Corrective Action Plans

Finding 404942 (2023-001)

Significant Deficiency 2023

MA

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

Corrective Action Plan – Workday Fiscal Year Ended September 30, 2023 Program name: Research and Development Cluster (R&D) and Provider Relief Fund (PRF) (93.498) Audit Contact: Matthew O’Connor Title: Senior Director, Human Resources Operations & Analytics Telephone: 617-638-8495 E-mail address: ...

Corrective Action Plan – Workday Fiscal Year Ended September 30, 2023 Program name: Research and Development Cluster (R&D) and Provider Relief Fund (PRF) (93.498) Audit Contact: Matthew O’Connor Title: Senior Director, Human Resources Operations & Analytics Telephone: 617-638-8495 E-mail address: Matthew.OConnor@bmc.org Audit Report Reference: 2023-001 Anticipated Completion Date: December 31, 2024 Corrective Action Planned: 1) For the Workday change review, management has been re-educated on the importance of this review as well as how to complete it completely and timely. Management will perform this review for the fiscal year ended September 30, 2024 and each subsequent fiscal year. Additionally, this review will be timely reviewed by somebody separate from the preparer and the documentation of the review and subsequent approval will be retained in BMC’s records. 2) For the access provisioning deficiency, management has been re-educated on the importance of following policy with respect to granting new access to Workday, including that this granting of access be appropriately documented and approved prior to the date of provisioning said access. Additionally, documentation of the approval of access will be properly retained in the company’s records.

View Audit 311344

Finding 404936 (2023-002)

Material Weakness 2023

Anthem Strong Families

TX

Allowable Costs / Cost Principles Material Weakness Period of Performance

CORRECTIVE ACTION PLAN: The Organization will adopt procedures that allow for the timely tracking of refundable advances, to ensure funds are properly expended during the period of performance.

View Audit 311322

Finding 404918 (2023-002)

Material Weakness 2023

District Health Department No 4

MI

Questioned Costs Allowable Costs / Cost Principles

Going forward, our internal policies and procedures will be updated to comply with the requirements in place for entities receiving federal awards. Additionally, we believe our new general ledger and payroll integrated software will provide better control and clarity to our recording and reporting o...

Going forward, our internal policies and procedures will be updated to comply with the requirements in place for entities receiving federal awards. Additionally, we believe our new general ledger and payroll integrated software will provide better control and clarity to our recording and reporting operations. We will consult with other agencies of similar size and construct, as well as the Michigan Association of Local Public Health in areas where guidance is needed to return to strict compliance.

View Audit 311309 Questioned Costs: $1

Finding 404910 (2023-001)

Material Weakness 2023

District Health Department No 4

MI

Reporting Allowable Costs / Cost Principles § 200.303 § 200.303(B) § 200.502 § 200.502(A) § 200.510

We take the findings and recommendations of the disinterested third party auditor very seriously. Going forward, all federal awards will be reconciled quarterly to ensure they comply with the Schedule of Financial Assistance and individual grant funding requirements. We will work with our auditors e...

We take the findings and recommendations of the disinterested third party auditor very seriously. Going forward, all federal awards will be reconciled quarterly to ensure they comply with the Schedule of Financial Assistance and individual grant funding requirements. We will work with our auditors early to determine acceptable documentation requirements and do random sampling internally, throughout the year, to determine appropriateness of all cash receipts, general expenditures, payroll expenditures, and allocated costs.

View Audit 311309

Finding 404874 (2023-001)

Material Weakness 2023

West Central Illinois Area Agency on Aging

IL

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

Finding 2023-001- Controls over Grant Reporting and Monitoring (Repeat Finding) Procedures for reconciling grant reports on a quarterly basis have been developed. This includes a report created for each grant from the accounting system by the fiscal department. This report is available to be reviewe...

Finding 2023-001- Controls over Grant Reporting and Monitoring (Repeat Finding) Procedures for reconciling grant reports on a quarterly basis have been developed. This includes a report created for each grant from the accounting system by the fiscal department. This report is available to be reviewed by the director or assistant director of the agency before being submitted to the grantor. A report comparing the cash request amounts made to the grantor to the general ledger has been implemented effective October 31, 2023. A procedure has also been developed to periodically monitor adherence to various grant requirements, as well as the development of documentation to support personnel activity tied to grants. The fiscal department implemented these effective January 1. 2024.

View Audit 311257

Finding 404862 (2023-004)

Material Weakness 2023

District Bridges

DC

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

Views of Responsible Officials: District Bridges is currently researching time-tracking options, specifically for employees whose salaries are covered, full or partially, by federally-funded grants.

View Audit 311249

Finding 404861 (2023-003)

Material Weakness 2023

District Bridges

DC

Reporting Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.302 § 200.303

Views of Responsible Officials: During our FY22 audit, GRF expressly noted that for an organization our size, tracking grant expenses outside of Quickbooks was understandable and acceptable. During this FY23 audit, GRF changed its stance and said we had to report grant expenses in Quickbooks. This s...

Views of Responsible Officials: During our FY22 audit, GRF expressly noted that for an organization our size, tracking grant expenses outside of Quickbooks was understandable and acceptable. During this FY23 audit, GRF changed its stance and said we had to report grant expenses in Quickbooks. This should be removed as a finding, as District Bridges was following the advice of GRF from the FY22 audit. It is unconscionable to discredit an organization after they followed the firm's advice. Additionally, over the last few months, we have consulted several other nonprofit finance experts, as well as peer organizations that receive federal funds, to see tracking templates and procedures, and understand best practices. We are currently exploring more robust grant expense tracking softwares based on their recommendations, but they all noted that spreadsheet tracking was acceptable for an organization of our size.

View Audit 311249

Finding 404823 (2023-001)

None 2023

Lafourche Parish Government

LA

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Reporting § 200.328

CORRECTIVE ACTION PLAN: We will take the necessary steps to get clear deadlines from the awarding agency on the reporting dates for Head Start and update our formal reporting schedule with those dates. The Head Start Fund Accountant will work with the Administrative Assistant/Facilities Manager in g...

CORRECTIVE ACTION PLAN: We will take the necessary steps to get clear deadlines from the awarding agency on the reporting dates for Head Start and update our formal reporting schedule with those dates. The Head Start Fund Accountant will work with the Administrative Assistant/Facilities Manager in gathering the necessary information earlier in the year for the yearly property reporting (SF-429). The Head Start Fund Accountant will email copies of these reports to the Director of Head Start to ensure compliance.

View Audit 311215

Finding 404816 (2023-007)

Material Weakness 2023

Mobridge Regional Hospital

SD

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s final expenditure listing identified as eligible and claimed under ...

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s final expenditure listing identified as eligible and claimed under the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution program (the program) was not reviewed and approved by a separate individual outside of the preparer. Additionally, the Hospital claimed mortgage reimbursements as expenditures under the program. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: A Grant Award Policy and Procedure Manual was established which includes, but not limited to, outlined internal controls around the review, approval, and tracking of grants/awards allowable expenses and reporting. Anticipated Completion Date: June 30, 2024

View Audit 311195 Questioned Costs: $1

Finding 404815 (2023-006)

Material Weakness 2023

Mobridge Regional Hospital

SD

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s lost revenue calculation was not reviewed and approved by a separat...

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s lost revenue calculation was not reviewed and approved by a separate individual outside of the preparer. The Hospital’s lost revenue calculation was based upon actual revenue billed and reported within the Hospital’s electronic medical records (EMR) system which does not consider monthly or quarterly adjustments. The Hospital’s special report submitted to the Department of Health and Human Services for Period 4 TIN#460255944 was not reviewed and approved by a separate individual outside of the individual who inputted and submitted the report. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: A Grant Award Policy and Procedure Manual was established which includes, but not limited to, outlined internal controls around the review, approval, and tracking of grants/awards allowable expenses and reporting. The Hospital did not have Period 2 or Period 3 reporting requirements. The Phase 4 special report was submitted without review and approval over the report and lost revenue calculation due to limited personnel in finance. The Hospital does not have any additional special reports to complete for this federal program. Anticipated Completion Date: June 30, 2024

View Audit 311195

Finding 404814 (2023-005)

Significant Deficiency 2023

Mobridge Regional Hospital

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

Corrective Action Plans

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