note that between April 2020 and June 2022 the Department was involved in the State?s strategic response to the COVID-19 pandemic. During this time, New Hampshire was under a state of emergency (Executive Order 2020-04), processes were rapidly converted to fully digital overnight, the State?s standard approval processes were suspended and non-standard templates were utilized to respond to the COVID-19 pandemic. The Department worked with other State Departments and the National Guard to create a record number of amendments, contracts, and other agreements (approximately 200% more than standard). The Department is in the process of instituting a new contract life cycle management solution that will utilize conditional logic to include the required attestation for agreements involving federal funds in order to ensure compliance. Implementation is anticipated to be complete in July 2023. As the COVID-19 pandemic strategic response has wound down, the Department has not suspended its regular standard approval or subrecipient risk assessment and monitoring processes and has not used non-standard templates to award federal funding. All standard templates require vendors to sign a certification regarding suspension and debarment. Anticipated Completion Date: July 2023 Contact Person: Melissa Kelleher, Grants Administrator

View Audit 49723

Finding 60996 (2022-005)

Significant Deficiency 2022

Refugee & Immigrant Self-Empowerment, Inc.

NY

Reporting Internal Control / Segregation of Duties

Name of Auditee: Refugee & Immigrant Self-Empowerment, Inc. Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended September 30, 2022 CAP Prepared by: Haji Adan, Executive Director Phone: 315-214-4480 (A) Current Finding on the Schedule of Findings and Responses (5) Audit...

Name of Auditee: Refugee & Immigrant Self-Empowerment, Inc. Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended September 30, 2022 CAP Prepared by: Haji Adan, Executive Director Phone: 315-214-4480 (A) Current Finding on the Schedule of Findings and Responses (5) Audit Finding 2022-005 (a) Comments on the finding and recommendation: Duly noted. (b) Actions Taken: As mentioned above for audit finding 2022-004, we are going to have some specific guidance regarding this process once the HR consultant completes his project. We have already started putting short term contractors in the ADP (payroll system). (c) Anticipated Completion Date: July 31, 2023.

View Audit 49622

Finding 60995 (2022-004)

Material Weakness 2022

Refugee & Immigrant Self-Empowerment, Inc.

NY

Procurement, Suspension & Debarment Reporting Internal Control / Segregation of Duties

Name of Auditee: Refugee & Immigrant Self-Empowerment, Inc. Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended September 30, 2022 CAP Prepared by: Haji Adan, Executive Director Phone: 315-214-4480 (A) Current Finding on the Schedule of Findings and Responses (4) Audit...

Name of Auditee: Refugee & Immigrant Self-Empowerment, Inc. Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended September 30, 2022 CAP Prepared by: Haji Adan, Executive Director Phone: 315-214-4480 (A) Current Finding on the Schedule of Findings and Responses (4) Audit Finding 2022-004 (a) Comments on the finding and recommendation: Approval process has been developed subsequent to September 30, 2022. (b) Actions Taken: We are working with an HR consultant to update our staff handbook, update payroll processing system, review, and update time management, and reassure all the HR procedures and guidelines are up to date and meet the state and federal requirements. We are also looking for some resources and non-profit financial management professionals to update our administrative and financial manuals and guidelines to put more controls in place to mitigate all financial risks. (c) Anticipated Completion Date: July 31, 2023.

View Audit 49622

Finding 60994 (2022-003)

None 2022

Refugee & Immigrant Self-Empowerment, Inc.

NY

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Name of Auditee: Refugee & Immigrant Self-Empowerment, Inc. Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended September 30, 2022 CAP Prepared by: Haji Adan, Executive Director Phone: 315-214-4480 (A) Current Finding on the Schedule of Findings and Responses (3) Audit...

Name of Auditee: Refugee & Immigrant Self-Empowerment, Inc. Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended September 30, 2022 CAP Prepared by: Haji Adan, Executive Director Phone: 315-214-4480 (A) Current Finding on the Schedule of Findings and Responses (3) Audit Finding 2022-003 (a) Comments on the finding and recommendation: Duly noted. (b) Actions Taken: The finance team is working on the financial requirements of the grants and in addition to that we are adding monthly grant reports to the pipeline for the finance department. The reports are going to be designed in a way to show the approved budget for all the lines, their relevant expenditures up to the month ended and remaining balances, all included with required matches approved in the individual grant budgets. (c) Anticipated Completion Date: May 31, 2023.

View Audit 49622

Finding 60992 (2022-003)

Significant Deficiency 2022

Saint Leo University, INC

FL

Student Financial Aid Reporting Significant Deficiency

2022-003 NSLDS Reporting Recommendation: We recommend the University review its reporting procedures to ensure that students? statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actio...

2022-003 NSLDS Reporting Recommendation: We recommend the University review its reporting procedures to ensure that students? statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: please see below Name(s) of the contact person(s) responsible for corrective action: Elizabeth Vestal, Registrar. Planned completion date for corrective action plan: December 31, 2022 with continued auditing after. Four areas of deficiency have been identified within our current enrollment reporting process. Specifically, 1) the university did not correct errors within ten days, 2) the program begin date reported to NSLDS (National Student Loan Data System) does not match the university?s records, 3) the student?s program enrollment effective date is incorrectly reported to NSLDS and 4) status changes were not certified and/or received within sixty days. In response to your findings, the Registrar?s Office has created a plan of action to remedy the errors. The enrollment reporting process has new leadership at the university. The findings from the new audit team will be corrected. The corrections will require the university to change current behaviors, practices, and reports. Findings two and three are connected to the program start date entered into Colleague. Currently, when processing a program add or change in Colleague (student information system), the program start date defaults to the first day of the month of the start of the term. In the past admissions and advising have been instructed to enter the upcoming term date as the program start date in the SACP (Student Academic Program) screen of Colleague. Unfortunately, this is not being done consistently and several teams have reverted to using the default date and the issue was not identified prior to reporting. The following outlines the proposed corrective action plan: 1) New and re-entry/re-admit students, program changes, or change of residency a. Effective for student programs starting in Fall 2 2022, the program start date in Colleague will match the start date of the upcoming term or end date of prior term. The operator will manually correct the default date to mirror the first day of the start term or end date of prior term in Colleague. i. If there is a potential issue with the date of the upcoming term, the Registrar?s Office must be consulted prior to committing to an alternate date. 2) Active continuing students a. Phase 1: The Fall 1 2022 census report will be used to generate a list of all currently active students. Each student will be manually reviewed to verify the program effective start date reflects the start of term at the university or start of term for the next declared program/major. Although the start date of a program change is not required to match the start of term for enrollment reporting purposes, this will eliminate processing confusion and increase consistency. i. The first phase of corrections will be completed by October 24, 2022. b. Phase 2: Prior census reports will be used to capture students who had been active in terms from Summer 1 2021 to Fall 1 2022. The program effective start dates will be reviewed and corrected as needed. i. The second phase of corrections will be completed by December 31, 2022. 3) Communication a. Issue a Registrar Communication memorandum (RegCom) outlining the new expectations for assigning the program effective start date, auditing schedule, and implications of errors to the following within the university, by October 24, 2022. i. Registrar team ii. Admissions operations iii. Deans, Chairs, and Program Directors iv. Campus success coaches, faculty advisors, and coordinators v. Center directors and staff 4) Inactive students (have not attended since Summer 1 2021) a. The program effective start date of students who have not been active at the university since the Summer 1 2021 term will be reviewed and updated upon re-entry/re-admit to the university (See bullet 1 above). 5) Report/Audit a. Coordinate with the Department of Information Technology (DoIT) to create a SQL report to pull student information from Colleague, including the student?s start term and declared program effective start date. b. The Registrar?s Office will audit the report weekly to ensure all dates are compliant and accurate prior to generating the enrollment file. 6) Colleague functionality a. Explore the possibility of amending the default date assigned by Colleague. i. This is restricted by the capabilities of the SIS. If unable to amend, we would continue with manual process noted above. Findings one and four relate to the timing of file submission and correcting roster errors. The Registrar will review the university?s reporting procedures and schedule to ensure that student statuses are accurately reported through the servicer to NSLDS within sixty days and errors are corrected within ten days. To do so, the Registrar will: 1) Establish an annual schedule to report student statuses every thirty to sixty days. a. Attention will be given to term dates, withdraw deadlines, as well as weekends and calendar holidays. 2) Create a sub-schedule of timing for correcting errors. This schedule should account for days necessary for the servicer and NSLDS to process the data. 3) Audit the SCHER5 and other reports weekly to ensure any remaining errors are corrected within ten days. By taking the above actions, Saint Leo will have processes in place to establish and maintain procedures to reasonably achieve compliance with NSLDS regulations providing timely and accurate data and audit the effectiveness of our data collection and reporting procedures. The university, specifically the Registrar?s Office, is committed to submitting complete, accurate, and timely enrollment data for Saint Leo University students.

View Audit 60987

Finding 60990 (2022-002)

Significant Deficiency 2022

Saint Leo University, INC

FL

Questioned Costs Student Financial Aid Significant Deficiency

2022-002 Return to Title IV Recommendation: We recommend the University review the R2T4 requirements and implement procedures to ensure the R2T4 calculations are using the correct amount of term days and are completed accurately. Explanation of disagreement with audit finding: There is no disagree...

2022-002 Return to Title IV Recommendation: We recommend the University review the R2T4 requirements and implement procedures to ensure the R2T4 calculations are using the correct amount of term days and are completed accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Report is being created that will allow staff to compare R2T4 manual data entries against source data. Discrepancies will be researched and corrected within 5 business days. Report will be generated weekly and reviewed by the manager over this area. Name(s) of the contact person(s) responsible for corrective action: Brenda Clark, Director of Financial aid Planned completion date for corrective action plan: Implementation of new quality control R2T4 report planned for October 24, 2022.

View Audit 60987 Questioned Costs: $1

Finding 60929 (2022-005)

Significant Deficiency 2022

Prince George's County, MD

MD

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Finding Number: 2022-005 Program: COVID-19 ? Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Award Number and Year: ELC08CHW (3/1/2021 ? 2/28/2022) Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Criteria...

Finding Number: 2022-005 Program: COVID-19 ? Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Award Number and Year: ELC08CHW (3/1/2021 ? 2/28/2022) Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Criteria or specific requirement: Compliance: Per Maryland Department of Health, subgrantees are required to submit Monthly Status Reports by the 10th of the month they are reporting on. Control: Per 2 CFR section 200.303(a), 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. These internal controls should comply with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: Prince George?s County (County) did not file Monthly Status Reports in a timely manner. Cause: The County?s procedures and controls were not sufficient to ensure that Monthly Status Reports were filed timely. Resolution: The Health Department will review and enhance internal controls and procedures to ensure that Monthly Status Reports are filed timely. Specifically, the Health Department will update the routing reporting deliverables matrix that documents all grant reporting requirements and frequency to ensure we are in compliance with the reporting requirements. In addition, we will update our internal grant guidance document to include all control requirements per 2 CFR section 200.303, by adding language to establish and maintain effective internal controls over the Federal award. We will hold a meeting with the fiscal team once the internal grant guidance document is updated to ensure compliance with guidance in standards for internal control in the Federal Government. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Responsible Party: Sezelle Gabriel Banwaree, Associate Director of Administration Anticipated corrective action plan completion date: The Health Department will continue to follow the established procedures and reporting requirements for a non-Federal entity to ensure we comply with the monthly status report requirements by the 10th of the month we are reporting on. We will have our reporting calendar and grant requirements document updated by no later than Friday, April 28, 2023.

View Audit 56502

Finding 60920 (2022-004)

Material Weakness 2022

Lake Region Special Education

ND

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.318 § 200.326

Finding 2022-004 Finding Summary: Procurement, Suspension, and Debarment Material Weakness in Internal Control over Compliance During the course of the engagement, Eide Bailly identified that the District did not have a procurement policy in compliance with Uniform Guidance. Responsible Individ...

Finding 2022-004 Finding Summary: Procurement, Suspension, and Debarment Material Weakness in Internal Control over Compliance During the course of the engagement, Eide Bailly identified that the District did not have a procurement policy in compliance with Uniform Guidance. Responsible Individuals: Rhandi Knutson, Director Corrective Action Plan: A procurement policy in compliance with Uniform Guidance will be approved and implemented. Anticipated Completion Date: June 30, 2023

View Audit 49382

Finding 60850 (2022-001)

Significant Deficiency 2022

Wesley at Millington, Inc.

TN

Subrecipient Monitoring HUD Housing Programs

Statement of condition #2022-001 (Assistance Listing #14.157): At June 30, 2022, deposits to the reserve for replacements account of $150 were not made. Recommendation: Management should transfer $150 from the operating account to the reserve for replacements account. Action(s) taken or planned on t...

Statement of condition #2022-001 (Assistance Listing #14.157): At June 30, 2022, deposits to the reserve for replacements account of $150 were not made. Recommendation: Management should transfer $150 from the operating account to the reserve for replacements account. Action(s) taken or planned on the finding: The Project transferred $150 on September 21, 2022 to the reserve for replacements account. Completion date: September 21, 2022

View Audit 54055

Finding 60848 (2022-001)

Material Weakness 2022

Alternatives to Hunger

WA

Subrecipient Monitoring Eligibility Material Weakness

Finding 2022-001 ? Eligibility ? Material Weakness in Internal Controls Over Compliance and Material Non-Compliance Condition and Context: As part of our testing of eligibility, using a random number generator, we selected 25 days the Organization was open for food distribution during the year ende...

Finding 2022-001 ? Eligibility ? Material Weakness in Internal Controls Over Compliance and Material Non-Compliance Condition and Context: As part of our testing of eligibility, using a random number generator, we selected 25 days the Organization was open for food distribution during the year ended December 31, 2022. Out of the 25 days tested, the Organization did not follow intake guidelines for required eligibility and data collection prescribed by the Washington State Department of Agriculture for 12 different days. Planned Corrective Action: The organization implemented procedures to collect client intake data for one of the programs identified in testing and expects to continue making progress on the remaining program during 2023 and 2024. Responsible Division/Office and Individual: Mike Cohen, Executive Director Estimated Completion Date: 12/31/2024

View Audit 50250

Finding 60845 (2022-002)

Material Weakness 2022

New Hampton Community School District

IA

Internal Control / Segregation of Duties

The District will investigate ways to further segregate duties with the limited staff of the District.

View Audit 49356

Finding 60776 (2022-003)

Significant Deficiency 2022

Port Washington Saukville School District

WI

Procurement, Suspension & Debarment § 200.214

2022-003 Child Nutrition Cluster ? Assistance Listing No. 10.553 and 10.555 Recommendation: We recommend the District design controls to ensure an adequate documentation of control and review of potential contractors to determine they are not suspended or debarred is retained for all applicable vend...

2022-003 Child Nutrition Cluster ? Assistance Listing No. 10.553 and 10.555 Recommendation: We recommend the District design controls to ensure an adequate documentation of control and review of potential contractors to determine they are not suspended or debarred is retained for all applicable vendor relationships. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will review vendor suspension and debarement evaluation policies and purchasing policies and implement polices and controls to ensure that District policies and controls comply with Uniform Guidance requirements. Name(s) of the contact person(s) responsible for corrective action: Mel Nettesheim Planned completion date for corrective action plan: June 30, 2023

View Audit 52248

Finding 60775 (2022-002)

Material Weakness 2022

Port Washington Saukville School District

WI

Procurement, Suspension & Debarment § 200.318

2022-002 Child Nutrition Cluster ? Assistance Listing No. 10.553 and 10.555 Recommendation: It is recommend the District should review and update as necessary the procurement policies to ensure they fully comply with Uniform Guidance and any other applicable requirements. The District should design...

2022-002 Child Nutrition Cluster ? Assistance Listing No. 10.553 and 10.555 Recommendation: It is recommend the District should review and update as necessary the procurement policies to ensure they fully comply with Uniform Guidance and any other applicable requirements. The District should design and implement control process to ensure grant transactions comply with Uniform Guidance requirements and proper documentation is maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will review procurement and purchasing policies and implement polices and controls to ensure that District policies and controls comply with Uniform Guidance requirements. Name(s) of the contact person(s) responsible for corrective action: Mel Nettesheim Planned completion date for corrective action plan: June 30, 2023

View Audit 52248

Finding 60766 (2022-001)

Material Weakness 2022

Nationwide Children's Hospital

OH

Procurement, Suspension & Debarment § 200.214 § 200.303

Finding 2022-001 Grantor: Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Pass-through Grantor Pass-Through Award Number Pass-through Award Period None None None Award Year: Fiscal year 2022 1/1/2022 ? 12/31/2022 Award Number: None Ma...

Finding 2022-001 Grantor: Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Pass-through Grantor Pass-Through Award Number Pass-through Award Period None None None Award Year: Fiscal year 2022 1/1/2022 ? 12/31/2022 Award Number: None Management agrees with the recommendation. Management will implement the following changes to Time and Effort practices. Corrective Action Plan and Anticipate Completion Date Management agrees with the recommendation. ? Review suspension and debarment? Management will review the monthly third-party vendor screening results. Management will retain documentation of the review and supporting documents used in the review. ? Reconciliation ? Management will implement a process to reconcile the number of vendor files sent to the third-party screening vendor with the number screened. Management will memorialize this reconciliation. ? Accuracy ? Management will implement a process to verify the accuracy of the results produced by the third-party vendor. Management will memorialize this review. Responsible Person: Kathleen Dunn, JD ? VP and Chief Compliance Officer Effective Date: October 1, 2023 Management?s corrective action plan includes: ? Initial screening ? Management will implement a process to ensure that supporting documentation of the initial screening process is maintained. Responsible Person: Mary Beth Colatruglio, CPA ? Director of Accounting Effective Date: October 1, 2023

View Audit 54476

Finding 60743 (2022-003)

Material Weakness 2022

Nationwide Children's Hospital

OH

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

Finding 2022-003 Grantor: Department of Agriculture and Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Title: Schedule of Expenditures of Federal Awards Award Year: Fiscal year 2021 1/1/2022 ? 12/31/2022 Award Number: Various Management...

Finding 2022-003 Grantor: Department of Agriculture and Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Title: Schedule of Expenditures of Federal Awards Award Year: Fiscal year 2021 1/1/2022 ? 12/31/2022 Award Number: Various Management agrees with the recommendation. Management will implement the following changes to the management of the Schedule of Expenditures. Corrective Action Plan and Anticipate Completion Date Management?s corrective action plan includes: ? Review and validate that grants are listed under the correct cluster. Responsible Person: Aaron Ufferman, Director, Sponsored Projects, Natasha Collins, Director of Research Accounting Completion Date: December 31, 2023

View Audit 54476

Corrective Action Plans

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