Corrective Action Plans

Finding 555214 (2024-001)

Significant Deficiency 2024

Spartanburg County First Steps to School Readiness Partnership

SC

Reporting Significant Deficiency

Spartanburg County First Steps (SCFS) management acknowledges its responsibility for complying with all applicable state and federal reporting requirements. SCFS maintains a comprehensive fiscal policies and procedures manual that outlines the responsibilities and processes necessary to ensure compl...

Spartanburg County First Steps (SCFS) management acknowledges its responsibility for complying with all applicable state and federal reporting requirements. SCFS maintains a comprehensive fiscal policies and procedures manual that outlines the responsibilities and processes necessary to ensure compliance with all reporting obligations. The late submission of certain federal reports for the 2023-2024 program year was primarily due to challenges associated with the agency's financial management system, Blackbaud. Specifically, the system generated extended wait times for necessary reports, significantly impacting the agency's ability to meet required deadlines. Over the past six months, SCFS has conducted an extensive evaluation of the Blackbaud system and determined that it does not adequately meet the operational needs of SC First Steps offices across the state. As a result, an emergency procurement process has been initiated to procure a new financial management system that will better support timely and accurate reporting. Spartanburg County First Steps is committed to ensuring all future state and federal reporting requirements are completed and submitted accurately and within required deadlines.

View Audit 353836

Finding 555213 (2024-001)

None 2024

Heritage Towers of the Christian Church (disciples of Christ)

WY

Management agrees with finding. The security deposit deficiency will be funded in the amount of $1,195. Management will ensure that the security deposits are properly funded in the future.

View Audit 353834

Finding 555211 (2024-001)

Significant Deficiency 2024

Housing Authority of the Township of Neptune

NJ

Questioned Costs Procurement, Suspension & Debarment

Views of responsible officials and planned corrective action: Management agrees with the Auditor's finding and will implement the required safeguards to ensure that the Authority follows its approved Procurement Policy to remedy the aforementioned deficiencies. Bart Cook, Executive Director, is resp...

Views of responsible officials and planned corrective action: Management agrees with the Auditor's finding and will implement the required safeguards to ensure that the Authority follows its approved Procurement Policy to remedy the aforementioned deficiencies. Bart Cook, Executive Director, is responsible for implementing this corrective action by September 30, 2025.

View Audit 353830 Questioned Costs: $1

Finding 555210 (2024-002)

Significant Deficiency 2024

Housing Authority of the Township of Neptune

NJ

Allowable Costs / Cost Principles HUD Housing Programs § 200.438

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing and Section 8 Vouchers Programs to ensure that established internal control policies are being followed on a t...

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing and Section 8 Vouchers Programs to ensure that established internal control policies are being followed on a timely basis. Bart Cook, Executive Director, is responsible for implementing this corrective action by September 30, 2025.

View Audit 353830

Finding 555208 (2024-005)

Significant Deficiency 2024

Marlboro County School District

SC

Equipment & Real Property Management

The District Administration has met and agrees with the above listed finding. This finding pertains to activities that occurred before the current CFO joined the District. Moving forward, the District is committed to strengthening internal controls to prevent future omissions related to Equipment an...

The District Administration has met and agrees with the above listed finding. This finding pertains to activities that occurred before the current CFO joined the District. Moving forward, the District is committed to strengthening internal controls to prevent future omissions related to Equipment and Real Property Management.

View Audit 353829

Finding 555207 (2024-001)

None 2024

Beloit Assisted Living, Inc. Hud #075-Ee099-Wah

WI

HUD Housing Programs

Beloit Assisted Living, Inc. submits the following corrective action plans for the identified finding for the audit period January 1, 2024, through December 31, 2024. Finding 2024-001: Reserve for Replacement Required Deposits Corrective Action Plan: 1. Community Action Inc, of Rock and Walworth Cou...

Beloit Assisted Living, Inc. submits the following corrective action plans for the identified finding for the audit period January 1, 2024, through December 31, 2024. Finding 2024-001: Reserve for Replacement Required Deposits Corrective Action Plan: 1. Community Action Inc, of Rock and Walworth Counties (CAI), contracts with Wisconsin Management Company Inc. (WiMCI) to provide property management services to CAI for Beloit Assisted Living Inc. 2. CAI conducts monthly meetings with WiMCI to review tenancy, financial performance and facility management. To address the Finding identified by WIPFLI, CAI will receive a monthly written confirmation from WMCI that the monthly Reserve for Replacement Deposits required by the U. S. Department of Housing and Urban Development (HUD) are made as required. 3. If WMCI anticipates that they are not able to make the deposit, CAI will be notified a minimum of 15 days prior to work with WIMCI to identify other payment options. Person(s) Responsible: Russ Enders, CEO, Wisconsin Management Company Inc. Marc Perry, Executive Director, Community Action Inc. of Rock and Walworth Counties. Timing for Implementation: Monthly meetings are currently scheduled for the 4th Monday of each month at 9:00 AM. The meeting schedule will remain with the addition of the monthly update regarding the deposit to the reserve.

View Audit 353826

Finding 555196 (2024-002)

Significant Deficiency 2024

Gratz College

PA

Special Tests & Provisions Subrecipient Monitoring Cash Management

Finding 2024-002 Corrective Action Plan The College reassigned the duties within its business office to ensure remittances to students or parent borrowers of credit balances are executed in accordance with the timeline mandated by the U.S. Department of Education. Gratz College notes that this was ...

Finding 2024-002 Corrective Action Plan The College reassigned the duties within its business office to ensure remittances to students or parent borrowers of credit balances are executed in accordance with the timeline mandated by the U.S. Department of Education. Gratz College notes that this was the only instance of noncompliance and resulted from turnover in Gratz College’s business office staff. Anticipated Completion Date The corrective action plan was completed June 1, 2024 Names of Contact People Responsible for Corrective Action Thomas R. Cipriano, Jr. – Manager of Business Operations and Facilities Ross Holgado – Manager of Financial Reporting Karen West – Senior Accounting Associate and Coordinator of Student Billing

View Audit 353822

Finding 555195 (2024-001)

Significant Deficiency 2024

Feeding San Diego

CA

Reporting

Condition During our audit, CBIZ noted that the Organization did not have adequate internal controls surrounding reception of food boxes, or backpacks provided as some selections did not contain recipient and driver signatures. Views of Responsible Officials: Management agrees with the finding and...

Condition During our audit, CBIZ noted that the Organization did not have adequate internal controls surrounding reception of food boxes, or backpacks provided as some selections did not contain recipient and driver signatures. Views of Responsible Officials: Management agrees with the finding and observation. Contact Person: Fendy Wogu, Finance Controller Proposed Completion Date: February 7, 2025

View Audit 353821

Finding 555193 (2024-001)

Material Weakness 2024

The Guidance Center, Inc.

AZ

Reporting Material Weakness

Item: 2024-001 Assitance Listing Number: 93.959 Programs: Block Grants for Substance Abuse Prevention, Treatment and Recovery Services Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: Care 1st Compliance Reqauirements: Reporting Criteria of Specific Requireme...

Item: 2024-001 Assitance Listing Number: 93.959 Programs: Block Grants for Substance Abuse Prevention, Treatment and Recovery Services Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: Care 1st Compliance Reqauirements: Reporting Criteria of Specific Requirement: In accordance with the grant agreement, the Organization is required to submit quarterly reports during the grant period which include qualifying costs incurred under the grant award. Condition: A required quarterly report submitted to the granting agency included inaccurate reporting of the qualifying expenditures. Additionally, for all four quarterly reports there was no evidence of management review or approval of the reports prior to submission to the funder. Name of Contact Person: Michael Kuzmin, Chief Financial Officer Phone Number: (928) 714-6478 Anticipated Completion Date: March 31, 2025 Views of Responsible Officials and Corrective Action: Management agrees with the finding and will implement additional controls to ensure expense information included in the quarterly reports in reviewed and approved prior to submission. Management will ensure this additional process includes clearly documenting the review and approval.

View Audit 353812

Finding 555192 (2024-001)

Significant Deficiency 2024

City of Fairburn, Georgia

GA

Procurement, Suspension & Debarment

The City will ensure all contactors of federal funds are not suspended or debarred in accordance with federal guidelines, including adding a clause to federal contracts. The City will also follow its procurement policy and ensure all contractor have a proper procurement.

View Audit 353803

Finding 555189 (2024-001)

Significant Deficiency 2024

Aletheia House

AL

Internal Control / Segregation of Duties

This deficiency was identified in the FY 2023 audit. Aletheia House addressed this deficiency beginning in January 2024 when it converted to a new payroll system (UKG) that includes timesheet processeing and will allow for supervisors' electronic approval of all nonexempt employee timesheets. In add...

This deficiency was identified in the FY 2023 audit. Aletheia House addressed this deficiency beginning in January 2024 when it converted to a new payroll system (UKG) that includes timesheet processeing and will allow for supervisors' electronic approval of all nonexempt employee timesheets. In addition, Aletheia House has strengthened its payroll procedures to ensure that at the end of each pay period before payroll is processed, managers and supervisors will review all nonexempt employees and approve hours worked for the period. The payroll department review all timesheets to ensure all have supervisor's approval. No employee's payroll will be processed until an approved timesheet for the respective pay period has been entered into the UKG system. This process will receive regular review by the Chief Financial Officer for quality assurance.

View Audit 353802

Finding 555184 (2024-001)

Material Weakness 2024

Holy Cross Services, Inc.

MI

Questioned Costs Procurement, Suspension & Debarment § 200.320

HCS currently has in place policy 2095-Procurement Standards, which requires obtaining 3 quotes for goods and services above $5000. This policy was not followed by the agency's leadership when the goods and services mentioned in this finding were procured, despite counsel recommending that it be fol...

HCS currently has in place policy 2095-Procurement Standards, which requires obtaining 3 quotes for goods and services above $5000. This policy was not followed by the agency's leadership when the goods and services mentioned in this finding were procured, despite counsel recommending that it be followed. Corrective action included termination of the individual who violated policy. Beginning on 11/15/2024, the above-referenced policy has been, and will continue to be, adhered to.

View Audit 353794 Questioned Costs: $1

Finding 555178 (2024-002)

Significant Deficiency 2024

Housing Authority of Somerset County

PA

Subrecipient Monitoring HUD Housing Programs Internal Control / Segregation of Duties

The Housing Authority of Somerset County disagrees with the second finding as per 2 CFR 200.511 part (c) as for the rent amount on the 50058 not matching the monthly rent amount. The reason that the Housing Authority disagrees and didn't put an action plan in place for this finding is because each f...

The Housing Authority of Somerset County disagrees with the second finding as per 2 CFR 200.511 part (c) as for the rent amount on the 50058 not matching the monthly rent amount. The reason that the Housing Authority disagrees and didn't put an action plan in place for this finding is because each file with the discrepancy had a more recent 50058 in the file which reflected the correct monthly rent amount.

View Audit 353786

Finding 555177 (2024-003)

None 2024

Mary Baldwin University

VA

2024-003 – Lack of Timely Filing of Data Collection Form to the Federal Audit Clearinghouse Department of Education, SFA Cluster; Compliance Requirement Affected Condition: The University did not file the Data Collection Form for fiscal year 2023-2024 to the Federal Audit Clearinghouse within the re...

2024-003 – Lack of Timely Filing of Data Collection Form to the Federal Audit Clearinghouse Department of Education, SFA Cluster; Compliance Requirement Affected Condition: The University did not file the Data Collection Form for fiscal year 2023-2024 to the Federal Audit Clearinghouse within the required timeline. Criteria: A Single Audit requires the submission of the Data Collection Form to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of an auditor’s report, or nine months after the end of the audit period, unless a different period is specified in a program-specific audit guide. Cause: Staff turnover contributed to the late filing. Effect: The University did not complete their required submission to the Federal Audit Clearinghouse by the deadline of March 31, 2025. Repeat Finding: No. Recommendation: We recommend that the University put procedures in place to ensure timely filing of the Data Collection Form. Management Response: The University has modified its year-end audit procedures to ensure timely filing of the Data Collection Form going forward. If the Federal Audit Clearinghouse has questions regarding this plan, please call Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer at (540) 887-7285. Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer, Mary Baldwin University, 540-887-7285

View Audit 353780

Finding 555176 (2024-002)

Significant Deficiency 2024

Mary Baldwin University

VA

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

2024-002 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster; Compliance Requirement Affected – Special Tests and Provisions Condition: The University did not report student enrollment data to the National Student Clearinghouse accurately and within minimum required ...

2024-002 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster; Compliance Requirement Affected – Special Tests and Provisions Condition: The University did not report student enrollment data to the National Student Clearinghouse accurately and within minimum required timeframe. Criteria: Based on requirements set forth by 34 CFR 685.309(b)(2), the University is responsible for notifying the National Student Loan Data System (NSLDS) to changes to student’s enrollment data within minimum required timeframes. Cause: The University does not have adequate procedures in place to ensure changes in students’ enrollment statuses are identified and reported in a timely manner. Effect: Enrollment data was not reported timely or accurately to the Department of Education thus, the Department could not properly service the student’s loans. The accuracy of Title IV student loan records depends heavily on the accuracy of the enrollment information reported by institutions. Context: A sample of nine official and unofficial student withdrawals was selected for audit from a population of 63. The test found three student withdrawals that were not in compliance with timely enrollment reporting in NSLDS, the enrollment status for one student was not updated after the student was no longer enrolled on at least a half-time basis, and one student’s enrollment status date reported to NSLDS did not agree to date of withdraw reported on the R2T4 form. Repeat Finding: No. Recommendation: We recommend that the University put procedures in place to ensure that student enrollment statuses are updated in a timely manner. Management Response: The University has modified its withdrawal procedures and instructions related to the requirements set forth by 34 CFR 685.309(b)(2). Related to the findings above, due to staffing turnover, the appropriate test of controls needed to identify changes in a student’s enrollment status was not run in a timely manner. Going forward, the University has informed related staff that the aforementioned test of controls needs to be run at the end of each semester, and upon completion, staff must notify the NSLDS within the required timeframe. If the Federal Audit Clearinghouse has questions regarding this plan, please call Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer at (540) 887-7285. Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer, Mary Baldwin University, 540-887-7285

View Audit 353780

Finding 555175 (2024-001)

Significant Deficiency 2024

Mary Baldwin University

VA

Special Tests & Provisions Student Financial Aid Reporting

2024-001 – Return of Title IV Funds (Significant Deficiency)Department of Education, SFA Cluster; Compliance Requirement Affected – Special Tests and Provisions Condition: Return of Title IV funds occurred untimely for three students, exceeding 45 days as required, when considering the University’s ...

2024-001 – Return of Title IV Funds (Significant Deficiency)Department of Education, SFA Cluster; Compliance Requirement Affected – Special Tests and Provisions Condition: Return of Title IV funds occurred untimely for three students, exceeding 45 days as required, when considering the University’s date of determination as reported on R2T4 forms. Criteria: Returns of Title IV funds are required to be deposited or transferred into the SFA account or electronic funds transfers initiated to the Department of Education as soon as possible, but no later than 45 days after the date the institution determines that the student withdrew in accordance with 34 CFR 668.173(b). Cause: The University does not have adequate procedures in place to ensure students’ Title IV funds are returned timely. R2T4 forms improperly reported the date of determination the same as the student withdraw date. Effect: The University failed to return Title IV funds to the Department of Education within 45 days of the students’ date of determination as reported on the R2T4 forms. Context: A sample of nine official and unofficial student withdrawals was selected for audit from a population of 63. The test found three student withdrawals that were not in compliance with timely return of funds. Repeat Finding: No. Recommendation: We recommend that the University implement procedures to ensure that R2T4 forms are filed timely and properly reflect the University’s date of determination for all student withdrawals. Management Response: The University concedes that the R2T4 forms improperly reported the date of determination as the same date reported for the student’s date of withdrawal and the University has modified its withdrawal procedures and processes to reflect separate dates when necessary for date of determination and date of withdrawal. Instructions related to R2T4 requirements and timeliness of return of funds will be triggered from the appropriate date of determination. Related to the findings above, the University failed to accurately report the date of determination on R2T4 documentation, causing the return of funds to be out of the window for timely return. Although the funds were returned in a timely manner, the recordkeeping of the determination date was not documented properly. The University has since clarified for staff the importance of this documentation and change in process. Additionally, the university has identified the appropriate test of controls needed to accurately identify the student withdrawal date. This test of controls will be run at the end of each semester, and upon completion, the date the report is run will be used as the correct date of determination. If the Federal Audit Clearinghouse has questions regarding this plan, please call Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer at (540) 887-7285. Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer, Mary Baldwin University, 540-887-7285

View Audit 353780

Finding 555174 (2024-005)

Material Weakness 2024

Miami Children's Health System, Inc. D/b/a Nicklaus Children's Health

FL

Questioned Costs Cash Management § 200.1

Identifying Number: 2024-005 Finding: Material Weakness: Cash Management Context: Drawdown on reimbursement requests were submitted to the grantor prior to the System incurring qualifying expenditures. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Mana...

Identifying Number: 2024-005 Finding: Material Weakness: Cash Management Context: Drawdown on reimbursement requests were submitted to the grantor prior to the System incurring qualifying expenditures. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Implementing organizational changes such as updated policies and/or procedures b. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices during the Grant management process c. Oversight of drawdwn requests by the Director of Sponsored Programs to ensure accuracy of request Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. - Oversight of all drawdown requests, ensring complete and accurate supporting documentation. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limited to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequently. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.

View Audit 353775 Questioned Costs: $1

Finding 555173 (2024-004)

Material Weakness 2024

Miami Children's Health System, Inc. D/b/a Nicklaus Children's Health

FL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Identifying Number: 2024-004 Finding: Material Weakness: Period of Performance Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were incurred prior to the budget period start date. Corrective Actions Taken or Planned: The Director ...

Identifying Number: 2024-004 Finding: Material Weakness: Period of Performance Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were incurred prior to the budget period start date. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Implementing organizational changes such as updated policies and/or procedures b. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices during the Grant management process c. Oversight of drawdown requests by the Director of Sponsored Programs to ensure accuracy of request Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. - Oversight of all drawdown requests, ensuring complete and accurate supporting documentation. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limted to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequently. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.

View Audit 353775 Questioned Costs: $1

Finding 555172 (2024-003)

None 2024

Miami Children's Health System, Inc. D/b/a Nicklaus Children's Health

FL

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

Identifying Number: 2024-003 Finding: Reporting Context: An incorrect progress report was submitted to the grantor. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-...

Identifying Number: 2024-003 Finding: Reporting Context: An incorrect progress report was submitted to the grantor. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Implementing organizational cjanges such as updated policies and/or procedures b. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices during the Grant management process c. Oversight of drawdown requests by the Director of Sponsored Programs to ensure accuracy of request Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. - Oversight of all drawdown requests, ensuring complete and accurate supporting documentation. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limited to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequesntly. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.

View Audit 353775

Finding 555171 (2024-002)

Material Weakness 2024

Miami Children's Health System, Inc. D/b/a Nicklaus Children's Health

FL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Identifying Number: 2024-002 Finding: Material Weakness: Allowable Costs/Cost Principles Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were not incurred until 2025. Corrective Actions Taken or Planned: The Director of the Office...

Identifying Number: 2024-002 Finding: Material Weakness: Allowable Costs/Cost Principles Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were not incurred until 2025. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Correcting the gaps between invoicing processes and collecting the Departments/AP proof of payment b. Returning overpayments, if applicable c. Implementing organizational changes such as updated policies and/or procedures d. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices duing the Grant management processes. Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Create processes in which we will adopt verification procedures for invoices and collections. - Create/update Standard Operating Procedures (SOPs) - Provide our team with updated training material (working practice guidelines - WPGs), so they have clear expectations and understand our compliance mechanism. - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limited to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequently. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.

View Audit 353775 Questioned Costs: $1

Finding 555170 (2024-001)

None 2024

Miami Children's Health System, Inc. D/b/a Nicklaus Children's Health

FL

Questioned Costs Allowable Costs / Cost Principles

Identifying Number: 2024-001 Finding: Allowable Costs/Cost Principles Context: The System received funding that was not net of appliccable credits. The funding received from the grantor was the full invoice amount, howver, the actual expenditure was net of applicable credits ($6,945). Corrective Act...

Identifying Number: 2024-001 Finding: Allowable Costs/Cost Principles Context: The System received funding that was not net of appliccable credits. The funding received from the grantor was the full invoice amount, howver, the actual expenditure was net of applicable credits ($6,945). Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Correcting the gaps between invoicing processes and collecting the Departments/AP proof of payment b. Returning overpayments, if applicable c. Implementing organizational changes such as updated policies and/or procedures d. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices during the Grant management process Planning Process Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Processes in which we will adopt verification procedures for invoices and collections. - Create/update Standard Operating Procedures (SOPs). - Provide our team with updated training material (working pratice guidelines -WPGs), so they have clear expectations and understand our compliance mechanism. - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limited to): - Retrain on updated policies and procedures (OSP tean, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implemeting new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processes more frequently. Deadline for Implementation: Immediate action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs). Checklists and training/retraining sessions for stakeholders and OSP team members.

View Audit 353775 Questioned Costs: $1

Finding 555169 (2024-001)

Significant Deficiency 2024

Central Indiana Corporate Partnership, Inc.

IN

Procurement, Suspension & Debarment § 200.303

FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2024-001 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Significant Deficiency in Internal Control Over Compliance – Appropriate Internal Control Structure Related to Compliance Requirements I. Procurement ...

FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2024-001 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Significant Deficiency in Internal Control Over Compliance – Appropriate Internal Control Structure Related to Compliance Requirements I. Procurement and Suspension and Debarment Recommendation: The auditor recommends the procurement checklist be completed in line with our written policies. Action Taken: We agree with the recommendation and it was implemented effective 2/14/2025.

View Audit 353772

Finding 555168 (2024-002)

Material Weakness 2024

Movement Strategy Center

CA

Procurement, Suspension & Debarment § 200.318 § 200.319 § 200.320

Audit Finding Summary: 2024-002 The Organization did not establish or follow sufficient internal controls to ensure compliance with federal procurement requirements, including maintaining the required documentation for procurement activities. Corrective Action Plan: Contact Person Responsible for C...

Audit Finding Summary: 2024-002 The Organization did not establish or follow sufficient internal controls to ensure compliance with federal procurement requirements, including maintaining the required documentation for procurement activities. Corrective Action Plan: Contact Person Responsible for Corrective Action: Wendi Gephart, Federal Contracts and Grants Compliance Manager wendi@movementstrategy.org | (510) 956-3849 Planned Action: MSC recognizes the need for improved procurement documentation and internal controls. To strengthen compliance with 2 CFR 200.318-326, MSC will take the following actions. Revised Procurement Policies: MSC is updating its procurement policies and procedures to reinforce adherence to federal regulations, ensuring full and open competition in all procurement transactions. Enhanced Documentation and Record-Keeping: A comprehensive process will be established to maintain detailed procurement records, including justification for vendor selection, contract pricing, and competitive bidding results. This will ensure transparency and compliance with federal requirements. Staff Training in Federal Procurement Standards: MSC will provide training to staff on procurement regulations, including conflict-of-interest policies, documentation requirements, and competitive bidding procedures. Periodic Compliance Review: Internal review will be conducted periodically to verify compliance with procurement policies and federal regulations. MSC remains committed to continuous improvement in financial and compliance practices to uphold the integrity of its federally funded programs. Expected Completion Date: June 30, 2025

View Audit 353769

Finding 555167 (2024-001)

Material Weakness 2024

Movement Strategy Center

CA

Questioned Costs Allowable Costs / Cost Principles § 200.430

FINDINGS – Single Audit Audit Finding Summary: 2024-001 The organization failed to implement adequate internal controls to ensure compliance with federal timekeeping and documentation requirements for personnel expenses. Additionally, there appears to be a lack of understanding of the documentation...

FINDINGS – Single Audit Audit Finding Summary: 2024-001 The organization failed to implement adequate internal controls to ensure compliance with federal timekeeping and documentation requirements for personnel expenses. Additionally, there appears to be a lack of understanding of the documentation and certification requirements under 2 CFR Part 200, Subpart E. Corrective Action Plan: Contact Person Responsible for Corrective Action: Marilyn Lovelace-Grant, Chief People and Culture Officer marilyn@movementstrategy.org | (510) 414-2674 Planned Action: MSC acknowledges the importance of accurate time and effort reporting in accordance with 2 CFR 200.430. To address the identified deficiencies, we will implement the following corrective measures. Policy and Procedure Enhancement: MSC is developing and implementing updated policies to ensure compliance with federal grant requirements. Employees who charge 100% of their time to a federal grant will be required to submit semi-annual certifications, while those working across multiple activities will maintain detailed time and effort reports aligned with federal guidelines. Improved Documentation and Controls: A standardized timekeeping and certification system will be enforced, requiring supervisory review and approval for all-time records. This will ensure that all reported work is properly documented and verified. Training and Compliance Monitoring: MSC will provide training for employees and supervisors to enhance their understanding of federal grant timekeeping and documentation requirements. Regular Internal Reviews: A periodic internal review process will be established to verify the accuracy and completeness of timekeeping records and ensure compliance with federal regulations. Resolution of Questioned Costs: MSC will work directly with the federal awarding agency to resolve the identified $50,000 in questioned costs and implement any additional corrective actions deemed necessary Expected Completion Date: September 30, 2025

View Audit 353769 Questioned Costs: $1

Finding 555144 (2024-004)

Material Weakness 2024

Grape Community Hospital, Inc. D/b/a George C. Grape Community Hospital

IA

Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking § 200.303

Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing: #10.766 Compliance Requirement: Special Tests and Provisions Criteria: The Hospital must establish and maintain effective internal control over federal a...

Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing: #10.766 Compliance Requirement: Special Tests and Provisions Criteria: The Hospital must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Hospital is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with program requirements. Terms and conditions of the federal award require the Hospital to maintain a debt service reserve fund as bookkeeping accounts or as separate bank accounts. Condition: Funds that represented the debt service reserve fund were commingled with an existing operating cash account. Planned Corrective Action: Management agrees with the funding and will deposit the required debt service reserve funds in either a separate bank account or general ledger account. Planned Completion Date: September 30, 2025 Person Responsible: Doug Brandt, Chief Financial Officer

View Audit 353739

Corrective Action Plans

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