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2024-004 Program: Foster Care Title IV-E Federal Financial Assistance Listing Number: 93.658 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Social Services Award No. and Year: 2401CAFOST and 2024, 2301CAFOST and 2023 Compliance Requirements: Subr...
2024-004 Program: Foster Care Title IV-E Federal Financial Assistance Listing Number: 93.658 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Social Services Award No. and Year: 2401CAFOST and 2024, 2301CAFOST and 2023 Compliance Requirements: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance Criteria: In accordance with Title 2 U.S. Code of Federal Regulations (CFR) 200.332, pass-through entities must comply with the following: • 2 CFR 200.332(b) – Evaluate each subrecipient’s risk of noncompliance for purposes of determining the appropriate subrecipient monitoring related to the subaward. This evaluation of risk may include consideration of such factors listed in 2 CFR 200.332(b)(1) through (4). • 2 CFR 200.332(d)- Monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward; and that subaward performance goals are achieved. Pass-through entity monitoring of the subrecipient must include the information at 2 CFR 200.332(d)(1) through (4). The California Department of Social Services further clarifies in its County Fiscal Letter No. 23/24-80 that Foster Family Agency (FFA), Group Home, and Short Term Residential Therapeutic Programs (STRTP) are “considered subrecipients and subject to the same audit requirements and require the same degree of oversight as other subrecipients”. Further, while there are some licensing and oversight functions performed by the state over FFAs, group homes, and STRTPs, “counties are still ultimately responsible for review of these audits and their findings, any follow-up to ensure compliance, and any other form of monitoring and oversight required by federal and state laws and regulations.” 2 CFR Section 180.300a, Responsibilities of Participants Regarding Doing Business with Other Persons (and repeated in the California Department of Social Services - County Fiscal Letter No. 21/22 – 115) counties are required to verify that recipients or contracts have not been suspended or debarred by using the federal SAM (Systems for Award Management) Condition: The Social Services Agency (SSA) did not maintain documentation that the subrecipient risk assessment or the monitoring activity tracker was reviewed. Cause: The SSA department did not document its review of the subrecipient risk assessment or the monitoring activity tracker. Effect: The County’s control policies were not consistently followed and documented. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A nonstatistical sample of twelve (12) out of fifty-eight (58) subrecipients were sampled, which included seven (7) Foster Family Agency, four (4) Short Term Residential Therapeutic Programs, and one (1) Transitional Housing Placement-Plus Foster Care types. The condition noted above was identified during our procedures related to subrecipient monitoring and was pervasive to the program. Repeat Findings from Prior Years: Yes, Finding 2023-001. Recommendation: We recommend that the County ensure the review over subrecipient monitoring activity is appropriately documented. Management Response and Corrective Action: 1. Person Responsible: Karen Vu, Procurement Contract Manager, Senior 2. Corrective Action Plan: An activity tracker spreadsheet (check list) was developed and implemented in September 2023 to ensure timely completion of subrecipient monitoring activities. The check list is not a requirement of 2 CFR 200.332, the checklist and risk assessment form were shared with the Auditors during prior year's Single Audit, and the auditors did not raise any concerns related to either during the audit. The subrecipient risk assessment and the monitoring activity tracker is reviewed by supervisors; however, review was not documented. We will accept the auditor’s recommendation and add a signature line to the risk assessment and activity tracker to document review by a supervisor. 3. Anticipated Implementation Date: April 2025
2024-014 Program: Refugee and Entrant Assistance State/Replacement Designee Administered Programs Federal Financial Assistance Listing Number: 93.566 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: Various Compliance Requirements: Activities Allowed or Unallowed, Al...
2024-014 Program: Refugee and Entrant Assistance State/Replacement Designee Administered Programs Federal Financial Assistance Listing Number: 93.566 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: Various Compliance Requirements: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Eligibility Type of Finding: Material Deficiency in Internal Control Over Compliance and Material Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Per Title 45 Subtitle B Chapter IV Part 400 Subpart E Section 400.53, General Eligibility Requirement, states that eligibility for refugee cash assistance is limited to those who: (1) Are new arrivals who have resided in the U.S. less than the RCA eligibility period determined by the Office of Refugee Resettlement (ORR) Director in accordance with Section 400.211; (2) Are ineligible for TANF, SSI, OAA, AB, APTDD, and AABD programs; (3) Meet immigration status and identification requirements in Subpart D (Immigration Status and Identification of Refugees); (4) Are not full-time students in institutions of higher education, as defined by the ORR. Per Title 45 Subtitle B Chapter IV Part 400 Subpart E Section 400.66, Eligibility and payment levels in a publicly-administered RCA program, states that in administering a publicly-administered refugee cash assistance program, the agency must operate its refugee cash assistance program consistent with the provisions of its TANF program including the determination of initial and on-going eligibility. Condition: During our testing of the SSA’s compliance with eligibility and allowable cost/cost principles, we noted the following: For two (2) out of forty (40) cases selected for testing, the participants’ country of origin did not meet the general eligibility requirements of the program. For two (2) out of forty (40) cases selected for testing, participants received cash assistance outside of the eligibility period. For six (6) out of forty (40) cases selected for testing, the SSA did not retain the required documentation to evidence eligibility under the program. Cause: The SSA did not follow their policies to verify and withhold the information described in the condition and did not consistently ensure that participants were eligible. Effect: Benefits were provided to ineligible participants. Questioned Costs: Questioned costs for cases tested in which we determined to be ineligible to receive cash assistance or cases in which there was insufficient documentation to substantiate the eligibility determination was $7,578. Context/Sampling: A nonstatistical sample of forty (40) out of all active program participants were sampled. For ineligible or unsupported cases we have projected the amount of questioned costs against the remining population for a total of $460,581. The condition above was identified during our procedures over eligibility, activities allowed or unallowed, and allowable costs/cost principles testing. Repeat Finding: No Recommendation: We recommend that the SSA department strengthen its internal controls to ensure that program eligibility criteria are properly supported and retained in case files. Management Response and Corrective Action: 1. Person Responsible: Rosa Palacios, Human Services Manager 2. Corrective Action Plan: SSA will implement the following to enhance internal controls over compliance with eligibility: • Policy and Procedure Review & Update: Review and update existing policies and procedures to ensure clarity of eligibility criteria, including country of origin, eligibility period, and documentation retention requirements. These actions will provide clearer guidelines to prevent future eligibility issues and ensure proper documentation retention. Complete by April 2025. • Ongoing Monitoring & Compliance Review: Establish a dedicated team to perform monthly reviews of all approved cases, ensuring compliance with eligibility requirements. A monthly report will detail trends, non-compliance issues, and corrective actions results. With these actions, we will have continuous oversight and prompt corrective actions to maintain program integrity. Implement reviews by May 2025. • Mandatory Eligibility Checklist: Implement a mandatory eligibility checklist for all staff to confirm the required eligibility documents, system entries, and action notices at initial application and semi-annual reporting. These actions ensure staff consistently follow eligibility requirements and semi-annual reporting processes. Implement by May 2025. 3. Anticipated Implementation date: April 2025 and May 2025
View Audit 351824 Questioned Costs: $1
2024-015 Program: Medicaid Cluster, Foster Care Title IV-E, Temporary Assistance for Needy Families, Refugee and Entrant Assistance State/Replacement Designee Administered Programs Federal Financial Assistance Listing Number: 93.778, 93.658, 93.558, 93.566 Federal Grantor: U.S. Department of Health ...
2024-015 Program: Medicaid Cluster, Foster Care Title IV-E, Temporary Assistance for Needy Families, Refugee and Entrant Assistance State/Replacement Designee Administered Programs Federal Financial Assistance Listing Number: 93.778, 93.658, 93.558, 93.566 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: Various Compliance Requirements: Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 2 CFR Section 200.413(c)(1), Direct Costs, state that direct costs are those costs that can be identified specifically with a particular final cost objective, such as a Federal award, or other internally or externally funded activity, or that can be directly assigned to such activities relatively easily with a high degree of accuracy. Costs incurred for the same purpose in like circumstances must be treated consistently as direct or indirect costs. 2 CFR Section 200.416(b), Cost Allocation Plans and Indirect Cost Proposals, states that individual departments typically charge Federal awards for indirect costs through an indirect cost rate. A separate indirect cost rate proposal for each operating department is usually necessary to claim indirect costs under Federal awards. Indirect costs include (1) the indirect costs originating in each operating department of the State, local government, or Indian Tribe carrying out Federal awards; and (2) the costs of central governmental services distributed through the central service cost allocation plan and not otherwise treated as direct costs. Condition: During our testing of pooled costs claimed through County Expense Claims, we noted that one (1) of forty (40) transactions was not a department cost that should have been included in the pooled cost. This pooled allocation affected the following major programs of SSA: 93.778, 96.658, 93.558, and 93.566. Cause: A journal entry was posted to the SSA Department’s general ledger by another County Department without SSA’s review/approval for allowable activities. The other County department inaccurately posted unallowable costs to the SSA department’s general ledger and SSA did not follow their procedures to ensure allowable costs were properly reported as a cost that can be specifically assigned to activities of the major programs identified in the County’s expense claims. Effect: Unallowable costs were included in the direct cost pool to be further allocated to the federal funded major programs. Questioned Costs: Questioned costs identified amounted to $50,971. The allocation of questioned costs to the major programs tested were as follows: • Medicaid Cluster (93.558) - $16,329 • Foster Care Title IV-E (93.658) - $17,009 • Temporary Assistance for Needy Families (93.778) - $17,633 The allocation to the Refugee and Entrant Assistance State/Replacement Designee Programs (93.566) was of a trivial amount. Context/Sampling: A sample of forty (40) amounting to $10,365,065 out of all costs included in the indirect cost pool of the County expense claims were selected for testing. Repeat Finding from Prior Years: No. Recommendation: We recommend the SSA enhance its procedures to ensure that allocated pooled costs have direct benefit to the department’s various federally funded programs. Management Response and Corrective Action: 1. Person Responsible: Jackqueline Ly, Financial Services Fiscal Administrator 2. Corrective Action Plan: SSA will work with other county agency’s financial team to ensure all transactions affecting SSA's ledger are reviewed and posted correctly. Conduct a monthly reconciliation of cost pool to verify compliance with allowable cost principles and provide more regular trainings for staff involved in cost allocations and expense tracking/reporting. 3. Anticipated Implementation date: April 2025
View Audit 351824 Questioned Costs: $1
2024-013 Program: Epidemiology and Laboratory Capacity for Infectious Disease Federal Financial Assistance Listing Number: 93.323 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: Various Compliance Requirements: Equipment and Real Property Management Type of Finding:...
2024-013 Program: Epidemiology and Laboratory Capacity for Infectious Disease Federal Financial Assistance Listing Number: 93.323 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: Various Compliance Requirements: Equipment and Real Property Management Type of Finding: Material Weakness in Internal Control Over Compliance and Material Instance of Noncompliance Criteria: In accordance with 2 CFR section 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the Federal Award Identification Number), who holds title, the acquisition date, cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Condition: Property records were not maintained in accordance with Uniform Guidance for all property and equipment purchased. As a result, we were unable to (1) test whether there were any differences between the physical inventory and equipment records were resolved and (2) sample equipment from the property records and physically inspect the equipment and determine whether the equipment is appropriately safeguarded and maintained. Cause: The HCA department did not have adequate internal controls to ensure its property records included all the requirements under Uniform Guidance or properly identify all property and equipment purchased with federal funds. Effect: Property records were not adequately maintained. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: No sampling was used. We examined the department’s property records in total. Repeat Finding from Prior Years: No. Recommendation: We recommend the HCA department enhance internal controls to ensure its property records include all the requirements under Uniform Guidance and properly identify all property and equipment purchased with federal funds. Management Response and Corrective Action: 1. Person Responsible: Tommy Bui, HCA Property Officer 2. Corrective Action Plan: County of Orange has implemented a new Asset tracking system that has fields which allow departments to identify the funding source. HCA is currently migrating and cleansing data from a legacy asset solution to this new system, OpenGov. 3. Anticipated Implementation date: June 30, 2025
2024-012 Program: Epidemiology and Laboratory Capacity for Infectious Disease Federal Financial Assistance Listing Number: 93.323 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: Various Compliance Requirements: Procurement and Suspension and Debarment Type of Findin...
2024-012 Program: Epidemiology and Laboratory Capacity for Infectious Disease Federal Financial Assistance Listing Number: 93.323 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: Various Compliance Requirements: Procurement and Suspension and Debarment Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 2 CFR section Appendix II to Part 200, Contract Provisions for Non-Federal Entity Contracts Under Federal Awards states that in addition to other provisions required by the Federal agency or non-Federal entity, all contracts made by the non-Federal entity under the Federal award must contain certain provisions, as applicable. Condition: During our testing of the HCA’s compliance with procurement and suspension and debarment requirements, we noted for two (2) of four (4) samples tested the following information was not provided at the time of the contract award: • Clean Air Act and the Federal Water Pollution Control Act We noted that the tested vendors had been notified of these contract provisions via email. However, there was no certification or acknowledgement obtained from the vendors to accept the contract provisions. Cause: The HCA did not follow their policy to verify the information described in the condition prior to entering the transactions and did not consistently ensure that the applicable required provisions were communicated to contractors at the time the contract was entered into. Effect: The HCA department did not identify the applicable required provisions of the contract to the contractors at the time of the contract award. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A nonstatistical sample of four (4) of eleven (11) procurement contracts were sampled. The condition above was identified during our procedures over procurement and suspension and debarment. Repeat Finding from Prior Years: No. Recommendation: We recommend the HCA department modify and strengthen its current policies and procedures to ensure that all applicable required provisions are communicated to contracts in accordance with 2 CFR Appendix II to Part 200. Management Response and Corrective Action: 1. Person Responsible: Juan Corral, HCA Procurement & Contracts Division Manager 2. Corrective Action Plan: HCA will review all federally funded contracts to ensure all necessary federal provisions, including Clean Air Act and Federal Water Pollution Control Act are included. If they are not, HCA will issue contract amendments to cure this deficiency. HCA conducted an all-staff training regarding the federal audit requirements on March 20, 2025. 3. Anticipated Implementation date: June 30, 2025
2024-009 Program: Aging Cluster Federal Financial Assistance Listing Number: 93.041, 93.042, 93.043, 93.044, 93.045, 93.052, 93.053 Federal Grantor: U.S. Department of Health and Human Services Passed-Through: California Department of Aging Award No. and Year: AP-2122-22 and 2022, AP-2324-22 and 202...
2024-009 Program: Aging Cluster Federal Financial Assistance Listing Number: 93.041, 93.042, 93.043, 93.044, 93.045, 93.052, 93.053 Federal Grantor: U.S. Department of Health and Human Services Passed-Through: California Department of Aging Award No. and Year: AP-2122-22 and 2022, AP-2324-22 and 2024 Compliance Requirements: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: Per 2 CFR 200.332, a pass-through entity must monitor the activities of a subrecipient as necessary to ensure that the subrecipient complies with Federal statutes, regulations, and the terms and conditions of the subaward. The pass-through entity is responsible for monitoring the overall performance of a subrecipient to ensure that the goals and objectives of the subaward are achieved. In monitoring a subrecipient, a pass-through entity must include the information at 2 CFR 200.332(1) through (4). Condition: During our testing of the Orange County Community Resources (OCCR) department’s provisions for subrecipient monitoring requirements, we noted that for one (1) of four (4) subrecipients tested, onsite monitoring and follow-up on documented deficiencies was not performed timely. Cause: Established policies and procedures related to subrecipient monitoring do not specify the timeframe within which monitoring must be completed. Effect: There is an increased risk that the department’s monitoring procedure may not address the subrecipient’s risk of noncompliance. Question Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A non-statistical sample of four (4) out of (10) subrecipients were selected for testing. The condition above was identified during our procedures over subrecipient monitoring. Repeat Finding: No. Recommendation: We recommend the department review its established policies and procedures to ensure subrecipient monitoring is performed timely. Management Response and Corrective Action: 1. Person Responsible: Elsa Rivera, Compliance & Monitoring Manager 2. Corrective Action Plan: Concur. Onsite monitoring and follow-up on documented deficiencies have been performed and/or scheduled in compliance with 2 CFR § 200.332. CFR § 200.332 provides guidance on subrecipient monitoring but does not specify exact timelines for when monitoring must be completed. We provided documentation to demonstrate that we are meeting monitoring requirements. Also, we will follow through with the monitoring activities that have already been scheduled for the subrecipient in question. We will review our departmental subrecipient monitoring practices to ensure compliance with County policy. 3. Anticipated Implementation date: June 30, 2025
2024-007 Program: Santa Ana River Mainstem Project Federal Financial Assistance Listing Number: 12.U01 Federal Grantor: U.S. Department of Defense Award No. and Year: 2020 Compliance Requirements: Procurement and Suspension and Debarment Type of Finding: Significant Deficiency in Internal Control Ov...
2024-007 Program: Santa Ana River Mainstem Project Federal Financial Assistance Listing Number: 12.U01 Federal Grantor: U.S. Department of Defense Award No. and Year: 2020 Compliance Requirements: Procurement and Suspension and Debarment Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Title 2 CFR Section 200.214 of the Uniform Guidance states that the County must comply with 2 CFR part 180, which implements Executive Orders 12549 and 12689. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. Per 2 CFR Section 180.300, when a non-Federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration (GSA) and available at https://www.sam.gov/SAM/, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity. 2 CFR section Appendix II to Part 200, Contract Provisions for Non-Federal Entity Contracts Under Federal Awards states that in addition to other provisions required by the Federal agency or non-Federal entity, all contracts made by the non-Federal entity under the Federal award must contain certain provisions, as applicable. Condition: During our testing of the Orange County Public Works’ (OCPW) compliance with procurement and suspension and debarment requirements, we noted for three (3) of three (3) contracts selected for testing, there was no evidence that the entity was not suspended or debarred or otherwise excluded from participating in the transaction, prior to entering the contract, in accordance with County Policy. In addition, the following information was not provided at the time of the contract award for three (3) of three (3) contracts selected: •Byrd Anti-Lobbying Amendment •Debarment and Suspension Cause: The OCPW did not follow their policy to verify the information described in the condition prior to entering the transactions and did not consistently ensure that the applicable required provisions were communicated to contractors. Effect: The County’s control and compliance were not consistently followed, which required verification of suspension and debarment prior to entering the contract. Additionally, the OCPW department did not identify the applicable required provisions of the contract to the contractors at the time of the contract award. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A nonstatistical sample of three (3) of ten (10) procurement contracts were sampled. The condition noted above was identified during our procedures related to procurement and suspension and debarment. Repeat Finding from Prior Years: No. Recommendation: We recommend that the OCPW department adhere to its procurement procedures requiring the suspension and debarment verification is performed prior to entering into a covered transaction. Additionally, we recommend the OCPW modify and strengthen its current policies and procedures to ensure that all applicable required provisions are communicated to contracts in accordance with 2 CFR Appendix II to Part 200. Management Response and Corrective Action: 1. Person Responsible: Joe Sly 2. Corrective Action Plan: OCPW will send a memo to impacted vendors requesting a contract modification to include the federal requirement 3. Anticipated Implementation date: September 15, 2025
Finding 547622 (2024-002)
Significant Deficiency 2024
Finding 2024-002 – Reporting Name of Contact Person: Karen Rimmer, County Clerk Corrective Action Plan: Reporting for federal grants falls under the department submitting the grant per the County Procurement Policy. Guidance will be developed to compliment policies in place to ensure reporting is co...
Finding 2024-002 – Reporting Name of Contact Person: Karen Rimmer, County Clerk Corrective Action Plan: Reporting for federal grants falls under the department submitting the grant per the County Procurement Policy. Guidance will be developed to compliment policies in place to ensure reporting is completed timely. This guidance will include best practices for document retention and resources for questions and/or difficulty with reporting portals. Additional training will be attended by appropriate staff, including the County Clerk, to ensure compliance requirements are understood and met. Some of this training has already taken place. Proposed Completion Date: Fiscal year ended June 30, 2025.
Condition: The documentation to support reasonable assurance for salaries and wages consisted of documentation of when employees completed a therapy session but no clear documentation of how much time when employees were on-call or completed case notes for this grant. Recommendations: We recommend T...
Condition: The documentation to support reasonable assurance for salaries and wages consisted of documentation of when employees completed a therapy session but no clear documentation of how much time when employees were on-call or completed case notes for this grant. Recommendations: We recommend The Center remind its employees complete a personnel activity report that show all of the hours employees spend on the grant not rely just hours documented in the Center system used to track therapy sessions. Management response: Management agrees with the finding and has already put a process in place for documenting time spent on grant-funded activities. Management is working with our Chief Compliance Officer to ensure that the process encompasses all necessary steps to ensure complete and accurate records of the grant-related activities by those who have the time covered by the grant funds.
The District acknowledges the material correction of an error to the District’s financial statements. This situation occurred due to internal controls checks and balances having not been corrected or delegated appropriately. Current management has improved procedures related to the these checks and ...
The District acknowledges the material correction of an error to the District’s financial statements. This situation occurred due to internal controls checks and balances having not been corrected or delegated appropriately. Current management has improved procedures related to the these checks and balances by changing the signatures on accounts that exclude staff who write checks. Administrative action occurred at the November board meeting. The process is already complete and working for the internal controls of the district.
Contact person(s) responsible for corrective action – Lisa Lawson, Sr. Accountant Corrective action planned – KMHS will move forward with billing benefit expenses as actual as of January 2025 contract billing. All employee and employer benefit costs will be billed out per the actual benefits enroll...
Contact person(s) responsible for corrective action – Lisa Lawson, Sr. Accountant Corrective action planned – KMHS will move forward with billing benefit expenses as actual as of January 2025 contract billing. All employee and employer benefit costs will be billed out per the actual benefits enrolled and received. Anticipated completion date – 1/31/2025
A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for reporting program personnel cost. B. Actions Taken or Planned: Management will continue to evaluate their controls with respect to current federal awards and requirements to insure accurate information capt...
A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for reporting program personnel cost. B. Actions Taken or Planned: Management will continue to evaluate their controls with respect to current federal awards and requirements to insure accurate information captured and reported. Anticipated completion date: Already implemented, ongoing Contact information for this finding: Michelle Walsh, 636-528-6117
A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for maintaining supporting documentation to provide evidence of LCHD’s compliance with requirements applicable to each program funded under Uniform Guidance requirements. B. Actions Taken or Planned: Management...
A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for maintaining supporting documentation to provide evidence of LCHD’s compliance with requirements applicable to each program funded under Uniform Guidance requirements. B. Actions Taken or Planned: Management implemented changes to the capturing and files maintained for documenting a participant’s eligibility for participation in program services. Management will continue to evaluate their controls with respect to current federal awards and requirements to ensure accurate information captured, reported and maintained. Anticipated completion date: Already implemented, ongoing Contact information for this finding: Michelle Walsh, 636-528-6117
Department of Health and Human Services TASC of Northwest Ohio respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 to June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings ...
Department of Health and Human Services TASC of Northwest Ohio respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 to June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT None FINDINGS—FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY 2024-001 Improper controls over allocation of salaried employees time and effort. Recommendation: Implement strategy of using time and effort documentation in determining payroll costs charged to grants Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: TASC of Northwest Ohio will implement a policy that includes a lookback and reconciliation to time and effort recorded by salaried employees to ensure that time is accurately charged to grants. Name(s) of the contact person(s) responsible for corrective action: Jason Pollick, Executive Director Planned completion date for corrective action plan: January 31, 2025 If the Department of Health and Human Services has questions regarding this plan, please call Sonya Sparks at 419-242-9955.
Finding 547610 (2024-002)
Significant Deficiency 2024
2. Identifying Number: 2024-002: Enrollment Reporting Finding: During the course of our special tests and provisions, we identified 3 students from a sample of 25 where the number of days between the enrollment change and reporting to National Student Loan Data System (NSLDS) was not within the req...
2. Identifying Number: 2024-002: Enrollment Reporting Finding: During the course of our special tests and provisions, we identified 3 students from a sample of 25 where the number of days between the enrollment change and reporting to National Student Loan Data System (NSLDS) was not within the required 60 days. We also identified 3 students from our sample of 25 whose withdrawal date was reported as the day after the withdrawal began and 1 student whose withdrawal date was reported as the end of the semester in which the student was attending. We also identified 2 students from our sample of 25 who were reported as withdrawn instead of graduated. Corrective Action Taken or Planned: Actions Taken The University has already taken corrective action on this finding. The issues raised were addressed in the following ways: number of days between the enrollment change and reporting was not within the required 60 days Graduate File Corrections: We discovered (Fall 2023) an error in the reporting of graduates, despite timely reporting via Degree Verify. Upon this discovery, we met with the National Student Clearinghouse (NSC) to determine the cause of the issue and how to correct it. We learned that students with enrollment in more than one program, or where the program reported did not match the program on record with NSC, were not being properly processed with a G status via the Degree Verify submissions. We were informed that this is common for institutions where students may be enrolled in more than one program at a time. We were advised by NSC to submit a “Graduates only” file, in addition to the Degree Verify file submission. Upon discovering this, we submitted Graduates only files for branches 02, 03, 04, 05, 80, 82, 84, and 97, for all terms for 2020, 2021, 2022, and 2023 beginning in December 2023 and ending in April 2024. We worked through these submissions with NSC, and incorrect withdrawn statuses were corrected to graduated statuses. Antioch’s enrollment reporting process has been updated to include a monthly submission of a graduates only file in addition to degree verify file monthly submission. The University has experienced changes in staffing for personnel involved in enrollment reporting. The person previously in charge of Enrollment Reporting retired on 02/29/24. He was responsible for the enrollment reporting for the majority of this audit period, as well as the prior year. Antioch University hired a new Director of Records Administration with a primary responsibility for NSLDS reporting on 03/28/24. The University has implemented a comprehensive training plan, including improved documentation of procedures, increased clarity regarding the process for the necessity of error resolution, and a review of system processing to help reduce errors in reporting and increase efficiency. The review of current practice and improved procedures was in conjunction with consultants from AACRAO, NSC, Ellucian (the student information system company). Actions Planned The University plans for corrective action on this finding. This includes policy updates for withdrawal processing and implementation of internal audits. Withdraw date was reported as the day after the withdraw began. It has been the practice to process withdrawal requests in this way: When a student withdrawal is submitted, the notification date is considered the last date of active enrollment. The withdraw (W) status begins effective on the following date. This has not been raised as a finding in prior audits. This process will be updated (effective April 1, 2025) to follow 34 CFR 668.22(c). For withdrawal processing effective immediately, this process will be updated to start the withdrawal on the date the student provides official notification, rather than starting on the day following. This means the last date attended and the start of the withdrawal will be the same date. Per the CFR 668.22(c). the student's withdrawal date is—(ii) The date, as determined by the institution, that the student otherwise provided official notification to the institution, in writing or orally, of his or her intent to withdraw; For withdrawal processing effective at the end of the term, the effective date for the ‘W’ status is the final day of the term in which the student was last enrolled. Per the Withdrawal versus Graduation and Effective Dates section of the NSLDS Manual Nov 2022, p.23 - In the case of the student who completes a term and does not return for the next term, leaving the course of study uncompleted, the effective date for the ‘W’ status is the final day of the term in which the student was last enrolled. The policy and process will be updated and training will occur to begin this processing change effective April 1, 2025. Withdraw date was reported as the end of the semester in which the student was attending It has been the practice to process withdrawal requests in this way: When a student requests withdrawal but has completed courses, the grades are updated prior to processing the withdrawal request. The withdrawal is effective on the start date of the next term. This process will be updated (effective April 1, 2025) to follow 34 CFR 668.22(c) and the NSLDS Manual as outlined in the prior bullet point. For students withdrawing immediately from a term in which they’ve already completed one or more courses, the effective date for the ‘W’ status is the date AU is notified. However, they will only be dropped from courses still in progress. Completed courses cannot be withdrawn. The policy and process will be updated and training will occur to begin this processing change effective April 1, 2025. Reported as withdrawn instead of graduated The Grads Only submission did not return student records for 24SPTRI. We will need to review this with Ellucian to determine the issue. Once this is determined, we will re-run the submission for this term to update records. An internal audit process will be implemented to spot check 3-5 records on each submission for enrollment, grads only, or degree verify reporting. In addition, an audit report will be created to review 9 sample records on a quarterly basis from the current list of active students and the last two years of graduated and withdrawn students. The review will select 3 records from each status. An audit log will document these reviews. Person Responsible for Corrective Action: The Registrar and Executive Director of Financial Aid & Scholarships are responsible for executing the corrective action plan. The Executive Director of Financial Aid and Scholarships and the University Registrar will meet on a recurring basis to jointly review enrollment reporting procedures and National Student Loan Data System (NSLDS) reporting timelines. This collaboration ensures that all enrollment data submitted for Title IV purposes is accurate, timely, and aligned with institutional policies and federal regulations. Any discrepancies or issues identified are addressed collaboratively and corrective steps are documented. Anticipated Completion Date: Fiscal year 2025
Finding 547609 (2024-001)
Significant Deficiency 2024
1. Identifying Number: 2024-001: Title IV Refund and Return of Funds Compliance Issue: A sample review found instances where Title IV refunds were miscalculated and not returned within the required timeframe. Cause: Administrative oversight led to inaccurate and untimely calculation. Effect: The U...
1. Identifying Number: 2024-001: Title IV Refund and Return of Funds Compliance Issue: A sample review found instances where Title IV refunds were miscalculated and not returned within the required timeframe. Cause: Administrative oversight led to inaccurate and untimely calculation. Effect: The University did not fully comply with FSA Handbook and federal regulations for returning Title IV aid in a timely manner. Corrective Actions Underway 1. Enhanced Quality Assurance Measures Implementation of a new review protocol for Title IV refund calculations, including a secondary verification process before fund returns. Establishment of a biweekly internal audit of refund calculations to identify and resolve errors before submission. 2.Ongoing Compliance Monitoring and Prevention Efforts Establishment of a quarterly compliance review conducted by the Financial Aid leadership team to proactively address potential issues. Development of a standardized documentation process for all Title IV transactions and NSLDS updates to ensure clear audit trails. Creation of staff retraining initiative to reinforce compliance expectations and best practices. Next Steps: Conduct a full compliance assessment at 30, 60, and 90 days to confirm improvement and adjust protocols as needed. Establish a reporting dashboard for real-time tracking of Title IV refunds and enrollment status updates. Formalize a policy review cycle to ensure that all processes remain aligned with the latest federal regulations. These actions are intended to strengthen the University’s compliance posture, mitigate risks, and enhance the accuracy and timeliness of financial aid administration. Please let me know if additional measures or oversight mechanisms should be considered. Person Responsible for Corrective Action:The Executive Director of Financial Aid & Scholarships is responsible for executing the corrective action plan. Anticipated Completion Date: Fiscal year 2025
Audit Finding Number 2024-001: The audit of the financial statements identified adjustments to the current year financial statements that were considered to be material. Management’s Response to the Finding and Recommendation: Management understands and agrees the corrections are required to the 2...
Audit Finding Number 2024-001: The audit of the financial statements identified adjustments to the current year financial statements that were considered to be material. Management’s Response to the Finding and Recommendation: Management understands and agrees the corrections are required to the 2024 financial statements and is in agreement with the finding and the related recommendations. Action(s) to be Taken or Planned to be Taken on the Finding: The 2024 financial statements have been corrected to properly present the financial statement amounts. Management will review its process for the preparation of financial statements and evaluation of transactions in accordance with generally accepted accounting principles for proper recording of balances and amounts going forward. Anticipated Completion Date: Completed November 2024
Finding Number: 2024-001 Reporting – Noncompliance (Control Deficiency) Programs: U.S. Department of Health and Human Services ALN Number: 93.959 ALN Name: Block Grants for Prevention and Treatment of Substance Abuse Contract Period: 07/1/2023 – 06/30/2024 Planned Corrective Action: SCAN-Harbor, Inc...
Finding Number: 2024-001 Reporting – Noncompliance (Control Deficiency) Programs: U.S. Department of Health and Human Services ALN Number: 93.959 ALN Name: Block Grants for Prevention and Treatment of Substance Abuse Contract Period: 07/1/2023 – 06/30/2024 Planned Corrective Action: SCAN-Harbor, Inc. (SCAN-Harbor) acknowledges that the 2024 consolidated fiscal report (CFR) was not filed timely. The planned correction plan is to file the CFR upon issuing these financial statements and ensure that future CFRs are filed timely. Person Responsible: Lewis Zuchman, Executive Director Expected Completion Date: March 31, 2025
To ensure the Town directly addresses all of the requirements under the Uniform Guidance for federal programs as it relates to procurement and suspension and debarment, the Town will establish written policies and procedures relating to compliance with the Uniform Guidance relating to procurement an...
To ensure the Town directly addresses all of the requirements under the Uniform Guidance for federal programs as it relates to procurement and suspension and debarment, the Town will establish written policies and procedures relating to compliance with the Uniform Guidance relating to procurement and suspension and debarment. Corrective action shall be performed by Mayor, Andrew J. D'Aquilla, immediately.
To ensure financial accuracy, procedural changes to the preparation of the SEFA will be made immediately. The Town Clerk, Stacy Orr, will prepare the SEFA, and it will be reviewed for accuracy and completeness by Mayor, Andrew J. D'Aquilla. This procedure update has been agreed upon and will be impl...
To ensure financial accuracy, procedural changes to the preparation of the SEFA will be made immediately. The Town Clerk, Stacy Orr, will prepare the SEFA, and it will be reviewed for accuracy and completeness by Mayor, Andrew J. D'Aquilla. This procedure update has been agreed upon and will be implemented immediately in preparation of the fiscal close.
Corrective Action Plan: The College agrees with this finding. After disbursing aid for the first time in the Fall 2023 semester and sending Pell origination and disbursement records to COD, the College ran the Pell COD Reject Report (PCRR) in Colleague to identify records that COD had rejected. CO...
Corrective Action Plan: The College agrees with this finding. After disbursing aid for the first time in the Fall 2023 semester and sending Pell origination and disbursement records to COD, the College ran the Pell COD Reject Report (PCRR) in Colleague to identify records that COD had rejected. COD identified 8 students whose Pell disbursement was rejected due to citizenship status issues. These files were reviewed and it was identified that a required field in Colleague was not populated correctly to indicate to COD that the citizenship issue had been reviewed by collecting the required documentation from the student. The files were being reviewed and updates were made in Colleague but not within the 15-day window. Procedure notes have been updated and training has occurred to ensure all relevant personnel understand the process and know where to make the appropriate updates in Colleague when reviewing citizenship documents. Status of Correction Action: Completed
The College agrees with this finding. The Registrar’s Office will proactively report withdrawals from the College between academic semesters manually to the National Student Clearinghouse (NSC) in a timely manner to ensure that NSLDS receives those status changes within the required 60-day window. ...
The College agrees with this finding. The Registrar’s Office will proactively report withdrawals from the College between academic semesters manually to the National Student Clearinghouse (NSC) in a timely manner to ensure that NSLDS receives those status changes within the required 60-day window. The Registrar will work with IT to create a report to assist in identifying all withdrawals that are processed between terms. Staff will use this report to crosscheck status changes reported to the NSC. The Registrar’s Office will follow up with the Audit Support division of the NSC regarding previous guidance on effective dating of withdrawals. The NSC’s directive to use the day after the final date of a completed term seems to contradict the effective date that the Clearinghouse automatically assigns when a student is not reported for the subsequent term.
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Assistance Listing Numbers: 14.871, 14.879, and 14.EHV Noncompliance – N. Special Tests and Provisions - Reasonable Rent Non Compliance Material to the Financial...
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Assistance Listing Numbers: 14.871, 14.879, and 14.EHV Noncompliance – N. Special Tests and Provisions - Reasonable Rent Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions Criteria: Reasonable Rent. The Authority must do the following: The Authority must determine that the rent to owner is reasonable at the time of initial leasing. Also, the Authority must determine reasonable rent during the term of the contract (a) before any increase in the rent to owner, and (b) at the HAP contract anniversary if there is a 5 percent decrease in the published Fair Market Rent in effect 60 days before the HAP contract anniversary. The Authority must maintain records to document the basis for the determination that rent to owner is a reasonable rent (initially and during the term of the HAP contract) (24 CFR sections 982.4, 982.54(d)(15), 982.158(f)(7), and 982.507). Condition: Based upon inspection of the Authority’s files and discussion with management, there were newly leased units for which the evaluation of rent reasonableness was not performed. Context: There were approximately 821 newly leased units. Of a sample size of forty-two (42) newly leased units, one (1) unit's documentation of reasonable rent was not available for examination. Our sample size is statistically valid. Known Questioned Costs: $16,685 Cause: There is a significant deficiency in internal controls over the compliance for the special tests and provisions type of compliance related to reasonable rent. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster is in non-compliance with the special tests and provisions type of compliance related to reasonable rent. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the significant deficiency in the Housing Voucher Cluster and will implement internal control procedures that will ensure compliance with federal regulations. Gabriela Rivero, Executive Assistant, will be responsible to implement this corrective action by June 30, 2025.
View Audit 351761 Questioned Costs: $1
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers and Mainstream Vouchers Federal Assistance Listing Numbers: 14.871, 14.879, and 14.EHV Noncompliance – N. Special Tests and Provisions – Selections from the Waiting List Non Com...
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers and Mainstream Vouchers Federal Assistance Listing Numbers: 14.871, 14.879, and 14.EHV Noncompliance – N. Special Tests and Provisions – Selections from the Waiting List Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Special Tests and Provisions Criteria: Selections from the Waiting List. The PHA must have written policies in its HCVP administrative plan for selecting applicants from the waiting list and PHA documentation must show that the PHA follows these policies when selecting applicants from the waiting list. Except for as provided in 24 CFR section 982.203(Special admission (non-waiting list)), all families admitted to the program must be selected from the waiting list. “Selection” from the waiting list generally occurs when the PHA notifies a family whose name reaches the top of the waiting list to come in to verify eligibility for admission (24CFR sections 5.410, 982.54(d), and 982.201 through 982.207). Condition: Based upon inspection of the waiting list provided to us during the time of audit, the new move-in list and discussions with management, it could not be determined with any certainty that new move-ins were selected from the wait list in an order that is in accordance with the Authority’s policy. Context: Forty-two (42) names were selected from the new move-in list and those names were to be traced to the waiting list to verify new move-ins were chosen in an order that was in accordance with the Authority’s policy. It was determined that thirty-eight (38) out of forty-two (42) new move-ins selected could not be traced with any certainty back to the Authority's waiting list. Known Questioned Costs: $741,293. Cause: There is a material weakness in internal controls over the compliance for the special tests and provisions type of compliance related to selections from the waiting list. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Housing Voucher Cluster is in material non-compliance with the special tests and provisions type of compliance related to selections from the waiting list. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Housing Voucher Cluster will implement internal control procedures that will ensure compliance with federal regulations. Gabriela Rivero, Executive Assistant, will be responsible to implement this corrective action by June 30, 2025.
View Audit 351761 Questioned Costs: $1
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Catalog Numbers: 14.871, 14.879, and 14.EHV Noncompliance – L. Reporting - Special Reporting Non Compliance Material to the Financial Statements: No Significant Deficiency in Inte...
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Catalog Numbers: 14.871, 14.879, and 14.EHV Noncompliance – L. Reporting - Special Reporting Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Reporting Criteria: The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family members to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Cause: There is a significant deficiency in internal controls over the compliance for the reporting type of compliance related to special reporting. The Authority has not maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster is in non-compliance with the reporting type of compliance related to special reporting. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed accurately and on a timely basis. Gabriela Rivero, Executive Assistant, will be responsible to implement this corrective action by June 30, 2025. Condition: Based upon inspection of the Authority’s files and on discussion with management, the Authority included income that was miscalculated during their annual reexamination. Context: Of a sample size of fifty-eight (58) tenant files, three (3) tenant's annual recertification (HUD-50058 form) included income that was miscalculated. Our sample size is statistically valid. Known Questioned Costs: $32,407
View Audit 351761 Questioned Costs: $1
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