Corrective Action Plans

Finding 529772 (2024-001)

Significant Deficiency 2024

SD

Questioned Costs Allowable Costs / Cost Principles § 200.303

Federal Agency Name: Department of Homeland Security Federal Financial Assistance Listing #97.036 Program Name: COVID-19 Disaster Grants - Public Assistance Finding Summary: Audit testing identified eleven instances where contract labor costs were over claimed under the program due to a calculation...

Federal Agency Name: Department of Homeland Security Federal Financial Assistance Listing #97.036 Program Name: COVID-19 Disaster Grants - Public Assistance Finding Summary: Audit testing identified eleven instances where contract labor costs were over claimed under the program due to a calculation error. Monument Health's methodology for identifying contract labor attributable to COVID to be based upon identifying total contact labor and multiplying by the percentage of COVID patient days as a percentage of total patient days. The methodology also identified certain cost centers were to be excluded from the calculation, including behavioral health and med/surg nursing. Based upon review of management's allocation percentage, it was noted the behavioral health and med/surg nursing COVID patient days were included within the total COVID patient days; therefore, a higher percentage of COVID patient days to total patient days was calculated. The calculation percentage was then utilized to calculate contract labor attributable to COVID for contract labor costs identified from July 2, 2022 through May 11, 2023. Responsible Individuals: Austin Willuweit, Chief Financial Officer Jen Schmaltz, Vice President of Finance Corrective Action Plan: Monument Health will review future calculations for consistency and accuracy. Anticipated Completion Date: June 30, 2025

View Audit 347766 Questioned Costs: $1

Finding 529770 (2024-002)

Material Weakness 2024

Allegany County, Maryland

MD

Allowable Costs / Cost Principles HUD Housing Programs Reporting

The County did not submit semi-annual status reports by the due dates and the reports were late by a few days. Management has discussed with staff and a plan will be developed to ensure reports and signatures will be prepared and submitted by the due dates.

View Audit 347745

Finding 529763 (2024-001)

Significant Deficiency 2024

Employee & Family Resources, Inc.

IA

Allowable Costs / Cost Principles Questioned Costs § 200.430

CORRECTIVE ACTION PLAN March 19, 2025 U.S. Department of Health an-d Human Services Employee & Family Resources, Inc. respectfully submits the following corrective action plan for the year ended 06/30/24. Name and address of independent public accounting firm: BerganKDV, Ltd.; 220 Park Ave South; St...

CORRECTIVE ACTION PLAN March 19, 2025 U.S. Department of Health an-d Human Services Employee & Family Resources, Inc. respectfully submits the following corrective action plan for the year ended 06/30/24. Name and address of independent public accounting firm: BerganKDV, Ltd.; 220 Park Ave South; St. Cloud, MN 56301 Audit period: July 1, 2023 - June 30, 2024 he finding from the scheduleoflindmgs and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Federal Award Finding Significant Deficiency Finding 2024-001: Proper Support for Payroll Cost Allocations Recommendation: We recommend that the Organization utilize the time and effort reporting system that ensures payroll costs are charged to federal awards based on actual hours worked and to train employees to properly code their hours. If actual hours are not used, management should review and adjust salary allocations periodically to align with documented time records. Action Taken: We concur with the recommendation. Information from the time and effort reporting system will support the payroll costs for the year July 1, 2024 - June 30, 2025. Beginning July 1, 2025, payroll costs charged to federal awards will be based on actual hours worked during the calendar month. Additional training has been conducted with staff and supervisors. Questions regarding this plan can be addressed to me at 515.471.2360. Sincerely, Tammy Hoyman CEO

View Audit 347720

Finding 529756 (2024-001)

Significant Deficiency 2024

St. Hope Public Schools

CA

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.514

Controls will be implemented for future reporting and the School will have the opportunity to correct the reporting errors in the subsequent periods.

View Audit 347714

Finding 529720 (2024-002)

Significant Deficiency 2024

Public Education & Business Coalition

CO

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303 § 200.403

On or before June 30, 2025, PEBC will implement controls that properly support the distribution of student educator teststipends in accordance with the Uniform Guidance. Controls shall include: • Standardized Documentation: Finance & Accounting Department will work with the Residency Department to d...

On or before June 30, 2025, PEBC will implement controls that properly support the distribution of student educator teststipends in accordance with the Uniform Guidance. Controls shall include: • Standardized Documentation: Finance & Accounting Department will work with the Residency Department to develop and maintain a clear inventory of required documents for each stipend award. • Resident File Management: Residency Department will establish a consistent and complete portfolio of documents for each student educator, including applications, agreements, award letters, diligence documents, and relevant correspondence. • Manager Review & Approval: Residency managers will review and attest to the completeness of each Resident File with documented approvals. • Disbursement Authorization: Finance & Accounting Department will work with the Residency Department to implement a formalized process to formalize and document requests to the Finance and Accounting Department for fund disbursement, including documentation of Residency Department manager approval. • Monthly Reconciliation: Finance & Accounting Department and Residency Department will conduct monthly reconciliations of all stipend disbursements to ensure accuracy and completeness. • Independent Oversight: Require approval of monthly reconciliations by an authorized manager who is not responsible for either approving, processing, or reconciling disbursements, or any combination thereof.

View Audit 347620

Finding 529683 (2024-001)

Material Weakness 2024

City of Taylor, Michigan

MI

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Condition: The community development manager’s payroll expenses charged to the grant were supported by time records, but these records were not reviewed or approved by another individual. Planned Corrective Action: The community development manager will submit his/her payroll time records to either ...

Condition: The community development manager’s payroll expenses charged to the grant were supported by time records, but these records were not reviewed or approved by another individual. Planned Corrective Action: The community development manager will submit his/her payroll time records to either the outside consultant or Chief of Staff who will review and approve accordingly before being charged to the grant. Contact person responsible for corrective action: Joan Hennessey (Outside Consultant) or Dan Bzura (Chief of Staff). Anticipated Completion Date: 3/12/2025

View Audit 347590 Questioned Costs: $1

Finding 529681 (2024-002)

Material Weakness 2024

Better Waterworks, Inc.

LA

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

Management Response: Management acknowledges that federal grant proceeds were not posted to the designated grant revenue account and were instead recorded as water sales. However, a grant revenue account was already established for these funds, and this was an error in posting rather than a lack of...

Management Response: Management acknowledges that federal grant proceeds were not posted to the designated grant revenue account and were instead recorded as water sales. However, a grant revenue account was already established for these funds, and this was an error in posting rather than a lack of proper account setup. The grant in question has now been fully expended and closed, so there will be no further transactions related to this specific award. Corrective Action Plan: Proper Posting Procedures – Going forward, any future federal grant funds will be recorded in the designated grant revenue account to ensure proper classification. Self-Review Process – The individual responsible for accounting will implement a self-review process to verify that all grant-related transactions are correctly posted. Person Responsible for Corrective Action: Becky Pullin, CFO Northeast Louisiana Utilities Anticipated Completion Date: March 31, 2025

View Audit 347582

Finding 529654 (2024-001)

Material Weakness 2024

West Memphis School District #4

AR

Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Reference 2024-001 Contact Person: Eric Foister, Superintendent Joyce Lowery, Special Education Bookkeeper will receive all signed approval for expenditures from Lynell McGruder, Director of Special Education before the expenditures are ordered. Once all items have been verified and received, Mrs....

Reference 2024-001 Contact Person: Eric Foister, Superintendent Joyce Lowery, Special Education Bookkeeper will receive all signed approval for expenditures from Lynell McGruder, Director of Special Education before the expenditures are ordered. Once all items have been verified and received, Mrs. McGruder will review and sign invoice giving approval to pay all invoices. The district will establish purchase order and payment policy procedures. Anticipated completion date: June 30, 2025.

View Audit 347548

Finding 529504 (2024-007)

Material Weakness 2024

Cannelton City School Corporation

IN

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.302 § 200.303 § 200.403

FINDING 2024-007 Finding Subject: Covid-19-Education Stabilization Fund-Allowable Costs/Cost Principles Summary of Finding: This finding claims federal awards were not in compliance with the terms and conditions as well as the allowable cost compliance requirements. Additionally, the School corporat...

FINDING 2024-007 Finding Subject: Covid-19-Education Stabilization Fund-Allowable Costs/Cost Principles Summary of Finding: This finding claims federal awards were not in compliance with the terms and conditions as well as the allowable cost compliance requirements. Additionally, the School corporation did not properly implement a process to identify and assess internal and external risks, or monitor internal control activities to ensure they were operating effectively. Contact Person Responsible for Corrective Action: Melissa Embry Contact Phone Number and Email Address: 812-547-2637 melissa.embry@cannelton.k12.in.us Views of Responsible Officials: We concur with the finding. The reason we spent the money the way we did is because the IDOE approved our budget. We spent exactly as it was approved not knowing that we could not spend it on items or services that were being paid for prior to the grant’s application. If it was not supposed to be spent this way, then IDOE should have never approved it. To prevent noncompliance going forward, the school’s grant administrator will review disbursements of the program to ensure they were not spent on items or services that were in place prior to the grant’s application. Description of Corrective Action Plan: To prevent noncompliance going forward, the school’s grant administrator will review disbursements of the program to ensure they were not spent on items or services that were in place prior to the grant’s application. Cannelton management will establish a proper system of internal controls including policies and procedures related to risk assessment and monitoring activities within the federal program. Anticipated Completion Date: The noncompliance will be addressed immediately. The additional controls will be implemented by August 2025.

View Audit 347515 Questioned Costs: $1

Finding 529487 (2024-004)

Material Weakness 2024

Cannelton City School Corporation

IN

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.334 § 200.403

FINDING 2024-004 Finding Subject: Child Nutrition Cluster-Activities Allowed or Unallowed, Allowable Costs/Cost Principles Summary of Finding: Payments made based on statements or no supporting documentation. The School corporation did not properly implement a process to identify and assess internal...

FINDING 2024-004 Finding Subject: Child Nutrition Cluster-Activities Allowed or Unallowed, Allowable Costs/Cost Principles Summary of Finding: Payments made based on statements or no supporting documentation. The School corporation did not properly implement a process to identify and assess internal and external risks, or monitor internal control activities to ensure they were operating effectively. Contact Person Responsible for Corrective Action: Melissa Embry Contact Phone Number and Email Address: 812-547-2637 melissa.embry@cannelton.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Invoices are already being given to the Corporation Treasurer monthly and are being attached to each Accounts Payable Voucher to show exactly what is being paid for. Cannelton management will establish a proper system of internal controls including policies and procedures related to risk assessment and monitoring activities within the federal program. Anticipated Completion Date: The noncompliance was corrected as of January 2025. The additional controls will be implemented by August 2025.

View Audit 347515 Questioned Costs: $1

Finding 529434 (2024-001)

None 2024

Central Pennsylvania Workforce Development Corporation

PA

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

Corrective Action Taken: The formula in question has been corrected. Further, in order to prevent any issues happening again, key cells in the document have been locked (password protected) and TRUE/FALSE checks have been added. These TRUE/FALSE checks will serve as an additional method to ensure th...

Corrective Action Taken: The formula in question has been corrected. Further, in order to prevent any issues happening again, key cells in the document have been locked (password protected) and TRUE/FALSE checks have been added. These TRUE/FALSE checks will serve as an additional method to ensure that the formulas are pulling correctly and with conditional formatting to serve as a color warning when something is wrong. If the formula is working correctly, the TRUE checks will show; if the formula is not working correctly, the check will show FALSE in bright red, indicating that there is a problem. The check fields will also be protected so they can not be inadvertently changed.

View Audit 347450

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

March 18, 2025

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

US Department of Health and Human Services

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

HIV CARE Formula Grants

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

Passed-through State of Hawaii Department of Health

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

1250 Punchbowl Street

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

Honolulu, HI 96813

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

Hawaii Health & Harm Reduction Center (HHHRC) respectfully submits the following corrective action plan for the year ended June 30, 2024 for the finding identified in the schedule of findings and questioned costs as identified by our auditors, KKDLY LLC, who are located at Topa Financial Center, 745...

Hawaii Health & Harm Reduction Center (HHHRC) respectfully submits the following corrective action plan for the year ended June 30, 2024 for the finding identified in the schedule of findings and questioned costs as identified by our auditors, KKDLY LLC, who are located at Topa Financial Center, 745 Fort Street, Suite 2100, Honolulu HI 96813

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

Significant Deficiency

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

Finding No. 2024-001

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

Activities Allowed or Unallowed / Allowable Costs / Cost Principles

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

U.S. Department of Health and Human Services

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

Federal Assistance Listing Number 93.917

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

Condition

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

During our audit, we selected a sample of 60 clients receiving assistance under the Ryan White HIV/AIDS Program Part B (RWB) program to ascertain whether those clients met program eligibility requirements and whether costs charged to the RWB program were allowable. We noted two instances where HHHR...

During our audit, we selected a sample of 60 clients receiving assistance under the Ryan White HIV/AIDS Program Part B (RWB) program to ascertain whether those clients met program eligibility requirements and whether costs charged to the RWB program were allowable. We noted two instances where HHHRC determined that the clients were ineligible; however, certain costs associated with these clients were charged to the RWB program. Specifically, we found that:

View Audit 347434

Corrective Action Plans

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