Corrective Action Plans

Finding 396140 (2023-005)

Material Weakness 2023

AK

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.400

Finding 2023-005 Lack of Internal Control / Noncompliance over Subrecipient Monitoring Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: HCSD established a Subrecipient Monitoring Checklist as a monitoring tool to ensure that subrecipients are successful and complia...

Finding 2023-005 Lack of Internal Control / Noncompliance over Subrecipient Monitoring Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: HCSD established a Subrecipient Monitoring Checklist as a monitoring tool to ensure that subrecipients are successful and compliant and the subawards are used in accordance with federal statutes, regulations, and the terms and conditions of the federal and state awards. Proposed Completion Date: Fiscal Year 2024

View Audit 305718 Questioned Costs: $1

Finding 396138 (2023-004)

Material Weakness 2023

Hydaburg City School District

AK

Questioned Costs Allowable Costs / Cost Principles § 200.400

Federal Award Findings and Questioned Costs Finding 2023-004 Lack of Internal Control / Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: Management will ensure that the system o...

Federal Award Findings and Questioned Costs Finding 2023-004 Lack of Internal Control / Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: Management will ensure that the system of internal controls over cash disbursements is designed appropriately and operates effectively to ensure all transactions are coded, reviewed, and approved before payment is made. The Business manager and the Superintendent will conduct a review of claims to determine whether they are proper and valid charges. Once reviewed, all transactions will be authorized. DocuSign will be used for electronic signature approval. Accounts payable clerk will ensure that all transactions include copies of receipts for the goods or services purchased. Finally, the Finance department will work with the program directors to ensure that expenses are coded accurately and within reasonable timeframe to allow for timely submission of grant reports. Proposed Completion Date: Fiscal Year 2024

View Audit 305718 Questioned Costs: $1

Finding 396130 (2023-001)

Significant Deficiency 2023

Goodwill Industries of Michiana, Inc.

IN

Allowable Costs / Cost Principles Cash Management Significant Deficiency

CORRECTIVE ACTION PLAN April 23, 2024 Goodwill Industries of Michiana, Inc. respectfully submits the following corrective action plan for the year ended 2023. Audit Period: Year Ended December 31, 2023 SIGNIFICANT DEFICIENCY FINDING – FEDERAL AWARDS 2023-001 ALLOWABLE COSTS An employee requested...

CORRECTIVE ACTION PLAN April 23, 2024 Goodwill Industries of Michiana, Inc. respectfully submits the following corrective action plan for the year ended 2023. Audit Period: Year Ended December 31, 2023 SIGNIFICANT DEFICIENCY FINDING – FEDERAL AWARDS 2023-001 ALLOWABLE COSTS An employee requested expense reimbursement through payroll which was default coded to the grant. The expense was for a different grant and noted as such in the description. The unallowed cost was charged to the incorrect grant and reimbursed by the grantor. Recommendation: Management should implement a review process to ensure payroll reimbursements are accurately allocated to the correct grant for reimbursement. Action Taken: The payroll expense reimbursement process has been reviewed and steps added to ensure expenses are being charged to the correct grants. This includes reviewing the notes included in the expense reimbursement submission. Correcting entries will be made when needed to ensure expenses are charged to the correct grant. Contact Person: Karman Eash, CFO keash@goodwill-ni.org Effective Date: April 23, 2024

View Audit 305709

Finding 396119 (2023-001)

Material Weakness 2023

Mountain Park Health Center

AZ

Questioned Costs Allowable Costs / Cost Principles Reporting

Mountain Park evidenced the full spend down of period four provider relief funds through lost revenue which was tested and appropriately supported. These funds are not subject to repayment as there were no questioned costs and the organization was able to attest and comply with the terms and conditi...

Mountain Park evidenced the full spend down of period four provider relief funds through lost revenue which was tested and appropriately supported. These funds are not subject to repayment as there were no questioned costs and the organization was able to attest and comply with the terms and conditions of the funding, including demonstrating that the distributions received were used for qualifying lost revenue attributable to COVID-19. To ensure compliance in the future, Mountain Park has implemented comprehensive internal control processes to ensure that expenses covered by other programs are excluded, including documented review and approval prior to report submissions. Expected completion date: November 30, 2023 Owner: Sandra Curtice, CFO

View Audit 305697 Questioned Costs: $1

Finding 396118 (2023-003)

Significant Deficiency 2023

The Puerto Rican Cultural Center

IL

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment

2023-003 - While we believe this was a legitimate cost, there was an uncommon problem due to the fact that these were charged on the company credit card instead of our normal procurement process. In the future we will make sure to use our normal procurement process. - May 31, 2024 - David Broutman C...

2023-003 - While we believe this was a legitimate cost, there was an uncommon problem due to the fact that these were charged on the company credit card instead of our normal procurement process. In the future we will make sure to use our normal procurement process. - May 31, 2024 - David Broutman CPA

View Audit 305679 Questioned Costs: $1

Finding 396062 (2023-007)

Significant Deficiency 2023

State of New Jersey

NJ

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.430

The Department of Human Services (DHS), Central Office Payroll group will run reports biweekly to determine if any employees are on a leave without pay status greater than 10 days. This added reporting function will ensure that all DHS employees who are on a leave of absence without pay beyond 10 d...

The Department of Human Services (DHS), Central Office Payroll group will run reports biweekly to determine if any employees are on a leave without pay status greater than 10 days. This added reporting function will ensure that all DHS employees who are on a leave of absence without pay beyond 10 days have their PMIS histories updated upon each extension and return to work. COMPLETION DATE/ CONTACT PERSON March 26, 2024 Maureen Taylor (609) 292-6106 Maureen.Taylor@dhs.nj.gov

View Audit 305672 Questioned Costs: $1

Finding 396040 (2023-001)

None 2023

Stonegate Housing, Ltd.

TX

Allowable Costs / Cost Principles

Reporting views of responsible officials Concur or do not concur with this finding: Concur Agree or disagree with auditor recommendations: Agree Completion date or proposed completion date: December 31, 2024 Actions taken or planned on the finding Participate in training to assist in the develo...

Reporting views of responsible officials Concur or do not concur with this finding: Concur Agree or disagree with auditor recommendations: Agree Completion date or proposed completion date: December 31, 2024 Actions taken or planned on the finding Participate in training to assist in the development of written policies and procedures, and standards of conduct to be in compliance with 2 Code of Federal Regulations Part 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Subpart D – Post Federal Award Requirements and Subpart E – Cost Principles.

View Audit 305664

Finding 396027 (2023-001)

Significant Deficiency 2023

Harrisburg Area YMCA

PA

Questioned Costs Allowable Costs / Cost Principles § 200.430

Recommendation: We recommend that controls be reviewed and revised to ensure that time and effort distribution records are prepared for staff who are charged to federal programs. These records should also be reviewed, approved, and maintained by administrative personnel. Action Taken: The Harrisbu...

Recommendation: We recommend that controls be reviewed and revised to ensure that time and effort distribution records are prepared for staff who are charged to federal programs. These records should also be reviewed, approved, and maintained by administrative personnel. Action Taken: The Harrisburg Area YMCA's Compliance Officer has created a tracking sheet that will allow employees to keep track of their tasks and hours as related to grant programs. The employee will sign off on each sheet.

View Audit 305627 Questioned Costs: $1

Finding 396004 (2023-004)

Material Weakness 2023

Boys and Girls Clubs of Philadelphia, Inc.

PA

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.329

Out of over 182 compliance records requested, the organization was unable to provide 3 health assessments, all other requested documentation was provided. The missing health assessments were for high school students, who are not required to provide them to attend school and often do not have access ...

Out of over 182 compliance records requested, the organization was unable to provide 3 health assessments, all other requested documentation was provided. The missing health assessments were for high school students, who are not required to provide them to attend school and often do not have access to updated health assessments. We have been directed by the funding agency never to exclude these youth from participation for an inability to obtain a health assessment. BGCP has already taken steps to address these issues. The funding agency, PHMC has begun sending monthly compliance reports. Over the last three months, we have collected 42% of missing health assessments organization wide. Additionally, on our recent FY24 Admin review from PHMC, which included a full compliance report, all of our sites received overall scores of above 95%. We will continue to monitor compliance and follow-up with youth and families to complete needed items.

View Audit 305611 Questioned Costs: $1

Finding 395992 (2023-003)

Material Weakness 2023

Boys and Girls Clubs of Philadelphia, Inc.

PA

Reporting Allowable Costs / Cost Principles

Management concurs the initial Schedule of Federal Awards was prepared using the total program expenditures and not the program expenditures incurred using just the federal portion of the program funding. Unfortunately, information regarding the federal versus non-federal breakdown of awards is not...

Management concurs the initial Schedule of Federal Awards was prepared using the total program expenditures and not the program expenditures incurred using just the federal portion of the program funding. Unfortunately, information regarding the federal versus non-federal breakdown of awards is not available in initial program contracts. This information is only disclosed as part of the confirmation process. However, moving forward, management will meet quarterly to update the tracking of federal expenditures. Additionally, management will communicate with funding entities bi-annually to verify what portions of the funding are federal. Management will also work closely with the auditors to ensure funding allocations per confirmations, if different than projected, are reflected properly in the Schedule of Federal Awards.

View Audit 305611

Finding 395990 (2023-002)

Material Weakness 2023

Boys and Girls Clubs of Philadelphia, Inc.

PA

Questioned Costs Allowable Costs / Cost Principles Cash Management

The questioned costs were immaterial and relate to a pay period that was split across the fiscal year (6/27/22 to 7/8/22, with a pay date of 7/15/22). Reports to the funder for the year ending 6/30/22 were due on 7/10/22, before all payroll information and supporting documentation for this pay perio...

The questioned costs were immaterial and relate to a pay period that was split across the fiscal year (6/27/22 to 7/8/22, with a pay date of 7/15/22). Reports to the funder for the year ending 6/30/22 were due on 7/10/22, before all payroll information and supporting documentation for this pay period was available. Therefore, the full pay period was included in the July reimbursement report. This practice was approved by the funder. Moving forward, the organization will be more cognizant of accrual dates for payroll reporting and submit a true-up as needed to ensure that payroll costs are correctly allocated at the end of the fiscal year. Additionally, in May 2024, the organization will be implementing a new electronic payroll system that will allow us to obtain this information more quickly at the close of each fiscal year to complete billing reports.

View Audit 305611 Questioned Costs: $1

Finding 395985 (2023-002)

Significant Deficiency 2023

Rfe/rl, Inc.

DC

Reporting Allowable Costs / Cost Principles § 200.301

Views of Responsible Officials: Management acknowledges the importance of timely reporting. RFE/RL is committed to improving timeliness by engaging an outside accounting firm to bring the company into compliance with current reporting requirements, increasing staff capacity, implementing a new repor...

Views of Responsible Officials: Management acknowledges the importance of timely reporting. RFE/RL is committed to improving timeliness by engaging an outside accounting firm to bring the company into compliance with current reporting requirements, increasing staff capacity, implementing a new reporting software tool, documenting sustainable reporting procedures and working with our funder on agreed upon reports and deadlines.

View Audit 305606

Finding 395832 (2023-005)

Significant Deficiency 2023

Bertie County

NC

Allowable Costs / Cost Principles Reporting Cash Management

Finding: 2023‐005: Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Daphine Little, Director of Bertie County Department of Social Services Corrective Action/Management's Response: DSS agrees that there were some discrepanc...

Finding: 2023‐005: Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Daphine Little, Director of Bertie County Department of Social Services Corrective Action/Management's Response: DSS agrees that there were some discrepancies found in two out of twenty‐three employee daysheets vs. timesheets resulting in more program time reported on the daysheets than the approved timesheets. Supervisors are responsible for ensuring that time reported on employee daysheets matches the timesheets. Bertie County DSS utilizes an Excel spreadsheet provided by Bertie County Government that is completed by each employee monthly to report time worked. As it is the Supervisor’s responsibility to verify and approve the accuracy of employee daysheets, the Supervisor is expected to reconcile time reported on employee daysheets to time reported on employee timesheets. Plan of Action:  Provide employees with a copy of Power Point Training ‐Day Sheets: Time Reporting and Reimbursement for County DSS (2022).  Reiterate the importance of employees reporting the same amount of time on the daysheet vs. the timesheet.  Communicate with Supervisors the importance of reconciling employee daysheets vs. timesheets. Proposed Completion Date: March 1, 2024

View Audit 305469

Finding 395816 (2023-103)

Material Weakness 2023

Greater Phoenix Urban League INC

AZ

Allowable Costs / Cost Principles Cash Management Material Weakness

Finding 2023-103 Allowable Costs/Cost Principles/Reporting (Material Weakness, Compliance Finding) Repeat Finding. Responsible Individuals: William Bridgeman, Chief Fiscal Officer Natalie Alvarez, Chief Operating Officer- Head Start Director Corrective Action Plan: Greater Phoenix Urban League (Dele...

Finding 2023-103 Allowable Costs/Cost Principles/Reporting (Material Weakness, Compliance Finding) Repeat Finding. Responsible Individuals: William Bridgeman, Chief Fiscal Officer Natalie Alvarez, Chief Operating Officer- Head Start Director Corrective Action Plan: Greater Phoenix Urban League (Delegate Agency) will continue its on- going collaborate with the City of Phoenix (Grantee) in evaluating the process and effectiveness of inserting and updating the “quarterly administrative reporting package”, relatively to its use and the accuracy of the content that flows within the excel workbooks. Anticipated Completion Date: On going throughout the contract period on an annualized basis. July 1, 2024

View Audit 305459

Finding 395815 (2023-102)

Material Weakness 2023

Greater Phoenix Urban League INC

AZ

Questioned Costs Allowable Costs / Cost Principles Reporting

Finding 2023-102 – Allowable Costs/Cost Principle (Material Weakness, Compliance Finding) Responsible Individual: William Bridgeman-Chief Fiscal Officer Corrective Action Plan: The organization tracks all revenue and expenses specifically and directly related to the Head Start Program CFDA 93.600 by...

Finding 2023-102 – Allowable Costs/Cost Principle (Material Weakness, Compliance Finding) Responsible Individual: William Bridgeman-Chief Fiscal Officer Corrective Action Plan: The organization tracks all revenue and expenses specifically and directly related to the Head Start Program CFDA 93.600 by individual general ledger. Each revenue and expenses account are supported with documentation. Classes within QuickBooks are available within the platform. However, using classes is optional and with the purchase of the more advance version of QuickBooks “QuickBooks Enterprise Platinum” it’s the intent of the organization to move to enhanced detail general ledger accounts (which will provide detail data relating to each individual transaction). As it relates to Assistance Listing No 93.185 National Urban League Vaccine Equity 2021-22 in the amount of $40,000 and Assistance Listing no. 10-551 in the amount of $52,129 is not affiliated with Head Start from a program perspective. No staff time or expenses of the two grants are related to the Head Start Program. Each of the reference programs are stand-alone funded through a third-party pass through grantee and not a direct grant from a federal agency. However, the organization will establish separate classes within QuickBooks Enterprise Platinum for each federal and state contract. The implementation of the vertical classes within the QuickBooks Enterprise Platinum platform will consist of the reconciliation of cost reimbursements with a separate and dedicated “in kind” calculation of 25% within the class where applicable as per grantee requirement. Implementation Date: July 1, 2024

View Audit 305459 Questioned Costs: $1

Finding 395814 (2023-101)

Material Weakness 2023

Greater Phoenix Urban League INC

AZ

Questioned Costs Allowable Costs / Cost Principles Cash Management

Finding 2023-101 Allowable Costs/Cost Principle and Reporting (Material Weakness Compliance Finding) Repeat Finding Responsible Individuals: William Bridgeman Chief Fiscal Officer Natalie Alvarez- Chief Operating Officer Head Start Director Corrective Action Plan: Greater Phoenix Urban League has r...

Finding 2023-101 Allowable Costs/Cost Principle and Reporting (Material Weakness Compliance Finding) Repeat Finding Responsible Individuals: William Bridgeman Chief Fiscal Officer Natalie Alvarez- Chief Operating Officer Head Start Director Corrective Action Plan: Greater Phoenix Urban League has received great support from our community partners by providing in-kind space in 4 school districts and the abundance of parent volunteer support for our Head Start program, however, the program struggles to identify the in-kind match during the turn to full on campus instruction. COVID19 has had a considerable impact on the programs ’s ability to meet the non-federal share obligation as families and community volunteers are not allowed fully back onto Head Start Campuses and enrollment has declined. The program was unable to open several classrooms due to lack of qualified staff and low enrollment. In the past, Greater Phoenix Urban League Head Start has relied heavily on in-kind Space as the main source of program match and with the closing of classrooms in-kind was very difficult to collect. We believe we have worked towards meeting the challenge of program in-kind match. We have used ARPA funds to develop “A grow your own program.” Greater Phoenix Urban League Head Start has recruited parents and the community to participant in a workforce development program to train and hire new Head Start staff as classroom aides and teacher assistances. We also have contracted with an organization to provided contracted instructional support to open up temporarily closed classrooms. The program will continue to identify non-federal share to meet the obligations of the grant award. COVID will continue to have an impact on the programs ’s ability to meet non-federal share but it certainly opens new channels of identifying non-federal share. The following steps are in progress of being implemented in fiscal year 23-24 within the grantee: • An internal control process has been developed to review the current system to document the resources for non-federal share. A Data Assistant will review and analyze at our process in collecting in kind. • Revised Policies and procedures will be developed to assisted instructional staff to collect parent volunteer hours. • Parent Policy Committee will be trained on the non-federal share in-kind as it relates to their important role within the Head Start Program. • Greater Phoenix Urban League Head Start will continue to review the internal control process annually to ensure compliance with the Head Start Program Performance Standards, federal regulations, and City of Phoenix Grantee regulations. • Greater Phoenix Urban League Chief Fiscal Officer, fiscal staff, Program Director and Grantee Fiscal and Program staff will meet monthly to review fiscal reporting and requirements, to ensure grant obligations are on track. • Greater Phoenix Urban League will continue their efforts to identify citywide partners that can provide non-federal share to the Head Start Program. • Greater Phoenix Urban League Chief Fiscal Officer, fiscal staff, Program Director and Grantee Fiscal and Program staff will meet monthly to review fiscal reporting and requirements, to ensure grant obligations are on track. • All third-party appraisals will be conducted in May 2024 to reflect the current market value of space and real property. • The activities mentioned above will assist the Greater Phoenix Urban League-Head Start Program in meeting its obligations in the coming years. Anticipated Completion Date: Ongoing throughout the contract period on an annualized basis. May 1, 2024

View Audit 305459 Questioned Costs: $1

Finding 395809 (2023-001)

None 2023

Health Department of Northwest Michigan

MI

Allowable Costs / Cost Principles

Accounting leadership will review general Federal guidelines for allowable costs with directors and supervisors. Additionally, directors and supervisors will be reminded of their responsibility for, and the importance of, carefully reviewing coding of individual program expenditures to align with Fe...

Accounting leadership will review general Federal guidelines for allowable costs with directors and supervisors. Additionally, directors and supervisors will be reminded of their responsibility for, and the importance of, carefully reviewing coding of individual program expenditures to align with Federal guidelines. Accountants currently meet monthly with directors and supervisors to review the financial status of each program, including unreasonable budget variances and the reasonableness of current expenditure levels. Going forward, they will also review the individual expenditures in categories deemed most likely to have unallowable transactions

View Audit 305437

Finding 395759 (2023-004)

Significant Deficiency 2023

Grand Forks Regional Airport Authority

ND

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures over payment requests to ensure allowability accuracy. Completion Date –December 31, 2024

View Audit 305388 Questioned Costs: $1

Finding 395755 (2023-002)

Significant Deficiency 2023

Occk, Inc.

KS

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Auditors’ Recommendation: We recommend the Agency implement control activities and monitoring procedures to ensure monthly reports that are submitted to the funding agencies are accurately reflecting allowable grant costs. Action Taken: We agree with the finding and have taken the actions as outlin...

Auditors’ Recommendation: We recommend the Agency implement control activities and monitoring procedures to ensure monthly reports that are submitted to the funding agencies are accurately reflecting allowable grant costs. Action Taken: We agree with the finding and have taken the actions as outlined in finding 2023‐001 to fully address and improve the control process. Specifically, Agency management has reviewed the internal processes and enhanced control activities to ensure the mechanic salaries are accurately reported in the monthly operating reports going forward.

View Audit 305387 Questioned Costs: $1

Finding 395754 (2023-001)

Significant Deficiency 2023

Occk, Inc.

KS

Questioned Costs Allowable Costs / Cost Principles

Auditors’ Recommendation: Agency management took immediate action to determine the effect for the entire year, communicated with the auditor, communicated with the Kansas Department of Transportation, and developed the plan to respond to the finding. As recommended by the Kansas Department of Transp...

Auditors’ Recommendation: Agency management took immediate action to determine the effect for the entire year, communicated with the auditor, communicated with the Kansas Department of Transportation, and developed the plan to respond to the finding. As recommended by the Kansas Department of Transportation, a check for $13,715 will be written to the Kansas Department of Transportation. The last six‐month amount of $20,781 will be reported on the February, 2024, operating report to reduce the Kansas Department of Transportation reimbursement provided to the Agency for the year ending June 30, 2024. Action Taken: We agree with the finding and have taken the following actions to fully address and correct the discrepancies. 1. Agency management reviewed all twelve months of 2023 billing to determine the total amount to return to the Kansas Department of Transportation. After this review, management determined that the overreporting discrepancies began in January, 2023, and occurred every month through December, 2023. 2. A meeting was held between Agency management and the Kansas Department of Transportation Program Administrator and Program Consultant to discuss the findings and determine a plan of action to correct the discrepancies. The action planned is outlined in the Recommendation section of this finding. 3. Monthly Operating Budget billings for January 2023 through December 2023, were reviewed and the appropriate amounts that should have been billed were determined and compared to the actual amount billed to KDOT. The net result is as identified in the Recommendation section of this finding. 4. Agency management has reviewed the internal processes and enhanced control activities to ensure the mechanic salaries are accurately reported in the monthly operating reports going forward.

View Audit 305387 Questioned Costs: $1

Finding 395744 (2023-003)

Material Weakness 2023

Ucan

IL

Allowable Costs / Cost Principles § 200.405

Identifying Number: 2023-003 Finding: Allowable Costs Corrective Action Taken or Planned: Procedures have been updated to include procedures and internal controls for regular review of the general ledger of their programs and reconcile to the vouchers prior to submission to the granting agency. Anti...

Identifying Number: 2023-003 Finding: Allowable Costs Corrective Action Taken or Planned: Procedures have been updated to include procedures and internal controls for regular review of the general ledger of their programs and reconcile to the vouchers prior to submission to the granting agency. Anticipated Implementation and Responsible Official: April 30, 2024, Suresh Sharma, Chief Financial Officer

View Audit 305385

Finding 395731 (2023-001)

Significant Deficiency 2023

Disability Rights Maine

ME

Allowable Costs / Cost Principles

Corrective Action Plan for Current Year Finding 2023-001 – Internal Control over Allocation of Payroll Description of Finding: The allocation of payroll between grants was inaccurate due to errors when restoring the allocation workbook used to calculate payroll as well as an employee changing progra...

Corrective Action Plan for Current Year Finding 2023-001 – Internal Control over Allocation of Payroll Description of Finding: The allocation of payroll between grants was inaccurate due to errors when restoring the allocation workbook used to calculate payroll as well as an employee changing programs and new position filled which were not reflected properly in the allocation. Cause: Insufficient internal controls due to inadequate staffing. Effect: Without ensuring the payroll allocation is proper based on time and effort records as well as predetermined program allocations, it is possible that grants could be overcharged, resulting in misstated financial statements and unallowable costs. Corrective Action: DRM is committed to adequate staffing levels. Executive Management realizes the necessity for adequate staffing levels to maintain top notch internal controls. The following corrective actions will be taken to avoid the misallocation of payroll funds moving forward. 1. All program allocation updates in the payroll workbook will be completed by the CFO. 2. Any malfunctions in the payroll workbook will be reported to the CFO by the payroll processor before the Labor Distribution Report (LDR) is imported for time distribution. 3. The CFO will review the LDR for any anomalies prior to it being imported into the payroll workbook each pay period. 4. The CFO will review the predetermined program allocations in the payroll workbook monthly to ensure that they are accurate and current. 5. The CFO will compare the employee timesheets, LDR, and payroll expense report to the payroll allocations outlined in the agency budget each month. Person(s) Responsible: Shannon Crocker, CFO Timing for Implementation: Immediately

View Audit 305363

Finding 395730 (2023-005)

Significant Deficiency 2023

Central Montana Medical Center

MT

Questioned Costs Allowable Costs / Cost Principles § 200.303

2023‐005 – Year Ended June 30, 2023 Department of Health and Human Services Federal Assistance Listing/# 93.498 Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Significant Deficiency in Internal Control over Compliance Finding Summary: 2 CFR 200.303(a) establis...

2023‐005 – Year Ended June 30, 2023 Department of Health and Human Services Federal Assistance Listing/# 93.498 Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Significant Deficiency in Internal Control over Compliance Finding Summary: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The Facilities claimed equipment costs under the Provider Relief Fund program for a project that was not complete at the end of the period of availability, or December 31, 2022. Costs were improperly included within the Period 4 report and caused the reporting submitted to the Department of Health and Human Services to be inaccurate. Responsible Individual: Perry Howell, CFO Corrective Action Plan: The Facilities will enhance internal control policies to ensure all amounts are adequately documented and properly recorded in the reports required to be submitted to the federal agency. The Facilities will enhance internal control policies to ensure that the required reports are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: June 2024

View Audit 305361 Questioned Costs: $1

Finding 395648 (2023-002)

Significant Deficiency 2023

Maine Guaranteed Access Reinsurance Association

ME

Allowable Costs / Cost Principles Significant Deficiency

Finding 2023‐002 Federal Agency Name: U.S. Department of Health and Human Services Pass‐Through Entity: Federal Financial Assistance Listing 93.423 Assistance Listing Number: 1332 State Innovation Waivers Program Name: Maine Guaranteed Access Reinsurance Association (MGARA) Finding Summary: The Asso...

Finding 2023‐002 Federal Agency Name: U.S. Department of Health and Human Services Pass‐Through Entity: Federal Financial Assistance Listing 93.423 Assistance Listing Number: 1332 State Innovation Waivers Program Name: Maine Guaranteed Access Reinsurance Association (MGARA) Finding Summary: The Association’s existing controls over their IT environment for reviewing and reimbursing carriers for claims was not able to detect and prevent a claim from being reimbursed twice.Corrective Action Plan: The duplicate payment to Aetna was requested back to the program and will be received in April 2024. Going forward, the administrator will run reports at the beginning of each calendar year to ensure that all insurance carrier exception reports are generated. This will ensure that whenever claims are processed that all duplicate claims will be identified and denied. Responsible Individual(s): Diane Kopecky, administrator Anticipated Completion Date: April 2024

View Audit 305278

Finding 395596 (2023-001)

Material Weakness 2023

Southwest Organizing Project

IL

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.100 § 200.510

Finding No. 2023-001 Schedule of Expenditures of Federal Awards Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate system of internal controls will be put in pla...

Finding No. 2023-001 Schedule of Expenditures of Federal Awards Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate system of internal controls will be put in place by the end of fiscal year 2024. To ensure SEFA will include accurate assisting listing numbers and accurate inclusion of all federal programs. Allowable and unallowable costs will be reviewed to ensure accurate federal expenditure reporting. Edith Robles will perform an exhaustive review of all grants to close out the fiscal year in preparation for the audit process. In addition to these, SWOP will work with a consultant to provide necessary training of finance personnel.

View Audit 305207

Corrective Action Plans

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