Corrective Action Plans

Finding 404814 (2023-005)

Significant Deficiency 2023

SD

Allowable Costs / Cost Principles Cash Management Eligibility § 200.303

Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Hospital’s requests for reimbursement under the Community Facilities Grant Agreement were not reviewed and approved by a sep...

Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Hospital’s requests for reimbursement under the Community Facilities Grant Agreement were not reviewed and approved by a separate individual. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: Hospital personnel will compile the initial requests for reimbursement with the help of Management to provide proof of invoices and payments. The final request for reimbursement will then be verified by Management prior to requesting reimbursement to the Communities Facilities Grant Coordinator. Anticipated Completion Date: June 30, 2024

View Audit 311195

Finding 404800 (2023-006)

Significant Deficiency 2023

Baltimore County, Maryland

MD

Allowable Costs / Cost Principles § 200.303 § 200.430

COVID-19 Emergency Rental Assistance – Assistance Listing No. 21.023 Recommendation: The County should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The County should not seek federal reimbursement unless it can substantia...

COVID-19 Emergency Rental Assistance – Assistance Listing No. 21.023 Recommendation: The County should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The County should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DHCD follows Baltimore County’s general payroll policies and procedures. DHCD allocates time and attendance based on a preset budgeted formula and monitors the staff’s time and attendance through biweekly timesheet prepared by the staff members and approved by unit managers and the review of payroll register. Baltimore County migrated to Workday system which has more robust features and capabilities to capture time and attendance. Name(s) of the contact person(s) responsible for corrective action: Amir Assadi Planned completion date for corrective action plan: 7/1/2024

View Audit 311187

Finding 404789 (2023-005)

Significant Deficiency 2023

Baltimore County, Maryland

MD

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.430

CDBG Entitlement Grant Cluster – Assistance Listing No. 14.218 Recommendation: The County should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The County should not seek federal reimbursement unless it can substantiate tha...

CDBG Entitlement Grant Cluster – Assistance Listing No. 14.218 Recommendation: The County should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The County should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DHCD follows Baltimore County’s general payroll policies and procedures. DHCD allocates time and attendance based on a preset budgeted formula and monitors the staff’s time and attendance through biweekly timesheet prepared by the staff members and approved by unit managers and the review of payroll register. Baltimore County migrated to Workday system which has more robust features and capabilities to capture time and attendance. . Name(s) of the contact person(s) responsible for corrective action: Amir Assadi Planned completion date for corrective action plan: 7/1/2024

View Audit 311187 Questioned Costs: $1

Finding 404783 (2023-002)

Material Weakness 2023

Allegany County Human Resources Development Commission, Inc.

MD

Questioned Costs Allowable Costs / Cost Principles Reporting

An excel workbook will be created to include all reports that need submitted. The workbook will have the program dates, how often it needs submitted and when, as well as the person responsible for completing and submitting the reports. This will be a part of the aforementioned accounting calendar an...

An excel workbook will be created to include all reports that need submitted. The workbook will have the program dates, how often it needs submitted and when, as well as the person responsible for completing and submitting the reports. This will be a part of the aforementioned accounting calendar and will also be outlined in the Finance Policies due in September as an appendix.

View Audit 311182 Questioned Costs: $1

Finding 404782 (2023-003)

Material Weakness 2023

Santa Fe Recovery Center, Inc.

NM

Allowable Costs / Cost Principles § 200.403 § 200.430

2023-003 – Allowable Costs/Cost Principles Corrective action plan: Management implemented a process to evaluate time spent each month. That allocation is used to classify actual salary paid to particular federal awards on a pay period basis. Personnel responsible for corrective action: Timothy Jodw...

2023-003 – Allowable Costs/Cost Principles Corrective action plan: Management implemented a process to evaluate time spent each month. That allocation is used to classify actual salary paid to particular federal awards on a pay period basis. Personnel responsible for corrective action: Timothy Jodway, Interim Chief Financial Officer; Peg Clark, Grant Accountant; Reyann James, Senior Accountant. Estimated corrective action completion date: May 2024

View Audit 311180

Finding 404775 (2023-001)

Significant Deficiency 2023

Area Agency on Aging of Western Michigan, Inc.

MI

Questioned Costs Allowable Costs / Cost Principles

Views of Responsible Officials and Planned Conect Actions: Management of the Agency concurs with the audit finding. The individual preparing the reports this year did not realize that the account was included in the group of accounts used for billings. Additional training will be provided, and manag...

Views of Responsible Officials and Planned Conect Actions: Management of the Agency concurs with the audit finding. The individual preparing the reports this year did not realize that the account was included in the group of accounts used for billings. Additional training will be provided, and management will perform a quality control review over future grant billings to ensure that costs meet the criteria defined by the regulations and included in contracts and grant agreements. AAA WM's CFO, will implement a process to reconcile match amounts, on a monthly basis, to ensure compliance.

View Audit 311179 Questioned Costs: $1

Finding 404771 (2023-001)

None 2023

American Soybean Association

MO

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Corrective Action Plan: USSEC will review expenses included in the Contribution Report more closely to ensure they are allowable under 2 CFR Part 200, Subpart E. For the report being submitted in June 2024 for program year 2023, all expenses related to meals, travel-related meals, and group meals at...

Corrective Action Plan: USSEC will review expenses included in the Contribution Report more closely to ensure they are allowable under 2 CFR Part 200, Subpart E. For the report being submitted in June 2024 for program year 2023, all expenses related to meals, travel-related meals, and group meals at events will be removed. Food and beverages, including alcoholic beverages will not be included in the 2023 EOY Report.

View Audit 311173

Finding 404765 (2023-001)

Material Weakness 2023

Troy City Board of Education

AL

Questioned Costs Allowable Costs / Cost Principles Special Tests & Provisions § 200.303 § 200.326

Item 2023-001 Special Tests and Provisions – Wage Rate Requirements Recommendation: We recommend the strengthening of controls to ensure the prevailing wage rate clauses are included in the contracts and that certified payrolls are received for each week in which construction work is performed. A...

Item 2023-001 Special Tests and Provisions – Wage Rate Requirements Recommendation: We recommend the strengthening of controls to ensure the prevailing wage rate clauses are included in the contracts and that certified payrolls are received for each week in which construction work is performed. Action Taken: The Board will strengthen the controls in place to provide assurance that proper prevailing wage rate clauses are added to construction contracts and certified payrolls are received from each week in which construction work is performed. Tricia Norman, CSFO, will be responsible for the corrective action plan and anticipates completion of corrective action will be taken before September 30, 2024.

View Audit 311161 Questioned Costs: $1

Finding 404734 (2023-012)

Significant Deficiency 2023

College Unbound

RI

Questioned Costs Allowable Costs / Cost Principles § 200.300 § 200.308 § 200.309 § 200.403

Finding number: 2023-012 Federal agency: U.S. Department of Treasury Programs: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance listing #: 21.027 Award year: 2023 Compliance requirement: Allowable Costs Corrective Action Plan: College Unbound has increased its adminis...

Finding number: 2023-012 Federal agency: U.S. Department of Treasury Programs: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance listing #: 21.027 Award year: 2023 Compliance requirement: Allowable Costs Corrective Action Plan: College Unbound has increased its administrative capacity and has implemented internal controls to properly track, account for and report on grant expenditures. CU hired the Vice President for Student and Institutional Sustainability in 2023 and subsequently a Controller and Bursar were hired in October 2023 to support the growing needs of the college. The Chief Development Officer, Program Staff and the Financial Team including the VP, Bursar, Financial Aid, and Controller have developed routines and procedures to ensure we are using grant funds as intended and have proper documentation. We are in the process of developing procurement protocols to align with federal grant expectations. Timeline for Implementation of Corrective Action Plan: Currently updating procedures to ensure compliance for FY25. Contact Person: Diana Perdomo, Vice President for Institutional and Student Sustainability/CFO

View Audit 311103 Questioned Costs: $1

Finding 404719 (2023-003)

Material Weakness 2023

Wise County Redevelopment and Housing Authority

VA

Allowable Costs / Cost Principles

The Housing Authority will initiate time studies each quarter to more accurately reflect costs charged to the effected programs.

View Audit 311099

Finding 404706 (2023-001)

Significant Deficiency 2023

M-1 Rail and Affiliates

MI

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties

Program: 20.507 Urbanized Area Formula Program Finding: No evidence of the review of FY2021 payroll expenditures were available at the time of the audit Recommendation: Management should ensure that they have a documented control that includes required evidence retention for reviewing and approvin...

Program: 20.507 Urbanized Area Formula Program Finding: No evidence of the review of FY2021 payroll expenditures were available at the time of the audit Recommendation: Management should ensure that they have a documented control that includes required evidence retention for reviewing and approving employee time and payroll expenditures Responsible Party: Kenneth DiLaura, CFO Corrective Action Plan: All hourly employees have an electronic access card they scan on the Time Clock when they arrive and when they leave. They also scan in and out for their lunch period. At the end of each pay period, the employee’s supervisor logs into the Time Clock website and reviews time sheets for all the employees that report to them. They approve each time sheet in the website. Salaried employees do not scan in and out but there is a time sheet in the software for each salaried employee that is approved by their supervisor. The timesheets for the President and General Manager are approved by the CFO. Once all time sheets are approved, the CFO reviews all the timecards in the time clock software and then submits the hours shown to the Costaff Payroll System. The hours are then populated in the Costaff Payroll. The CFO will log into the Costaff Payroll System, review the hours again and submit the timesheet. A CoStaff employee reviews the payroll time sheet that is entered and submits it to be approved. A CoStaff employee generates an email stating that the payroll is ready for approval. The email goes to Paul Vollmerhausen of Quatrro Business Solutions. He reviews the payroll and approves the payroll in the CoStaff Payroll System. Anticipated Completion Date: Implemented June, 2022

View Audit 311090

Finding 404704 (2023-001)

Material Weakness 2023

Iliamna Village Council

AK

Allowable Costs / Cost Principles Special Tests & Provisions § 200.302 § 200.302(B)

MANAGEMENT WILL WORK WITH THEIR CONSULTANT AND DEVELOP WRITTEN POLICIES AND PROCEDURES OVER THEIR FEDERAL AWARDS IN ACCORDANCE WITH THE REQUIREMENTS OF THE UNIFORM GUIDANCE

View Audit 311087

Finding 404698 (2023-002)

Significant Deficiency 2023

Ke Ola Mamo

HI

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting § 200.303

Ref No. 2023-002 SIGNIFICANT DEFICIENCYI It was noted one instance out of forty that the employee timesheet did not agree with the payroll register. The hours on the timesheet were 45, while the hours on the payroll register were 48 hours. This resulted in an overcharge of $159 to the program. I...

Ref No. 2023-002 SIGNIFICANT DEFICIENCYI It was noted one instance out of forty that the employee timesheet did not agree with the payroll register. The hours on the timesheet were 45, while the hours on the payroll register were 48 hours. This resulted in an overcharge of $159 to the program. It was also noted one out of seventy-one timesheets were not approved by the supervisor. Recommendation: Ke Ola Mamo should exercise greater care in reviewing timesheets and data entered into the payroll system to ensure that only allowable costs are charged to the program. Action Taken: Ke Ola Mamo was in the process of implementing an on-line payroll processing system during Fiscal Year 2023. The implementation was completed during Fiscal Year 2023. This process minimizes potential clerical errors as employees input the hours they work directly into the on-line payroll system, with employees’ supervisors and the Human Resources Specialist approving prior to the payroll being processed.

View Audit 311070

Finding 404542 (2023-001)

Significant Deficiency 2023

West Michigan Partnership for Children

MI

Allowable Costs / Cost Principles Significant Deficiency § 200.431

Responsible Person: Tim Bergsma, CFO - West Michigan Partnership for Children (WMPC). Management View: Management agrees with the finding and is in the process of implementing the recommendation. Corrective Action: WMPC will create a Compensation Adjustement Policy. This policy will reference the co...

Responsible Person: Tim Bergsma, CFO - West Michigan Partnership for Children (WMPC). Management View: Management agrees with the finding and is in the process of implementing the recommendation. Corrective Action: WMPC will create a Compensation Adjustement Policy. This policy will reference the compensation policy, connect to the budget approval process, and identify clear directions regarding the approval process for compensation adjustments. Anticipated Completion Date: August 15, 2024

View Audit 311062

Finding 404424 (2023-001)

Significant Deficiency 2023

Primary Care Medical Services of Poinciana, Inc.

FL

Subrecipient Monitoring Special Tests & Provisions Allowable Costs / Cost Principles § 200.303

MANAGEMENT’S CORRECTIVE ACTION PLAN Finding Number: 2023-001 Planned Corrective Action: We concur with the finding. We will continue with retaining documentation of sliding scale determination electronically. The CFO will continue to monitor whether the record retention policy is being followed. In ...

MANAGEMENT’S CORRECTIVE ACTION PLAN Finding Number: 2023-001 Planned Corrective Action: We concur with the finding. We will continue with retaining documentation of sliding scale determination electronically. The CFO will continue to monitor whether the record retention policy is being followed. In regard to the finding, we had usual turnover in the department during the year which resulted in procedures not being followed precisely. We have since hired new employees and have provided additional training to prevent similar documentation errors from occurring. In additional, we have instituted a monitoring process to ensure that all policies and procedures are followed without exception. Anticipated Completion Date: On-going Responsible Contact Person: Cynthia Diaz, Chief Financial Officer

View Audit 311030

Finding 404223 (2023-005)

Material Weakness 2023

Atrium Health, Inc.

NC

Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303

Corrective Action Plan: Atrium Health CMHA management will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT systems specific to the SFA program. Proposed Completion Date: ...

Corrective Action Plan: Atrium Health CMHA management will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT systems specific to the SFA program. Proposed Completion Date: Management will complete the corrective action plan by the end of 2024.

View Audit 310986

Finding 404222 (2023-004)

Material Weakness 2023

Atrium Health, Inc.

NC

Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303

Corrective Action Plan: Atrium Health CMHA management will address the current year finding either through system modifications to allow for electronic saving of the applicable notifications or by implementing a manual process to retain them. Proposed Completion Date: Management will complete...

Corrective Action Plan: Atrium Health CMHA management will address the current year finding either through system modifications to allow for electronic saving of the applicable notifications or by implementing a manual process to retain them. Proposed Completion Date: Management will complete the corrective action plan by October 2024.

View Audit 310986

Finding 404221 (2023-003)

Material Weakness 2023

Atrium Health, Inc.

NC

Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

Corrective Action Plan: Atrium Health CMHA management will address the gap in SFA transactional review and approval internal controls, arising due to the SFA program size and limited number of subject matter experts, by implementing mitigating controls and policies to ensure accuracy and completene...

Corrective Action Plan: Atrium Health CMHA management will address the gap in SFA transactional review and approval internal controls, arising due to the SFA program size and limited number of subject matter experts, by implementing mitigating controls and policies to ensure accuracy and completeness of transactions. Proposed Completion Date: Management will complete the corrective action plan by October 2024.

View Audit 310986

Finding 404220 (2023-002)

Material Weakness 2023

Atrium Health, Inc.

NC

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

Corrective Action Plan: As part of the audit planning for 2024, Atrium Health CMHA management will ensure that the internal controls within the SFA IT Systems are documented and tested, or compensating controls implemented. Proposed Completion Date: In November of 2024, management would intend ...

Corrective Action Plan: As part of the audit planning for 2024, Atrium Health CMHA management will ensure that the internal controls within the SFA IT Systems are documented and tested, or compensating controls implemented. Proposed Completion Date: In November of 2024, management would intend to incorporate and complete this IT systems controls testing into the planning phase of the December 31, 2024 reporting period audit.

View Audit 310986

Finding 404195 (2023-002)

Significant Deficiency 2023

Whitfield Place Inc.

GA

Allowable Costs / Cost Principles HUD Housing Programs Significant Deficiency

A new HUD lease will be prepared, presented, and signed at the time of the annual recertification for every tenant.

View Audit 310969

Finding 404194 (2023-001)

Significant Deficiency 2023

Dalton Senior Housing, Inc.

GA

Allowable Costs / Cost Principles HUD Housing Programs Significant Deficiency

A new HUD lease will be prepared, presented and signed at the time of the annual recertification for every tenant.

View Audit 310967

Finding 404187 (2023-002)

Significant Deficiency 2023

National Federal of Families for Children's Mental Health

MD

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.430

Action Taken: NFFCMH plans to implement changes overall to the Federation’s timekeeping processes to ensure that payroll costs accurately reflect the work performed, and to reconcile and true up any budget estimates on a consistent basis.

View Audit 310958

Finding 404157 (2023-003)

Material Weakness 2023

City of Jacksonville

FL

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.212 § 200.303 § 200.318 § 200.332 § 200.514

Action Plan: Upon learning of this finding during the FY2022 audit, we worked with our external consultant, our Council auditors and our external auditor to reperform and review the base year and subsequent year calculations of revenue, using financial information in our final audit reports. These...

Action Plan: Upon learning of this finding during the FY2022 audit, we worked with our external consultant, our Council auditors and our external auditor to reperform and review the base year and subsequent year calculations of revenue, using financial information in our final audit reports. These corrected calculations of lost revenue have been clearly documented and will be reported going forward. We will continue to work to ensure that all controls for grants be documented with written procedures. The procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, reperformable manner including the name of each responsible individual, the specific control they performed over compliance for the grant and the date(s) the controls were performed. Contact Names responsible for the plan – Marcia Saulo Anticipated completion date of the plan – September 30, 2024

View Audit 310950

Finding 404156 (2023-002)

Material Weakness 2023

City of Jacksonville

FL

Allowable Costs / Cost Principles Special Tests & Provisions Subrecipient Monitoring § 200.303 § 200.330

Action Plan: Upon learning of this finding during the FY2022 audit, we worked with the Neighborhoods Department to ensure wage rate requirement compliance was prioritized going forward. Considering this finding was presented near the completion of the FY2023 year, we expect this finding to be resolv...

Action Plan: Upon learning of this finding during the FY2022 audit, we worked with the Neighborhoods Department to ensure wage rate requirement compliance was prioritized going forward. Considering this finding was presented near the completion of the FY2023 year, we expect this finding to be resolved in FY2024. We will continue to work with our departments to ensure that all controls for grants are documented with written procedures. The procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, reperformable manner including the name of each responsible individual, the specific control they performed over compliance for the grant and the date(s) the controls were performed. Contact Names responsible for the plan – Marcia Saulo Anticipated completion date of the plan – September 30, 2024

View Audit 310950

Finding 404123 (2023-002)

Significant Deficiency 2023

Hampton Roads Community Action Program, Inc.

VA

Questioned Costs Allowable Costs / Cost Principles Reporting

DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-002 Head Start Cluster- Federal Assistance Listing Number 93.600 - Significant Deficiency in Internal Control over Allowable Costs Recommendation: Internal Controls should be implemented around expense cutoff to ensure all expenses relate to the appropria...

DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-002 Head Start Cluster- Federal Assistance Listing Number 93.600 - Significant Deficiency in Internal Control over Allowable Costs Recommendation: Internal Controls should be implemented around expense cutoff to ensure all expenses relate to the appropriate period, or in this case, school year. Action taken: We concur with the recommendation. On May 30, 2024, HRCAP drafted Accounting Policy 3.10 to be reviewed for addition to the Finance Policy Manual. This policy would serve to provide internal control procedures for grant-related transactions in accordance with Generally Accepted Accounting Principles (GAAP). Specifically, it outlines precise year end and cut-off procedures tailored to grant revenue and expenses, emphasizing the critical importance of recording these transactions within the appropriate grant period. Sincerely yours, Audrea Lambert, Chief Financial Officer

View Audit 310907 Questioned Costs: $1

Corrective Action Plans

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