Corrective Action Plans

Clients receiving assistance under the RWB program are subject to eligibility requirements contained in the Health Resources and Services Administration’s HIV/AIDS Bureau Policy Clarification Notice No. 13-02 Clarifications on Ryan White Program Client Eligibility Determinations and Recertification ...

Clients receiving assistance under the RWB program are subject to eligibility requirements contained in the Health Resources and Services Administration’s HIV/AIDS Bureau Policy Clarification Notice No. 13-02 Clarifications on Ryan White Program Client Eligibility Determinations and Recertification Requirements. To be eligible, clients must have a medical diagnosis of HIV/AIDS and be (a) a low-income individual, (b) a resident of the state, and (c) uninsured or underinsured, as defined by the state. Eligibility determination is required before participation in the RWB program during the in-take process. Re-assessments are performed at least once every 6 months thereafter.

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

Per HHHRC’s Ryan White Eligibility Policy, these eligibility criteria are to be documented in their Annual Certification forms. HIV status must be documented by a written statement from a medical provider. Lab results may only be used on an interim basis. Residency must be documented with a State...

Per HHHRC’s Ryan White Eligibility Policy, these eligibility criteria are to be documented in their Annual Certification forms. HIV status must be documented by a written statement from a medical provider. Lab results may only be used on an interim basis. Residency must be documented with a State ID card or a driver’s license, lease agreement, utility bill, official government mail, bank statement, pay stub, or a verification letter from an agency providing the client with housing. Income levels must be documented with the most recent pay stubs covering 30 consecutive days, benefit statements, IRS tax transcripts, or a signed statement from the client attesting to no income or very low income. For the payer of last resort criteria, HHHRC’s policy states that they must, at a minimum, assess and re-assess the client’s eligibility for benefits such as MedQuest. In addition, HHHRC must make reasonable efforts to secure funding, besides the Ryan White program, including pursuing enrollment into health care coverage.

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

Additionally, costs associated with clients determined to be ineligible to receive assistance under the RWB program are unallowable.

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

Cause

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

HHHRC did not adhere to established policies and procedures requiring that the client meet all eligibility requirements during the in-take and re-assessment process before costs are charged to the RWB program.

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

Effect

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

HHHRC did not comply with the RWB program allowable cost requirements for the two instances noted above. As a result, $379 of unallowed costs were erroneously billed to the RWB program.

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

Recommendation

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

We recommend that HHHRC adhere to established policies and procedures requiring that only allowable costs associated with clients determined to be eligible to receive benefits be charged to the RWB program.

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

In addition, we recommend that HHHRC follow up with the State to determine the appropriate action for any costs erroneously billed to the RWB program.

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

Views of Responsible Officials and Planned Corrective Action

View Audit 347434

Finding 529427 (2024-001)

Significant Deficiency 2024

Hawaii Health & Harm Reduction Center

HI

Allowable Costs / Cost Principles Eligibility

HHHRC agrees that policies and procedures must be followed so that only allowable costs with clients documented to be eligible are processed. HHHRC is working with the State to determine the best process for ensuring there were no other billings for ineligible clients. HHHRC will be instituting a ...

HHHRC agrees that policies and procedures must be followed so that only allowable costs with clients documented to be eligible are processed. HHHRC is working with the State to determine the best process for ensuring there were no other billings for ineligible clients. HHHRC will be instituting a fiscal review to ensure any errors are caught prior to processing billings.

View Audit 347434

Finding 529413 (2024-001)

Significant Deficiency 2024

Action, Inc.

MA

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303

2024-001 – Reporting Federal Agency: U.S. Department of Energy Federal Program: 81.042 Weatherization Assistance for Low-Income Persons Responsible Official Jennifer Beloff, Chief Program Officer Plan Detail Action is in the process of enhancing its internal controls over reporting to ensure that on...

2024-001 – Reporting Federal Agency: U.S. Department of Energy Federal Program: 81.042 Weatherization Assistance for Low-Income Persons Responsible Official Jennifer Beloff, Chief Program Officer Plan Detail Action is in the process of enhancing its internal controls over reporting to ensure that only federally related costs and activities are reported within its Federal programs and training its employees on its internal controls. Anticipated Completion Date March 2025

View Audit 347411

Finding 529411 (2024-001)

Significant Deficiency 2024

Plumas County Community Development Commission

CA

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

Management's Response: This issue was brought before the Board of Commissioners in July of 2024. It was recommended to reach out to other Agencies to determine best practices. Upon completion of the research, it was determined that all staff timesheets be approved by their supervisor; supervisor's t...

Management's Response: This issue was brought before the Board of Commissioners in July of 2024. It was recommended to reach out to other Agencies to determine best practices. Upon completion of the research, it was determined that all staff timesheets be approved by their supervisor; supervisor's timesheets will be approved by their appropriate Director; Housing Director and Finance Director's timesheets will be approved by the Executive Director; and, lastly, the Executive Director's will be approved by both the Finance Director and the Housing Director. This procedure is to be effective in the next fiscal year, pending Board approval. Estimated Completion Date: 06/30/2025 Responsible Party: Finance Director and Executive Director

View Audit 347407

Finding 529369 (2024-001)

Material Weakness 2024

Duneland School Corporation

IN

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.208 § 200.303 § 200.403

FINDING 2024-001 Finding Subject: Special Education Cluster (IDEA) - Earmarking Contact Person Responsible for Corrective Action: Lynn A. Kwilasz Contact Phone Number and Email Address: 219.983.3604; lkwilasz@duneland.k12.in.us Views of Responsible Officials: We concur with the finding. Description ...

FINDING 2024-001 Finding Subject: Special Education Cluster (IDEA) - Earmarking Contact Person Responsible for Corrective Action: Lynn A. Kwilasz Contact Phone Number and Email Address: 219.983.3604; lkwilasz@duneland.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: School corporation personnel will work with PCES Cooperative personnel to appropriately review the PCES processes and procedures that have been established by PCES to ensure that the required level of expenditures for non-public school students with disabilities is tracked and met for the school corporation. Anticipated Completion Date: June 30, 2025

View Audit 347371

Finding 529306 (2024-102)

Material Weakness 2024

The Academy of Tucson

AZ

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Questioned Costs § 200.300 § 200.306 § 200.308

We concur with the condition. 1. Name of the contact person responsible for corrective action: Grants Manager 2. Corrective action planned: Grants Manager will be tasked with the following: ● Researching and understanding what items are allowable within each federal grant ● Ensuring each budgeted it...

We concur with the condition. 1. Name of the contact person responsible for corrective action: Grants Manager 2. Corrective action planned: Grants Manager will be tasked with the following: ● Researching and understanding what items are allowable within each federal grant ● Ensuring each budgeted item is not already written into another grant ● Presenting a list of budgeted items and their corresponding fund codes at a grants meeting prior to submitting the budget ● Notifying the Business Manager when the budgets have been approved and that those budgeted items can now be allocated to the corresponding grant under their specific fund code ● Checking the expenditure report to make sure it accurately reflects what was written in the grant before submitting information to the state ● Reporting any errors in coding to the Business Manager to ensure an accurate representation of expenditures is reported before submitting to the state 3. Anticipated completion date: Implementation of the corrective action plan began March 15, 2025.

View Audit 347332 Questioned Costs: $1

Finding 529305 (2024-103)

Significant Deficiency 2024

The Academy of Tucson

AZ

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Questioned Costs § 200.300 § 200.306 § 200.308

We concur with the condition. 1. Name of the contact person responsible for corrective action: Grants Manager 2. Corrective action planned: Grants Manager will be tasked with the following: ● Researching and understanding what items are allowable within each federal grant ● Ensuring each budgeted it...

We concur with the condition. 1. Name of the contact person responsible for corrective action: Grants Manager 2. Corrective action planned: Grants Manager will be tasked with the following: ● Researching and understanding what items are allowable within each federal grant ● Ensuring each budgeted item is not already written into another grant ● Presenting a list of budgeted items and their corresponding fund codes at a grants meeting prior to submitting the budget ● Notifying the Business Manager when the budgets have been approved and that those budgeted items can now be allocated to the corresponding grant under their specific fund code ● Checking the expenditure report to make sure it accurately reflects what was written in the grant before submitting information to the state ● Reporting any errors in coding to the Business Manager to ensure an accurate representation of expenditures is reported before submitting to the state 3. Anticipated completion date: Implementation of the corrective action plan began March 15, 2025.

View Audit 347332

Finding 529295 (2024-003)

Material Weakness 2024

Scott County School District 1

IN

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

FINDING 2024-003 Finding Subject: Special Education Cluster (IDEA) - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, Material Weakness Summary of Finding: There is no administrate review of reimbursable expenses submitted to MAESSU by the district payroll cle...

FINDING 2024-003 Finding Subject: Special Education Cluster (IDEA) - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, Material Weakness Summary of Finding: There is no administrate review of reimbursable expenses submitted to MAESSU by the district payroll clerks. Lack of an internal control. Contact Person Responsible for Corrective Action: Jami Parks, Business Manager Contact Phone Number and Email Address: 812-794-9630, jami.parks@scsd1.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Payroll Clerk will submit the reimbursement requests to the corporation Business Manager for review before the reimbursement is submitted to MAESSU for payment. Anticipated Completion Date: The anticipated completion date will be with the April reimbursement submission.

View Audit 347331

Finding 529288 (2024-002)

Significant Deficiency 2024

Housing Authority of Portage County

WI

Allowable Costs / Cost Principles Reporting

The Authority’s Board of Commissioners and management will continue to rely on the use of their outside auditors to prepare the schedule of expenditures of federal awards that were presented in accordance with generally accepted accounting principles. Management will assign a person within the Autho...

The Authority’s Board of Commissioners and management will continue to rely on the use of their outside auditors to prepare the schedule of expenditures of federal awards that were presented in accordance with generally accepted accounting principles. Management will assign a person within the Authority with the skills, knowledge and expertise to review and approve the schedule of expenditures of federal awards.

View Audit 347328

Finding 529281 (2024-003)

Material Weakness 2024

Greensburg Community Schools

IN

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.208 § 200.303 § 200.403

FINDING 2024-003 Finding Subject: Special Education Cluster (IDEA) - Earmarking Contact Person Responsible for Corrective Action: Andrea Phillips, Director of Finance Contact Phone Number and Email Address: (812) 663-4774 aphillips@greensburg.k12.in.us Views of Responsible Officials: We concur with ...

FINDING 2024-003 Finding Subject: Special Education Cluster (IDEA) - Earmarking Contact Person Responsible for Corrective Action: Andrea Phillips, Director of Finance Contact Phone Number and Email Address: (812) 663-4774 aphillips@greensburg.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: At the end of each nine week grading period employees will turn in actual hours worked with non-pub students to the Director of Special Education. The Director of Special Education will verify the actual hours worked with non-pub students, sign off, and then submit the information to the Director of Finance. The Director of Finance will then reconcile actual hours worked to budgeted hours estimated and make any adjustments necessary in the accounting software. Anticipated Completion Date: By April 30, 2025, the Director of Finance should be able to reconcile the 2024-2025 IDEA grants for the 2024-2025 school year thus far.

View Audit 347322

Finding 529203 (2024-001)

Significant Deficiency 2024

Community Health of Central Washington

WA

Questioned Costs Allowable Costs / Cost Principles Material Weakness

The current year Schedule of Findings and Questioned Costs reported no matters in Section II – Financial Statement Findings and one matter in Section III – Federal Award Findings and Questioned Costs. Current year audit findings: 2024-001 Reporting of Draws to UDS Finding Description: Significant D...

The current year Schedule of Findings and Questioned Costs reported no matters in Section II – Financial Statement Findings and one matter in Section III – Federal Award Findings and Questioned Costs. Current year audit findings: 2024-001 Reporting of Draws to UDS Finding Description: Significant Deficiency – Internal Control over Compliance; It was identified that the UDS report submitted for reporting year 2023 was prepared using the accrual basis of accounting instead of the required cash basis. Planned corrective actions: Staff Training and Education: provide training to finance and compliance staff on UDS reporting requirements; require annual refresher training on financial reporting compliance. Review and Reconciliation Procedures: implement an internal review process before UDS report submission to ensure compliance with reporting standards; assign an independent reviewer within the finance team to verify that financial data is recorded on the correct basis before final submission. Internal Control Enhancements: implement periodic internal audits to assess compliance with reporting requirements and accounting standards. Corrective action taken: Upon discovery of this issue, CHCW promptly reviewed the reporting methodology and identified the discrepancy. The finance team corrected this issue for the 2024 UDS report, ensuring that all financial data was reported using the correct cash basis of accounting. Internal controls have been strengthened to prevent future occurrences of similar issues. Completion date: The correction for the 2024 UDS report has been completed. Staff training was conducted January 16, 2025. Review procedures and internal control enhancements have been fully implemented. Contact person responsible for corrective action: Tamiko Wilkens, Controller – Responsible for training and oversight. Desiree Ashbrooks, Chief Financial Officer – Responsible for reviewing and ensuring compliance.

View Audit 347194

Finding 529196 (2024-001)

Material Weakness 2024

Prairie Power, Inc.

IL

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

Federal Agency Name: Department of Homeland Security Pass-Through Entity: State of Illinois Office of Emergency Management Federal Financial Assistance Listing #97.036 Program Name: Disaster Grants – Public Assistance Finding Summary: The Cooperative did not retain documentation to support the revi...

Federal Agency Name: Department of Homeland Security Pass-Through Entity: State of Illinois Office of Emergency Management Federal Financial Assistance Listing #97.036 Program Name: Disaster Grants – Public Assistance Finding Summary: The Cooperative did not retain documentation to support the review and approval over material costs claimed for reimbursement under the program. Responsible Individuals: Scott Seipel (Warehouseman), Ryan Ruppel (Superintendent) Corrective Action Plan: A line or lines will be added to the material charge out sheet to formalize the review and approval. The Superintendent of Operations will begin reviewing and approving all material charge out sheets and documenting that review to supplement the review currently being done by the Warehouseman when entering the material charge out sheets prepared by other employees or contractors. Anticipated Completion Date: We believe this corrective action plan can be reasonably incorporated into our internal controls by June 2025 and will make necessary arrangements to ensure that it does get incorporated.

View Audit 347181

Corrective Action Plans

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