Corrective Action Plans

Finding 528948 (2024-003)

Material Weakness 2024

AK

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303 § 200.313

Finding 2024-003 Reporting – Material Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan The District acknowledges the finding regarding failure to retain source check documentation supporting student count certification for the Impact Aid program. In resp...

Finding 2024-003 Reporting – Material Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan The District acknowledges the finding regarding failure to retain source check documentation supporting student count certification for the Impact Aid program. In response to this issue, which pertained to source check forms from FY22 that were subject to review when payment was made in FY24, we have already implemented corrective measures. Under the oversight of our Director of Federal Programs, the District established and implemented comprehensive records retention procedures compliant with 2 CFR 200.303, including clear documentation requirements for federally connected children, a centralized digital repository for all Impact Aid records, a verification checklist system, and staff training on proper documentation protocols. This implementation was completed in June 2024, ensuring all records are now maintained in accordance with federal uniform guidance requirements. Expected Completion Date 07/01/2024

View Audit 346942

Finding 528943 (2024-007)

Significant Deficiency 2024

City of Southfield, Michigan

MI

HUD Housing Programs Eligibility Significant Deficiency

Condition: The City had insufficient controls in place that resulted in the City releasing HAP payments on behalf of a participant, despite a failed HQS inspection, which was not rectified within the 30-day cure period or the months that followed. Questioned Costs $1,542 Planned Corrective Action:...

Condition: The City had insufficient controls in place that resulted in the City releasing HAP payments on behalf of a participant, despite a failed HQS inspection, which was not rectified within the 30-day cure period or the months that followed. Questioned Costs $1,542 Planned Corrective Action: The City has implemented controls with our inspection vendors to ensure reinspection is completed within the necessary 30 days and communicated to the PHA. If the owner fails to make the necessary corrections within the 30-day cure period, the PHA will withhold housing assistance payments in accordance with 24 CFR Chapter IX, Part 982 until the PHA verifies the corrections have been made. The City has also implemented a process to ensure reinspection documentation, when applicable, is included in the participant file. We expect this finding to be corrected by June 30, 2025. Contact person responsible for corrective action: Austen Michaels, Director of Fiscal Services and Sherry Veal, Executive Director Section 8 Program Anticipated Completion Date: June 30, 2025

View Audit 346929

Finding 528938 (2024-002)

Significant Deficiency 2024

Interfaith Works, Inc.

MD

Questioned Costs Allowable Costs / Cost Principles § 200.439

View of Responsible Officials: IW has implemented enhanced procedures for capital expenditures allocated to Federal awards. These procedures include an additional compliance review before the capital cost is incurred to ensure adherence to all applicable rules and regulations, including obtaining a ...

View of Responsible Officials: IW has implemented enhanced procedures for capital expenditures allocated to Federal awards. These procedures include an additional compliance review before the capital cost is incurred to ensure adherence to all applicable rules and regulations, including obtaining a written prior approval from a granting agency. To further strengthen IW internal controls over Federal award management, IW has instituted regular quarterly meetings to review projected expenses to be charged to the Federal awards and discuss specific award compliance requirements applicable to these projected expenditures.

View Audit 346925 Questioned Costs: $1

Finding 528937 (2024-001)

Significant Deficiency 2024

Interfaith Works, Inc.

MD

Reporting § 200.512

View of Responsible Officials: As a result of the 2023 audit, IW has developed and implemented enhanced procedures for the preparation of the SEFA. This process is designed to prevent any future discrepancies between the SEFA and the general ledger. As noted in Section IV of the FY24 audit report (F...

View of Responsible Officials: As a result of the 2023 audit, IW has developed and implemented enhanced procedures for the preparation of the SEFA. This process is designed to prevent any future discrepancies between the SEFA and the general ledger. As noted in Section IV of the FY24 audit report (Finding 2023-004), during the 2024 audit, IW was able to provide supporting general ledgers for each individual award under the major program together with the SEFA at the start of audit fieldwork over Uniform Guidance. In addition, the audit for 2024 started earlier than in prior years to ensure that the audit is completed in time and the audit reports are submitted to the Federal Audit Clearinghouse by the deadline.

View Audit 346925

Finding 528918 (2024-008)

Material Weakness 2024

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Cash Management

Office of Administration (OA) – SSBG: The Bureau of Financial Operations (BFO) will continue conducting during-the-award subrecipient monitoring for the SSBG based on the results of the documented risk assessment. As it relates to the cash management portion of the finding, given the relatively sm...

Office of Administration (OA) – SSBG: The Bureau of Financial Operations (BFO) will continue conducting during-the-award subrecipient monitoring for the SSBG based on the results of the documented risk assessment. As it relates to the cash management portion of the finding, given the relatively small amount of funds involved and the number of counties affected, DHS has determined that it is not economically feasible to change the payment methodology at this time. Anticipated Completion Date: 06/30/2025 Contact Name: Kelly Graham, Director, Division of Financial Policy and Operations

View Audit 346904 Questioned Costs: $1

Finding 528915 (2024-009)

Significant Deficiency 2024

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Reporting § 200.332 § 200.425

DHS: New Directions, Cash Grants The DHS Office of Income Maintenance (OIM) has implemented fiscal onsite monitoring starting October 1, 2024, which will be part of its regular program monitoring going forward. Anticipated Completion Date: 06/30/2025 Contact Name: Joel O’Donnell, Dir., Bureau of Pr...

DHS: New Directions, Cash Grants The DHS Office of Income Maintenance (OIM) has implemented fiscal onsite monitoring starting October 1, 2024, which will be part of its regular program monitoring going forward. Anticipated Completion Date: 06/30/2025 Contact Name: Joel O’Donnell, Dir., Bureau of Prog. Support, OIM Alternatives to Abortion Despite repeated attempts and efforts by the DHS Office of Policy Development (OPD) to engage this subrecipient in monitoring activities, they were uncooperative and unresponsive to the requests and therefore regular monitoring was not completed. Effective December 31, 2023, the grant agreement with this subrecipient ended and was not renewed. Anticipated Completion Date: Completed Contact Name: Louie Marven, Executive Policy Specialist, OPD L&I: TANF Youth Development Program (TANF YDP) operations transitioned from the Bureau of Workforce Development Administration (BWDA) to the Bureau of Workforce Partnerships and Operations (BWPO) in January 2023. Due to this transition, BWPO did not conduct on-site monitoring of the TANF YDP program in program year 2023. BWPO did begin onsite monitoring in program year 2024 on a limited basis as a pilot with 3 local areas in September of 2024. BWPO plans to expand monitoring efforts in 2025 by aligning TANF YDP monitoring with the onsite WIOA Data Validation schedule. Larger areas will be monitored annually with smaller areas monitored on a 3-year rotating schedule concurrent with WIOA Data Validation which is expected to commence late summer or early fall 2025. BWPO intends to also facilitate exit meetings with each area monitored and provide a written communication within 45 days post monitoring to issue results, concerns, recommendations, and corrective actions as needed. The goal of monitoring activities is to ensure that TANF YDF funding is used for authorized purposes by subrecipients, in compliance with Federal statutes and regulations. Also, that the TANF YDP program is being implemented in accordance with current L&I policies and procedures. Anticipated Completion Date: 11/30/2025 Contact Name: Dorraine Rauch, Division Chief

View Audit 346904 Questioned Costs: $1

Finding 528897 (2024-003)

Material Weakness 2024

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Reporting

A new monitoring component, consisting of fifteen measurable elements, has been developed to actively monitor compliance of the 52 Area Agencies on Aging (AAA) subrecipients through a revised Phase IX monitoring tool. The revised tool, used by three (3) Fiscal Field Representatives, includes questi...

A new monitoring component, consisting of fifteen measurable elements, has been developed to actively monitor compliance of the 52 Area Agencies on Aging (AAA) subrecipients through a revised Phase IX monitoring tool. The revised tool, used by three (3) Fiscal Field Representatives, includes questions regarding invoice verification, on-site monitoring, and checks that the monitoring tool the AAAs utilize adheres to all requirements. Citation documents point to the specific Chapter and Section of the Aging Service Policy and Procedure Manual for ease of reference. 1. Recognizing the need to formally document the process of monitoring, PDOA has drafted a AAA Fiscal Monitoring process map. 2. Actively working with Deloitte Consulting to finalize the process map with additional input by the Fiscal Field Representatives responsible for executing the annual requirement. 3. With the use of a monitoring log, PDOA has been working with the AAAs to correct reporting in preparation of the next round of monitoring. 4. A risk assessment has been developed to evaluate each subrecipient’s risk of noncompliance to proactively address any weaknesses in internal controls over Federal programs. 5. Pointed questions regarding the organization are included to gauge management’s ability to follow all terms and conditions of the contract. 6. General policies will be reviewed for adherence to all Federal and State regulations and the competence of personnel administering the programs. 7. Since multiple Federal funding streams are involved, a fiscal component will also be administered to review internal controls for financial issues. 8. The Risk Assessment tool has been distributed across the entire AAA Network and evaluations have been completed. 9. Performance Improvement Plans have been distributed to those found not in compliance. 10. The Comprehensive Aging Performance Evaluation (CAPE) is a new approach to PDOA’s evaluation of aging services provided by AAAs. It includes a review of programs such as Caregiver Support, OPTIONS, and Protective Services. A fiscal component is now included in the review which includes key fiscal performance measures. Part of the fiscal review is conducted virtually to evaluate the performance measures that can’t be completed off-site. 11. Performance Check-Ins previously launched in April 2024 as part of a Statewide Comprehensive Monitoring as a new form of regulatory measure to observe compliance with Older Adults Protective Services Act (OAPSA, 35 P.S. §§10225.101, et seq.), related 6 Pa. Code Chapter 15. regulations, and OAPSA Documentation Procedure Manual, Aging & Disability (A&D). Specific Fiscal components will relate to APD 05-01-09, APD 24-01-01, and the Cooperative Block Grant 2021-25 Agreement. 12. Despite PDOA recognizing time and insufficient staffing as a barrier to achieving the goal of performing a risk assessment for every AAA, we have surpassed our expectation of reaching half at a minimum by conducting a full assessment of all 52. 13. Follow-up procedures resulting from this finding will be reviewed and adjusted as needed to deliver optimal outcomes. Preliminary procedures will be directed to the agency’s audit review committee for resolution of completeness. 14. In the event the audit review committee determines additional steps beyond the monitoring efforts outlined above are insufficient, additional efforts will be communicated to the AAA network. Anticipated Completion Date: 06/30/2025 Contact Name: Jennifer Cave, Fiscal Management Specialist, PDOA Audit Liaison

View Audit 346904 Questioned Costs: $1

Finding 528888 (2024-013)

Significant Deficiency 2024

Commonwealth of Pennsylvania

PA

Subrecipient Monitoring

The Office of Budget Operations has already completed the steps to correct the issues cited. OB-OBO's prior year CAP identified the following issues to be resolved as a result of the audit finding: Capital Project Justification Did Not Include All Required Elements - - The capital project justific...

The Office of Budget Operations has already completed the steps to correct the issues cited. OB-OBO's prior year CAP identified the following issues to be resolved as a result of the audit finding: Capital Project Justification Did Not Include All Required Elements - - The capital project justification was corrected to include all the required elements within the 3/31/2024 quarterly report to U.S. Treasury. Capital Project In Excess Of $10 million - - The capital project in excess of $10 million was correctly reported as a capital project within the 6/30/2023 quarterly report to U.S. Treasury. PEMA Capital Project Reporting - - After the audit finding was issued in February 2024, OBO worked with PEMA to create a survey to request additional capital expenditure information from the grant's beneficiaries. The survey responses were included, along with additional information from the agency pertaining to the capital project explanation and the capital project type in the 6/30/2024 quarterly report. - The additional capital project information was collected and reported within the 6/30/2024 quarterly report to U.S. Treasury. Anticipated Completion Date: Completed Contact Names: Colleen Kling, Division Manager, Program Analysis and Performance Improvement; Mike Wood, Bureau Director, Bureau of Performance, Revenue and Program Analysis

View Audit 346904

Finding 528885 (2024-011)

Significant Deficiency 2024

Commonwealth of Pennsylvania

PA

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

Guidance email was provided to program supervisors in February 2025, reiterating the requirement that all RESEA Checklists must be completed by staff and supervisors. Yearly file reviews – Bureau of Workforce Partnership and Operations (BWPO) is currently conducting case file reviews of the local o...

Guidance email was provided to program supervisors in February 2025, reiterating the requirement that all RESEA Checklists must be completed by staff and supervisors. Yearly file reviews – Bureau of Workforce Partnership and Operations (BWPO) is currently conducting case file reviews of the local offices. Once the review is completed, each area will get a results email with concerns and recommendations. These reviews started in September 2024 and will continue until they are completed. Anticipated completion is November 2025. Quarterly meetings were held for all local areas (2/4/25, 2/5/25 & 2/6/25). Next quarterly meetings will be held in May 2025. These meetings will reiterate the importance of following the RESEA process as detailed in the RESEA desk guide. Anticipated Completion Date: 11/30/2025 Contact Name: Dorraine Rauch, Division Chief

View Audit 346904

Finding 528884 (2024-010)

Significant Deficiency 2024

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Eligibility § 200.303

L&I has taken the following steps to resolve the finding: - The system issue which caused the lack of denials was fixed in December 2024. - Maximum potential overpayment amount was estimated by getting a list of all those union hiring hall members since the launch of the new system and then removing...

L&I has taken the following steps to resolve the finding: - The system issue which caused the lack of denials was fixed in December 2024. - Maximum potential overpayment amount was estimated by getting a list of all those union hiring hall members since the launch of the new system and then removing the following from the list: - Those who registered for work. - Those exempt for other reasons. - Those denied benefits for other reasons. - Those with no payments for weeks beyond the 4th week of the claim. - The remaining individuals’ payments for the fifth week of the claim and later were totaled in January 2025: - 3,481 individuals - $22,597,596.92 - These amounts are described as “maximum” because only an individual review of each claim would reveal if the person was truly not properly registered and if weeks of benefits should be overpaid. - The Department is choosing to waive these individuals’ requirement to register based on UC law section 401(b)(6): The department may waive or alter the requirements of this subsection in cases or situations with respect to which the secretary finds that compliance with such requirements would be oppressive or which would be inconsistent with the purposes of this act. Since the individuals would currently be told of requirements they needed to meet in the past and, as a result, given debts to repay, this is oppressive in nature and inconsistent with the purpose behind the registration requirement. Anticipated Completion Date: Completed Contact Names: Stacy Walter, Management Analyst 2, Special Projects, Office of UC Service Centers; Rick Plesnarski, Management Supervisor, Special Projects Unit & Quality Assurance, Office of UC Service Centers

View Audit 346904 Questioned Costs: $1

Finding 528881 (2024-012)

Significant Deficiency 2024

Commonwealth of Pennsylvania

PA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

BWPO acknowledges that these errors were made, and the indicated accounts were updated immediately. The following steps will be taken to prevent this from happening again. 1. Desk Guides and Training Manuals for Central Offices CWDS Access Administrators will be updated to clearly define what ro...

BWPO acknowledges that these errors were made, and the indicated accounts were updated immediately. The following steps will be taken to prevent this from happening again. 1. Desk Guides and Training Manuals for Central Offices CWDS Access Administrators will be updated to clearly define what roles are restricted to state staff. Completed February 2025. 2. The Access Forms will be updated with the AdministratorLO role being in the restricted roles section and marked as only available to state staff. Completed February 2025. 3. During future reviews of restricted roles CWDS Users with these roles will be checked against staffing lists to confirm their employment status and availability for these roles. To be completed at the next Annual Review of Restricted Roles. A supplementary Annual Restricted Role Audit being completed currently for Restricted Roles. Completed March 2025. Anticipated Completion Date: Completed Contact Name: Jeremy Bender, Customer Service Unit Workforce Development Supervisor BWPO acknowledges that these errors occurred. The accounts were immediately deactivated upon discovery that the staff were no longer with the Commonwealth. The following steps will be taken to prevent a re-occurrence of this issue. 1. Three of the accounts in question were originally BWPO staff who moved to ATO, still needing CWDS Access, and then left state employment at a later date. There is currently not a system in place to review ATO staff separations. Going forward, Monthly Account Deactivation reviews will be expanded to BWDA and ATO with those Bureaus having to attest to all separations during the prior month. This should help ensure the Customer Service Unit is notified timely of staff separations in the other Bureaus. To begin March 31, 2025. 2. During periodic review of deactivations, the Customer Service Unit will compare CWOPA accounts against state staffing lists provided by HR, to ensure separated staff have their accounts deactivated timely. This will likely have to be quarterly or semi-annually as it is unfeasible for HR to have to generate full staff complements monthly for the multiple Bureaus whose CWDS Access BWPO’s Customer Service Unit manages. This will catch any issues that step 1 doesn’t resolve. To begin March 31, 2025. Anticipated Completion Date: 03/31/2025 Contact Name: Jeremy Bender, Customer Service Unit Workforce Development Supervisor

View Audit 346904

Finding 528878 (2024-006)

Significant Deficiency 2024

Commonwealth of Pennsylvania

PA

Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.405 § 200.406

1. All offices will ensure timely and effective communication. The WIC Finance staff will meet with Budget Office (BO) Analysts monthly to review SAP forms, expenditure adjustments, Grant Status Reports and other fiscal items for accuracy and action. Program, budget and comptroller staff will meet a...

1. All offices will ensure timely and effective communication. The WIC Finance staff will meet with Budget Office (BO) Analysts monthly to review SAP forms, expenditure adjustments, Grant Status Reports and other fiscal items for accuracy and action. Program, budget and comptroller staff will meet at least quarterly to review expenditures, processes and needed actions for federal grants. BO and program office staff have agreed to the following verbally: Program staff will submit a final federal report three months after the end of the grant period. Program staff will monitor all active federal grant internal orders paying careful attention to expenditures that post after the close of federal grant budget period. If there is a late expenditure, program staff will revise the final report and submit it to the DOH BO for review using the BO workflow. The DOH BO will also monitor all active internal order numbers and alert the program office of any unusual transactions. The DOH BO will inform the program office of unusual transactions and add them to regular meeting agendas for further discussion and planning. DOH will create a bulletin to outline federal grant management policies and procedures and disseminate to all DOH program offices. 2. BO staff that made the error were notified and counseled on ways to minimize errors. BO shall update the workflow and expenditure adjustment instructions in coordination with the program office. 3. The credit was largely due to overcharges of costs for a Software License Agreement that was not allowed to be charged to the grant. The IT staff that initiated the overcharge and directed the program office to make the adjustment has been counseled on policy and procedures for charging expenditures to a federal source. All fiscal transactions for IT expenditures are reviewed by program staff as well as BO staff via the BO workflow. Policies and procedures specific to IT expenditures charged to a federal fund will be reviewed and updated to ensure information and instructions are robust and clear. Updated policies and procedures will be disseminated to all DOH staff with a responsibility in the process. Anticipated Completion Date: 05/31/2025 Contact Names: Steven Marsden, Audit Resolution Manager; Andrea Race, Chief Financial Officer

View Audit 346904

Finding 528865 (2024-015)

Material Weakness 2024

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Reporting § 200.208 § 200.332 § 200.339 § 200.501 § 200.505

PDOA: 1. Designing a means to follow-up and ensure timely action of deficiencies through an audit tracking log to monitor reporting submissions, document when they were received, initiated, findings requiring follow-up, and subsequent steps to finalize the audit. 2. Management decisions for applic...

PDOA: 1. Designing a means to follow-up and ensure timely action of deficiencies through an audit tracking log to monitor reporting submissions, document when they were received, initiated, findings requiring follow-up, and subsequent steps to finalize the audit. 2. Management decisions for applicable findings will be issued and tracked. 3. Improvements have been made with regards to regularity in reporting to more effectively monitor activities of subrecipients consistently with respect to Federal statutes and regulations. 4. PDOA is looking to fill a vacant position with a focus of tracking subrecipient expenditures in the aggregate and tracking single audit submissions on a Commonwealth-wide basis since the Aging Cluster program is material and has material sub-granted expenditures in NSIP and Title III. 5. It is PDOA’s impression that having increased oversight of the SEFA will allow for timely dissemination of management decision letters (MDL) in the six-month timeframe for making a management decision for federal award findings. 6. Discussions have started regarding considerations to take enforcement action against noncompliance by building language into the terms and conditions of the Cooperative Block Grant Agreements to exercise ability to withhold funding as approved in the Cost Allocation Plan. 7. PDOA has reached out to the BAFM to verify all outstanding audit items for PDOA since action is required within six months of receipt. 8. Follow-up procedures resulting from this finding will be reviewed and adjusted as needed to deliver optimal outcomes. Anticipated Completion Date: 06/30/2025 Contact Name: Jennifer Cave, Fiscal Management Specialist, PDOA Audit Liaison PDA: PDA has added a Financial Management Specialist 1 (FMS1) to its complement with the primary duty of agency audit liaison. The FMS1 will report to the PDA’s Budget Office. This is a new position and role within the department and has training and certification requirements to complete which will allow the position to: 1. Evaluate single audit report submissions received from BAFM to determine program purpose acceptability by verifying, at a minimum, that all agency-funded programs are properly included on the applicable financial schedules; that findings affecting the agency contain sufficient information to facilitate a management decision; and that the subrecipient has submitted an adequate corrective action plan. 2. Issue management decisions relative to audit findings and crosscutting findings assigned to the agency for resolution, as required by 2 CFR §200.521. If responsible for the resolution of crosscutting findings, notify the affected agency or agencies upon resolution of such findings. 3. Impose or coordinate the imposition of remedial action in accordance with 2 CFR Part 200.339 and Management Directive 325.08 Amended, Remedies for Recipient Noncompliance with Audit Requirements, when subrecipients fail to comply with the provisions of Subpart F. The new FMS1 will help ensure effective and efficient audit resolutions. This newly created position will also be responsible for the department wide audit tracking log that is in development. Anticipated Completion Date: 06/30/2025 Contact Name: Nichole Nedinsky, Fiscal Management Specialist, PDA Audit Coordinator PDE: The PDE Audit Section is working with divisions to develop processes to ensure timely responses. A training will be conducted by April 2025 on audit procedures, best practices, and federal regulations governing single audit management decisions. Anticipated Completion Date: 04/30/2025 Contact Names: Clayton P. Carroll II, Audit Coordinator; Jessica Sites, Director, Bureau Financial Operations DEP: DEP has updated the concur subrecipient letter to include the specific language related to the management decision that was previously in our non-concur letters. This ensures whichever template is used, the management decision and related finding information will be included in the subrecipient letter. Revised letters were sent to both subrecipients, in which DEP was the lead agency and had findings for in the audited timeframe. Staff are reviewing all the steps of our standard operating procedures to ensure we will be in compliance regardless of whether DEP is or is not the lead agency and regardless of whether we are preparing a concur or non-concur letter for the subrecipient. Anticipated Completion Date: 06/30/2025 Contact Names: Jennifer Brandt, Senior Fiscal Mgmt. Specialist; Kristen Szwajkowski, Lead Fiscal Mgmt. Specialist DHS: As stated in the DHS finding response, this was the result of human oversight, and not a systemic issue with internal controls. We have reminded staff to make sure that a management decision is timely communicated to subrecipients at the time of making the management decision. Anticipated Completion Date: Completed Contact Names: David Bryan, Mgr., Audit Res. Section; Alexander Matolyak, Dir., Div. of Audit & Rev.

View Audit 346904 Questioned Costs: $1

Finding 528864 (2024-014)

Significant Deficiency 2024

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring § 200.1 § 200.332

DHS: TANF – Child Care All applicable federal Notice of Awards (NOAs), which include the Federal Award Identification Number, will be emailed to the grantees both prior to the spending period and as they become available for the spending as indicated on the NOA. They will also be included in the an...

DHS: TANF – Child Care All applicable federal Notice of Awards (NOAs), which include the Federal Award Identification Number, will be emailed to the grantees both prior to the spending period and as they become available for the spending as indicated on the NOA. They will also be included in the annual Audit Guidelines. Anticipated Completion Date: Completed Contact Names: Nia Harris, Dir, Bur. of Early Learning Res. Center Ops.; Adrienne Smyth, Human Service Prgm. Executive; Paula Piasecky, Human Serv. Prgm. Rep. TANF – Other The DHS Office of Policy Development (OPD) will perform risk assessments for all grantees annually. Anticipated Completion Date: 06/30/2025 The DHS Office of Income Maintenance (OIM) reestablished the completion of risk assessments in the fall of 2024 and has provisionally completed them for all subrecipients, including TANF – Other, for FY23-24. The risk assessments seek to test various financial controls of subrecipients based on their risk assessment scores and will also assist in ranking subrecipients across the risk continuum. Anticipated Completion Date: Completed Contact Names: Louie Marven, OPD, Exec. Policy Splst.; Sheldon Marcus, OIM, Dir., Div. of Mgmt. & Bgt.; Ron Seliga, OIM, Mgr., Fin. Planning; Judy Alfaro, OIM, Mgr., Financial Accountability; Laura Schlagnhaufer, OIM, Dir., Div. of Contr. Progs. & Sys. Social Services Block Grant (SSBG) OPD will provide all grantees receiving federal funding with a letter identifying federal award information and applicable requirements. OPD will provide this letter annually. Anticipated Completion Date: Completed Contact Name: Louie Marven, OPD, Exec. Policy Specialist DOH: DOH planned to develop and implement a robust subrecipient monitoring program which included establishing a new section within the Budget Office. The PA Legislature did not approve a budget with funding that could accommodate a new section. Alternatively, a consulting firm was engaged to perform a review of policies and procedures across the agency, including providing a gap analysis to determine compliance. A recommendation report is to be provided to DOH by March 31, 2025. DOH will initiate a comprehensive training plan for department staff based on the recommendation report. DOH will then develop training materials with an anticipated completion of June 30, 2025, with a goal to conduct training across the department by September 30, 2025. Anticipated Completion Date: 09/30/2025 Contact Name: Andrea Race, CFO PDA: PDA’s Bureau of Food Assistance (BFA) will develop a process to evaluate each subrecipient’s risk of noncompliance with federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring. The evaluation will be based on Key Performance Indicators, such as leadership tenure; prior incidents of food spoilage; or qualitative feedback from clients served. If the evaluation determines that additional monitoring tools beyond the routine performance of on-site reviews of the subrecipient’s program operations are necessary, such conditions will be laid out in a separate letter communication to the sub-awardee. PDA will also develop and implement a system to document the evaluation of each subrecipients risk of noncompliance. Anticipated Completion Date: 09/30/2025 Contact Name: Caryn Long Earl, Director, Bureau of Food Assistance PDOA: Concerning the evaluation of each Subrecipient’s Risk of Noncompliance, PDOA has developed a new monitoring component, consisting of fifteen measurable elements, to actively monitor compliance of the 52 Area Agencies on Aging (AAA) subrecipients through a revised Phase IX monitoring tool. The revised tool, used by three Fiscal Field Representatives, includes a review of Program and Procurement, Contract Monitoring, Record Retention and Environmental Modifications. • Timelines have been established to evaluate each subrecipients risk of noncompliance with Federal statutes, regulations and the terms and conditions of their subaward. - The Bureau of Finance coordinated with the Bureau of Quality Assurance to ensure schedules do not conflict and become burdensome to the AAA network. - The Fiscal Representatives plan to follow-up on any Performance Issues identified within the succeeding 6-9 months as identified in the approved Cost Allocation Plan. - Prior to the start of a new State Fiscal Year, the Risk Assessment surveys are distributed to adequately evaluate each subrecipient’s risk of noncompliance timely. • PDOA has drafted a AAA Fiscal Monitoring process map to formally document the monitoring process which highlights the requirement to disseminate Risk Assessments. • PDOA has been working with the AAAs to correct reporting in preparation of the next round of monitoring to ensure accuracy of Financial Reporting requirements and Line-Item Budgets on record. • To avoid future deficiencies in compliance, revised risk assessments have been developed to evaluate each subrecipient’s risk of noncompliance to proactively address any weaknesses in internal controls over Federal programs. • Despite PDOA recognizing time and insufficient staffing as a barrier to achieving the goal of performing a risk assessment for every AAA, we have surpassed our expectation of reaching half at a minimum by conducting a full assessment of all 52 for fiscal year ending June 30, 2024. • PDOA confirmed the Comprehensive Aging Performance Evaluation (CAPE) approach to evaluations of aging services provided by AAAs a success and shifted it out of pilot status which features a fiscal component. • To best review internal controls for financial issues concerning the Aging Cluster, a fiscal component will be administered since multiple Federal funding streams are involved. • This finding has aided in our approach to the subrecipient section of contract language as the Cooperative Block Grants are actively being developed. The proposed policy addresses Subrecipient requirements in the Admin Chapter as opposed to the appendix as a result. Anticipated Completion Date: 06/30/2025 Contact Name: Jennifer Cave, Fiscal Management Specialist, PDOA Audit Liaison DDAP: DDAP understands the need to develop policies to ensure all required federal award information is disseminated to all subrecipients at the time of the subaward. DDAP currently includes the following federal award information in its grant agreements to subrecipients: • Subaward Period of Performance Start and End Date • Total amount of Federal funds obligated to the subrecipient • Total amount of the Federal award committed to the subrecipient • Name of Federal awarding agency, pass-through entity, and contact information for awarding official of pass-through entity • Assistance Listings Number (ALN) and title However, not all the required information is available at the time the grant agreements are executed, such as the Federal Award Identification Number (FAIN) and the Federal award date. To ensure subrecipients are compliant with the Uniform Guidance in 2 CFR Section 200 and other applicable federal regulations, DDAP will develop policies to ensure notification is sent to all subrecipients that includes all required federal award information once the information has been received through the Notice of Award from the Substance Abuse and Mental Health Services Administration (SAMHSA). • First draft of P&P and proposed letter to subrecipients: Person responsible - Ellie Stache and Tia Roebuck: Anticipated completion date - 03/28/2025 • Review of first draft and letter by Bureau Director: Person responsible - Marie Plumer, Director, Bureau of Administration: Anticipated completion date - 04/11/2025 • Revision to first drafts: Person responsible - Ellie Stache: Anticipated completion date - 04/25/2025 • Review of second drafts by Executive staff: Person responsible - Kelly Primus, Deputy Secretary: Anticipated completion date - 05/09/2025 • Revisions to second drafts: Person responsible - Ellie Stache: Anticipated completion date - 05/23/2025 • Final review by Bureau Director and Executive staff: Person responsible - Marie Plumer and Kelly Primus: Anticipated completion date - 06/06/2025 • Submission to auditor: Person responsible - Tia Roebuck: Anticipated completion date - 06/30/2025 Anticipated Completion Date: 06/30/2025 Contact Names: Tia Roebuck, Director, Division of Budget and Procurement; Ellie Stache, Section Chief, Fiscal Planning and Contractual Operations L&I: Once L&I’s Bureau of Workforce Development Administration (BWDA) identified that the incorrect funding source was listed on the Notice of Obligation (NOO) associated with the TANF Youth Development Program contract, BWDA updated the list of funding sources in the Commonwealth Workforce Development System to encompass ALN 93.558. This update was implemented on February 20, 2025, and the updated NOOs were disseminated through CWDS. This change ensures that all NOOs created under ALN 93.558 now and in the future will have the correct funding source listed for the subrecipient. Anticipated Completion Date: Completed Contact Names: Brenda Duppstadt, Director; Gordon Zook, Division Chief

View Audit 346904 Questioned Costs: $1

Finding 528863 (2024-005)

Significant Deficiency 2024

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Eligibility

PDA, BFA has already or will put the following steps in place to address this deficiency and noncompliance finding. 1. Upon identification of this finding, BFA directed our Field Representatives to immediately complete reviews of the 47 identified soup kitchens. As of 2/20/25, 18 of these soup kitc...

PDA, BFA has already or will put the following steps in place to address this deficiency and noncompliance finding. 1. Upon identification of this finding, BFA directed our Field Representatives to immediately complete reviews of the 47 identified soup kitchens. As of 2/20/25, 18 of these soup kitchen reviews have been completed and 8 of these reviews are in-process or pending final review approval. 2. BFA Field Representatives have been advised that Soup Kitchen reviews must be completed once every four years, just like other TEFAP agencies with which we have direct agreements. This requirement is also being added to the Field Representative work manual. Anticipated Completion Date: 06/30/2025 Contact Name: Caryn Long Earl, Director, Bureau of Food Assistance

View Audit 346904 Questioned Costs: $1

Finding 528854 (2024-004)

Significant Deficiency 2024

Commonwealth of Pennsylvania

PA

Reporting School Nutrition Programs Special Tests & Provisions

PDA, Bureau of Food Assistance (BFA) has already or will put the following steps in place to address this deficiency and noncompliance finding. 1. BFA will communicate to our contractor, Hunger-Free Pennsylvania, that all required uploads of information related to the Commodity Supplemental Food Pr...

PDA, Bureau of Food Assistance (BFA) has already or will put the following steps in place to address this deficiency and noncompliance finding. 1. BFA will communicate to our contractor, Hunger-Free Pennsylvania, that all required uploads of information related to the Commodity Supplemental Food Program (CSFP) must be entered in PAMeals by the final day of the month following the program month (i.e., data from May must be entered by June 30, data from June must be entered by July 31, etc.). BFA will also implement a monthly check in PAMeals to occur on the 1st of each month, to ensure that data from the previous reporting period has been entered into PAMeals timely (i.e., data from May should be entered by July 1, data from June should be entered by August 1, etc.). 2. In response to finding 2023-004, BFA cross-trained the NSLP Specialist on the process of completing the Monthly Processor Reports (MPRs) as a back up to the NSLP Processing & Procurement Specialist. The NSLP Specialist was then tasked with completing a monthly review of the completed MPRs to ensure accuracy. BFA has now added an additional layer to the process, with the Assistant Bureau Director serving as a backup to the NSLP Specialist, to ensure that should there be a vacancy in either of the two NSLP positions, there will always be a primary and a back-up to ensure accuracy. 3. BFA will add a validation step to the Distributor data import process for PAMeals to flag and disallow any transactions that are dated prior to the current fiscal year. BFA will also put in place a warning system on PAMeals to flag incorrect dates in any manual adjustments. 4. To ensure that processor inventories are accurate, BFA has programmed PAMeals to run a weekly check (on Sunday) to ensure that beginning processor inventories entered match the previous month and to ensure that ending inventories are accurate. BFA staff are also completing a 6-month periodic processor inventory review to ensure that records are accurate. 5. To ensure correct and timely data submissions from Share Food Program, one of our two contract distributors, PDA will require them to implement a corrective action plan detailing their plans to ensure that they provide timely and accurate reporting. This CAP will help to ensure that correct transactions are posted to PAMeals in a timely manner and will aid in addressing the issues with SEFA submission. Anticipated Completion Dates: 1. 06/30/2025, 2. Completed, 3. 06/30/2025, 4. Completed, 5. 06/30/2025 Contact Name: Caryn Long Earl, Director, Bureau of Food Assistance

View Audit 346904

Finding 528851 (2024-007)

Material Weakness 2024

Commonwealth of Pennsylvania

PA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Office of Income Maintenance (OIM) Bureau of Operations (BOO): BOO will take the following actions to address the finding: 1. All CAOs and district offices will be reminded of the EBT Coordinators’, alternates’, pinners’, and card makers’ responsibilities. The BOO will ensure users in the EBT Card ...

Office of Income Maintenance (OIM) Bureau of Operations (BOO): BOO will take the following actions to address the finding: 1. All CAOs and district offices will be reminded of the EBT Coordinators’, alternates’, pinners’, and card makers’ responsibilities. The BOO will ensure users in the EBT Card Tracking Database know their responsibilities and segregation of duties. 2. The BOO will ensure offices know EBT cards are only to be made during business hours. BOO will work with the EBT Project Office to update the OIM EBT Procedure Manual for clarification. This will occur by April 1, 2025. 3. All CAOs and district offices will be reminded to update the EBT card tracking database within 24 hours of an individual’s status change. Clarification will be sent to the Area Managers to distribute to staff. This will occur by April 1, 2025. 4. All EBT Coordinators will be reminded to review the updates/changes to the OIM EBT Procedure Manual quarterly. Anticipated Completion Date: 04/01/2025 Contact Name: Jeanette Coulston, Staff Assistant to Director of Bureau of Operations OIM Bureau of Program Support (BPS)/EBT Project Office: BPS will take the following actions to address the finding: 1. The EBT Project Office will provide clarification and make updates to the OIM EBT Procedure Manual, in the Staff Security Section, for removing individuals from the EBT card tracking database. The updates will include screenshots for easier comprehension. This is expected to be completed by April 1, 2025. 2. The EBT Project Office will make updates to the OIM EBT Procedure Manual, in the EBT Security for Over the Counter (OTC) Card Mailing Section, to include “CAOs should not print OTC EBT Cards outside of normal business hours”. This is expected to be completed by April 1, 2025. 3. The OIM EBT Procedure Manual is updated quarterly. An email notification is sent to all EBT Coordinators, via a distribution list, notifying them of the updates/changes. This is expected to be completed by April 1, 2025. Anticipated Completion Date: 04/01/2025 Contact Name: Tonya Holloway, Division Director OIM Bureau of Program Evaluation (BPE)/Division of Corrective Action (DCA): BPE will take the following actions to address the finding: The Bureau of Program Evaluation, Division of Corrective Action conducts EBT Card Security reviews at every CAO and District Office that issues EBT cards. These reviews are completed on a three-year rotation to ensure compliance in the execution of documented policies and procedures. When needed, BPE/DCA will adjust the review criteria to incorporate any procedural changes implemented in the OIM EBT Procedure Manual. Annually, BPE/DCA EBT Headquarters staff provide training to DCA Income Maintenance Examiners in both field offices, to ensure awareness of any policy or procedure changes, prior to the start of the EBT reviews. The current rotation schedule spans FFY 2025- FFY 2027. The new three-year schedule began October 2024. Anticipated Completion Date:Completed Contact Name: Amira S. Milikin, Division Director

View Audit 346904 Questioned Costs: $1

Finding 528836 (2024-001)

Significant Deficiency 2024

Community Council of Idaho, Inc.

ID

Reporting § 200.510

The SEFA report will have the accountants enter the appropriate SEFA numbers and expenses and have them reviewed by the CFO as an internal control. The report run from the accounting system will add a line for just federal grants on the auditor's report, and the rest of state and private grants will...

The SEFA report will have the accountants enter the appropriate SEFA numbers and expenses and have them reviewed by the CFO as an internal control. The report run from the accounting system will add a line for just federal grants on the auditor's report, and the rest of state and private grants will be under other grants. Person(s) Responsible: Irma Morin, CEO and Wanda Davis, CFO Timing for Implementation: Immediately

View Audit 346898

Finding 528835 (2024-001)

None 2024

Fort Lee Board of Education

NJ

Questioned Costs

The district will ensure supporting documentation for payroll charges are used with the use of a time sheet for each employee charged to the grant.

View Audit 346894 Questioned Costs: $1

Finding 528832 (2024-003)

Significant Deficiency 2024

Lukachukai Community School

AZ

Special Tests & Provisions Significant Deficiency

Finding Number: 2024‐003 Program Name/Assistance Listing Title: Indian School equalization; Title I Grants to Local Educational Agencies Assistance Listing Number: 15.042; 84.010 Contact Persons: Carmen Jodie, Principal; Renee Begay, Human Resource Technician Anticipated Completion Date: June 30, 20...

Finding Number: 2024‐003 Program Name/Assistance Listing Title: Indian School equalization; Title I Grants to Local Educational Agencies Assistance Listing Number: 15.042; 84.010 Contact Persons: Carmen Jodie, Principal; Renee Begay, Human Resource Technician Anticipated Completion Date: June 30, 2025 Planned Corrective Action: It is recommended that the School completes all the outstanding background checks. Secondly, the School will ensure that all background checks are fully completed with the appropriate documents for all newly hired and current employees. It is understood that all current and new employees must be reinvestigated every five years and performed in a timely manner (before “the expiration of the preceding investigation”). This is how the school will attempt to attain compliance.

View Audit 346886

Finding 528831 (2024-002)

Significant Deficiency 2024

Lukachukai Community School

AZ

Procurement, Suspension & Debarment § 200.320

Finding Number: 2024‐002 Program Name/Assistance Listing Title: Indian School Equalization; Title I Grants to Local Educational Agencies Assistance Listing Number: 15.042; 84.010 Contact Persons: Carmen Jodie, Principal; Patrice Henderson, Business Manager Anticipated Completion Date: June 30, 2025 ...

Finding Number: 2024‐002 Program Name/Assistance Listing Title: Indian School Equalization; Title I Grants to Local Educational Agencies Assistance Listing Number: 15.042; 84.010 Contact Persons: Carmen Jodie, Principal; Patrice Henderson, Business Manager Anticipated Completion Date: June 30, 2025 Planned Corrective Action: The School previously experienced a high turnover rate in the Business Office and Administration. The School had a Principal and Acting Principals throughout School Year 2023‐24. The business office has obtained outside consulting services to assist in reconciliation and financial processes. The business office will continue to work with other departments in making sure they submit three written quotes for purchases above $10,000. All Department Supervisors/Administrators will be trained on the procurement process. The school’s policies will be updated to comply with 2 CFR §200.320, along with supporting forms.

View Audit 346886

Finding 528830 (2024-001)

Material Weakness 2024

Lukachukai Community School

AZ

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Cash Management

Program Name/Assistance Listing Title: Indian School Equalization Assistance Listing Number: 15.042 Contact Persons: Carmen Jodie, Principal; Patrice Henderson, Business Manager Anticipated Completion Date: June 30, 2025 Planned Corrective Action: The School previously experienced a high turnover ra...

Program Name/Assistance Listing Title: Indian School Equalization Assistance Listing Number: 15.042 Contact Persons: Carmen Jodie, Principal; Patrice Henderson, Business Manager Anticipated Completion Date: June 30, 2025 Planned Corrective Action: The School previously experienced a high turnover rate in the Business Office and Administration. The School had a Principal and Acting Principals throughout School Year 2023‐ 24. The business office has obtained outside consulting services to assist in reconciliation and financial processes. The business office will continue to work with other departments in making sure they submit documentation accurately and timely. The business office will continue to work on improving the following areas: travel reimbursement, receiving reports, timely payment of bills, payment of goods, journal entries, purchase orders; per the findings listed. A Credit Card User Agreement form will be developed to support the school’s Credit Card Policies and Procedures.

View Audit 346886

Finding 528829 (2024-004)

Material Weakness 2024

Frankton Lapel Community School Corporation

IN

Equipment & Real Property Management Internal Control / Segregation of Duties § 200.313

Information on the federal program : Subject: Education Stabilization Fund – Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425U Federal Award Numbers: S425U210013 Pass-Through Entity: Indiana Departmen...

Information on the federal program : Subject: Education Stabilization Fund – Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425U Federal Award Numbers: S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Equipment and Real Property Management Audit Findings: Material Weakness Context : For the 2 sample items tested, the School Corporation expended $205,068 on building renovations which was charged to the ESSER III (84.425U) grant award. It was noted these capital asset acquisitions were not reported on the capital asset listing for the School Corporation as of June 30, 2024. Additionally, we noted the School Corporation’s capital asset listing did not contain all the required information, including the source of funding for the property, outlined in the criteria above. Contact Person Responsible for Corrective Action: Candace McDonald Contact Phone Number: 765-734-1261 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will request that funding sources be updated on our capital asset ledger. Personnel will ensure that all improvements are listed on the capital asset ledger. Anticipated Completion Date: November 2025

View Audit 346885

Finding 528827 (2024-003)

Material Weakness 2024

Frankton Lapel Community School Corporation

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.302 § 200.303 § 200.328

Information on the federal program : Subject: Education Stabilization Fund (ESSER) – Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Nu...

Information on the federal program : Subject: Education Stabilization Fund (ESSER) – Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D210013, S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Context : The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) during the audit period to meet federal reporting requirements for ESSER grant awards. We noted that the ESSER II amount reported for the reports covering the FY22 time period ($230,281) did not agree to the underlying expenditure records ($4,290 for the period of July 1, 2021 through June 30, 2022). We also noted there was no documented, secondary review of the information in the annual data reports by someone other than the preparer. Contact Person Responsible for Corrective Action: Candace McDonald Contact Phone Number: 765-734-1261 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Director of Finance will review financial statements and ensure they agree to amounts reported on the annual data reports. Reviews will be documented with a signature. FTE documentation will be retained. Anticipated Completion Date: When the next report is due

View Audit 346885

Finding 528824 (2024-002)

Material Weakness 2024

Frankton Lapel Community School Corporation

IN

Allowable Costs / Cost Principles School Nutrition Programs Internal Control / Segregation of Duties § 200.303 § 200.430

Information on the federal program : Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying...

Information on the federal program : Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2023, FY2024 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Finding: Material Weakness Context : For 18 selections, in a sample of 40 payroll transactions, the School Corporation based the employees’ time charged to the grant on an annual time and effort log. The employee’s time was split with a non-federal fund. The School Corporation allocated the employee’s time based on a time and effort log completed in September of each year which was reviewed by the Superintendent. The School Corporation did not complete time and effort logs more frequently than annually to ensure the amounts being charged to food service were based on worked performed for each payroll period. Contact Person Responsible for Corrective Action: Candace McDonald Contact Phone Number: 765-734-1261 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Instead of doing a time study, we will fully implement an analysis of percentages paid by the school lunch program on a monthly basis. Anticipated Completion Date: Beginning of April 2025, fully implemented and corrected by the end of May 2025.

View Audit 346885

Corrective Action Plans

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