Corrective Action Plans

Finding 565175 (2022-011)

Material Weakness 2022

City of Paterson

NJ

Questioned Costs Allowable Costs / Cost Principles

City was delayed due to staff shrotages. City is catching up and has controls set

View Audit 359090 Questioned Costs: $1

Finding 564446 (2022-004)

Significant Deficiency 2022

Day One

RI

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.405

Management’s Planned Corrective Action: Disagree; There was an error in staff name and not billed to SAPC Substance Abuse Prevention and Control-CPS. Responsible Party: Beaulieu Accountancy Corporation, Accountant Completion Date: 9/25/2024

View Audit 358580

Finding 563973 (2022-009)

Significant Deficiency 2022

Bach Viet

CA

Allowable Costs / Cost Principles Cash Management

Management’s Planned Corrective Action: It is our policy that employees submit a time sheet that sets forth the hours worked on a bi-weekly basis. I have now requested that the employee reports the amount of time that they spend on program activities to accurately report time spent. Responsible Part...

Management’s Planned Corrective Action: It is our policy that employees submit a time sheet that sets forth the hours worked on a bi-weekly basis. I have now requested that the employee reports the amount of time that they spend on program activities to accurately report time spent. Responsible Party: Mel Demoff, Executive Director Completion Date: October 1, 2023

View Audit 358145

Finding 563971 (2022-007)

Significant Deficiency 2022

Bach Viet

CA

Allowable Costs / Cost Principles Cash Management Significant Deficiency

Management’s Planned Corrective Action: I am in the process of working with our CPA in implementing a Cost Allocation plan that will accurately allocate costs between all programs and these costs will be developing a system whereby the monthly reports will be based on number served rather than the n...

Management’s Planned Corrective Action: I am in the process of working with our CPA in implementing a Cost Allocation plan that will accurately allocate costs between all programs and these costs will be developing a system whereby the monthly reports will be based on number served rather than the number of participants. Responsible Party: Mel Demoff, Executive Director Completion Date: January 1, 2024

View Audit 358145

Finding 562181 (2022-001)

Material Weakness 2022

City of Williamsport

PA

Allowable Costs / Cost Principles Equipment & Real Property Management Special Tests & Provisions

During the audit period through 2022, there was a transition of fiscal and administrative personnel at the City of Williamsport. Due to findings of an internal financial investigation, the City communicated with appropriate parties and a grand jury was convened. The City has been and continues to be...

During the audit period through 2022, there was a transition of fiscal and administrative personnel at the City of Williamsport. Due to findings of an internal financial investigation, the City communicated with appropriate parties and a grand jury was convened. The City has been and continues to be under state and federal criminal investigations since February of 2020. Numerous financial records, extending over a 10-year period, have been provided to investigators. In June of 2022, the City hired a consultant to provide fiscal oversight on an ongoing basis and reconcile, to the extent possible prior financial records. Since that time, the City has enhanced internal control and implemented policies to assure accurate financial reporting and compliance. The City anticipates a similar finding for the December 31, 2020, 2021, and 2022 audits, but with the exception of the results of the criminal investigations, expects to resolve this finding for the December 31, 2023 audit.

View Audit 357789

Finding 561490 (2022-008)

Material Weakness 2022

Sayre Health Center

PA

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

Finding No. 2022-008: Lack of Management Oversight to Ensure Retention of Timesheets Grant timesheets are now being maintained with appropriate charging of time to the related programmatic or administrative functions. The timesheets are signed off by the employee and their related supervisor and mai...

Finding No. 2022-008: Lack of Management Oversight to Ensure Retention of Timesheets Grant timesheets are now being maintained with appropriate charging of time to the related programmatic or administrative functions. The timesheets are signed off by the employee and their related supervisor and maintained in the shared file for immediate availability and reference.

View Audit 357068 Questioned Costs: $1

Finding 561489 (2022-007)

Material Weakness 2022

Sayre Health Center

PA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding No. 2022-007: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will rec...

Finding No. 2022-007: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will recognize a “full discount” for individuals and families with annual incomes at or below 100% Federal poverty level (FPL) with only nominal fees charged, three levels of discount between 100% and 200%, and no discounts for copays for individuals and families earning over 200% FPL. This policy will be in accordance with Section 330(k)(3)(G) of the PHS Act and 42 CFR Part 51c.303(f) and 42 CFR Part 51c.303(u) which are incorporated herewith. We will charge a nominal fee to individuals and families with annual incomes at or below 100% of the FPL. Patients whose incomes are above 100% or below 200% of the FPL will be charged according to our sliding fee scale based on income and family size. Discounts will be provided to patients with incomes up to 200% of the FPL for medical visits. Discounts will be provided to patients with incomes up to 250% of the FPL for family planning visits. Staff will assess patients’ incomes based upon a sliding fee scale and no patient will be denied care based upon their inability to pay. The organization also has a policy of nondiscrimination in the delivery of health care as stated in its Patient Bill of Rights. Also, the Board of Directors define the income and family size, and has defined the family size to be all parents, minors or guardians that are financially responsible for the household. The tracking and documentation of sliding fees is now maintained with the deposit record of each fee received in the shared file for immediate availability and reference.

View Audit 357068 Questioned Costs: $1

Finding 561169 (2022-001)

Significant Deficiency 2022

M. Carter Plaza

OR

HUD Housing Programs Allowable Costs / Cost Principles Reporting § 200.512

Finding no.: 2022-001 Contact person(s) responsible: Kymberly Horner, Executive Director Corrective action planned: The late filing was due to the fiscal manager position at PCRI experiencing turnover in September of 2019, this, along with the onset of COVID-19 in the first quarter of 2020 led ...

Finding no.: 2022-001 Contact person(s) responsible: Kymberly Horner, Executive Director Corrective action planned: The late filing was due to the fiscal manager position at PCRI experiencing turnover in September of 2019, this, along with the onset of COVID-19 in the first quarter of 2020 led to delays in the normal review and submission of the data collection form. The fiscal manager position has been staffed and is aware of the deadline related to the submission of the data collection form. Anticipated completion date: October 2023

View Audit 356760

Finding 560504 (2022-010)

Material Weakness 2022

Orutsararmiut Native Council

AK

Allowable Costs / Cost Principles Eligibility Material Weakness

Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments have been filled to ensure that the Council follows internal control policies over grant reporting. Proposed Completion Date: Complete as of June 30, 2024

View Audit 356419

Finding 560502 (2022-008)

Material Weakness 2022

Orutsararmiut Native Council

AK

Allowable Costs / Cost Principles Material Weakness Reporting

Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments will be filled to ensure that the Council follows internal control policies over payroll transactions. Proposed Completion Date: Complete as of June 30, 2024

View Audit 356419

Finding 560501 (2022-007)

Material Weakness 2022

Orutsararmiut Native Council

AK

Allowable Costs / Cost Principles Material Weakness Reporting

Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments will be filled to ensure that the Council follows internal control policies over cash disbursements. Proposed Completion Date: Complete as of June 30, 2024

View Audit 356419

Finding 560149 (2022-016)

Material Weakness 2022

Oregon Coast Community Action

AL

Cash Management Subrecipient Monitoring Allowable Costs / Cost Principles

The Energy program has been current on the required reporting since the referenced audit period. The program is aware of the grants' requirements now. Additionally, ORCCA plans to utilize grant tracker system with the ability to send reminders for important dates to avoid future delinquent reporting...

The Energy program has been current on the required reporting since the referenced audit period. The program is aware of the grants' requirements now. Additionally, ORCCA plans to utilize grant tracker system with the ability to send reminders for important dates to avoid future delinquent reporting that was experienced during the audit period. The system will be utilized by the program directors as well as finance team (Finance Director, Accounting Manager, Program Fiscal Compliance Coordinator) working with grants/directors. ORCCA's current process at the Energy program level has already improved to ensure proper documentation of eligibility. The Energy program director and staff are implementing this internal control at the program level to review the supporting documents and information and proper coding to the correct period. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 2025

View Audit 356132

Finding 560138 (2022-013)

Material Weakness 2022

Oregon Coast Community Action

AL

Allowable Costs / Cost Principles Eligibility Period of Performance § 200.303

ORCCA's current process at the program level has improved to ensure proper documentation of eligibility. The Housing director and staff have implemented this internal control at the program level. The finance department's internal control (as noted earlier) is in place to ensure the payment requests...

ORCCA's current process at the program level has improved to ensure proper documentation of eligibility. The Housing director and staff have implemented this internal control at the program level. The finance department's internal control (as noted earlier) is in place to ensure the payment requests have sufficient supporting documentation. As for record retention, ORCCA hired additional temp workers to ensure completed transactions are filed timely with the goal of going paperless in the near future. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 2025

View Audit 356132

Finding 560113 (2022-008)

Material Weakness 2022

Oregon Coast Community Action

AL

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.403 § 200.404 § 200.405 § 200.430

The HS program has established an internal process of requester/approver in place to review the transaction requested. Documents then get reviewed again by HR or Finance staff based on the transaction type before getting processed. Responsible party: Bonnie Foroudi, Finance Director Estimated compl...

The HS program has established an internal process of requester/approver in place to review the transaction requested. Documents then get reviewed again by HR or Finance staff based on the transaction type before getting processed. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 2025

View Audit 356132 Questioned Costs: $1

Finding 560043 (2022-001)

Significant Deficiency 2022

Wisconsin Cheese Makers Association

WI

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

Comments on findings and recommendations Management should implement a process to evaluate and allocate expenses on a regular basis. Actions taken or planned Management implemented a process to evaluate and allocate expenses based on employee estimates of time spent by function and proportion of th...

Comments on findings and recommendations Management should implement a process to evaluate and allocate expenses on a regular basis. Actions taken or planned Management implemented a process to evaluate and allocate expenses based on employee estimates of time spent by function and proportion of the association’s floor space utilized by each employee during the year. Anticipated completion date July 1, 2023

View Audit 355971

Finding 559917 (2022-001)

Material Weakness 2022

Uvalde County Hospital Authority Dba Uvalde Memorial Hospital

TX

Allowable Costs / Cost Principles Reporting

We are in receipt of the finding required to be reported by Uniform Guidance, regarding other instances of noncompliance with respect to Reporting. Management agrees with the findings. Policies and procedures over federal grant reporting will be modified to ensure reports are prepared using complet...

We are in receipt of the finding required to be reported by Uniform Guidance, regarding other instances of noncompliance with respect to Reporting. Management agrees with the findings. Policies and procedures over federal grant reporting will be modified to ensure reports are prepared using complete and accurate information. We will increase compensating controls by introducing additional oversight and review for future Provider Relief Fund reporting. Terri Contreras, CFO, will be responsible for ensuring the corrective action plan is followed. The Authority had enough allowable expenditures for Period 2 and Period 3 funding received so that no lost revenues were utilized as a basis for the funding received. The corrective action plan was implemented in March 2023 with the submission of Period 4 reporting.

View Audit 355856

Finding 559797 (2022-005)

Significant Deficiency 2022

Redevelopment Authority of the County of Berks

PA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.400

ALLOWABLE ACTIVITIES AND ALLOWABLE COSTS - SIGNIFICANT DEFICIENCY Federal Program Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause During 2022 payments of rental and utility assistance were entered as batches within the financial accounting software. A se...

ALLOWABLE ACTIVITIES AND ALLOWABLE COSTS - SIGNIFICANT DEFICIENCY Federal Program Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause During 2022 payments of rental and utility assistance were entered as batches within the financial accounting software. A separate spreadsheet was utilized to track individual payments included within the batches. The original spreadsheet provided contained data entry errors. After revising for corrections, the detail provided by the Authority outlining individual payments was $472,226 lower than expenses reported in the financial reporting software and could not be reconciled by management. For 6 out of 60 cases tested, the amount paid for rent did not agree to a lease agreement or bills on file for the following reasons: (1) clerical errors, (2) duplicate payments due to multiple staff working on the same file, or (3) failure to request support before payment was made. The Authority did not have controls in place to detect the noncompliance prior to issuing payments. Recommendation We recommend the Authority revisit and strengthen internal controls over tracking individual payments for transactions entered as batches, particularly when related to federal awards. We encourage the Authority to continue working to identify the individual transactions making up the remainder of the federal expenditures under this program. We also recommend the Authority revisit and strengthen internal controls over allowable activities and allowable costs related to grant programs. Management Response The Authority launched the Emergency Rental Assistance Program (ERAP) with little administrative guidance from the U.S. Treasury. The Authority contracted with the Berks Coalition to End Homelessness (BCEH) to undertake various aspects of the Emergency Rental Assistance Program and in the late fall of 2021, the Authority began reviewing all case documentation provided by BCEH. This review eliminated the vast majority of the errors noted. The Authority also updated case documentation checklists as well as provided training for staff involved with ERAP.

View Audit 355767 Questioned Costs: $1

Finding 559666 (2022-002)

Significant Deficiency 2022

Greater Lawrence Technical School

MA

Allowable Costs / Cost Principles Reporting Significant Deficiency

Audit Finding Reference: 2022-002 Planned Corrective Action: The district created a Federal and State Grants Procedures Manual that includes specific procedures for Time and Effort. The Grant Procedure Manual was approved by the District Committee on December 12, 2023. Name of Contact Person: Melis...

Audit Finding Reference: 2022-002 Planned Corrective Action: The district created a Federal and State Grants Procedures Manual that includes specific procedures for Time and Effort. The Grant Procedure Manual was approved by the District Committee on December 12, 2023. Name of Contact Person: Melissa Martel, Director of Finance Completion Date: December 12, 2023

View Audit 355524

Finding 559023 (2022-005)

Significant Deficiency 2022

Alston Wilkes Society

SC

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.1 § 200.439 § 200.452

Response of Responsible Society Official: We will review 2 CFR 200 Subpart E - Cost Principle to in an effort to refamiliarize ourselves with the Cost Principles.

View Audit 355287 Questioned Costs: $1

Finding 558988 (2022-003)

Significant Deficiency 2022

Foothill House of Hospitality

CA

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

Management has worked with a few outside accounting firms over the last year and believes they have found a competent accounting person to assist with the financial statements and processes. Management is working with the new accounting firm to document the procedures and maintaining records.

View Audit 355237

Finding 556195 (2022-003)

Material Weakness 2022

Benton County

WA

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

Thank you for bringing this to our attention. There were several factors that contributed to the difficulties we encountered submitting the required quarterly reports and have since remedied those issues. The Human Services Department has worked with Treasury on the challenges we encountered uploa...

Thank you for bringing this to our attention. There were several factors that contributed to the difficulties we encountered submitting the required quarterly reports and have since remedied those issues. The Human Services Department has worked with Treasury on the challenges we encountered uploading the required reporting templates and we now has multiple people with access to the reporting portal and in the event of staff turnover we can continue to submit required reports. The Human Services Manager and the Budget and Finance Analyst have created reminders on their calendars to ensure reporting is completed on time and with accurate data.

View Audit 354873

Finding 555907 (2022-001)

None 2022

Bluetide Puerto Rico, INC

PR

Allowable Costs / Cost Principles Reporting

Title: Audit Submission and Financial Recovery for Bluetide Puerto Rico Inc. Author: Danixa Rivera-Merced, Executive Director Date: March 3rd,2025 1. Background: • Organization: Bluetide Puerto Rico Inc. Action Plan • Issue: Inability to complete and submit the 2022 audit on time due to delays in re...

Title: Audit Submission and Financial Recovery for Bluetide Puerto Rico Inc. Author: Danixa Rivera-Merced, Executive Director Date: March 3rd,2025 1. Background: • Organization: Bluetide Puerto Rico Inc. Action Plan • Issue: Inability to complete and submit the 2022 audit on time due to delays in reimbursement from the Economic Development Administration (EDA) and subsequent grant suspension. 2. Timeline of Events: • March 2023: o Bluetide Puerto Rico Inc. was awaiting reimbursement from the EDA for over two months. o EDA suspended the grant due to findings, leading to the organization using its operational funds to sustain operations, resulting in a negative budget. • Resolution of Findings: o The executive director, Danixa Rivera-Merced, clarified and resolved the findings. time limit. 3. Current Status: o The EDA reactivated the grant and made the reimbursements, but it was too late to submit the 2022 audit within the original Tel. 787-727-8980 P.O. Box 13832 San Juan, PR 00908 • Bluetide Puerto Rico Inc. is now recovering its financial continuous. • The organization is no longer dependent on federal funds to maintain operations. • The 2022 audit has completed for submission. 4. Action Steps: 1. Audit Submission: o Submit the 2022 audit to the relevant authorities as soon as possible, highlighting the extenuating circumstances that led to the delay. o Ensure all financial documents and evidence of the reimbursement delays and grant suspension are included. 2. Financial Recovery: o Continue to monitor and manage the organization's financial health to ensure sustained recovery. o Implement a robust financial management system to avoid future sole sourced dependencies on federal funds. 3. Future Audits: o Set aside budget and time resources to carryout required financial audits in a timely manner. o Implement a tracking system for grants and reimbursements to avoid future delays. o Ensure all necessary audits are processed as per regulatory requirements. 4. Communication: o Communicate the situation to stakeholders to maintain transparency. o Provide updates on financial recovery and plans for audits and funding management. Tel. 787-727-8980 P.O. Box 13832 San Juan, PR 00908 5. Monitoring and Evaluation: • Quarterly review and assess the progress of the action steps outlined above. • Adjust the plan as necessary to ensure financial stability and compliance with Bluetide Puerto Rico Inc.

View Audit 354564

Finding 555781 (2022-005)

Material Weakness 2022

Morgan County

OH

Subrecipient Monitoring Allowable Costs / Cost Principles Period of Performance § 200.329

The Auditors Office will take the lead on tracking and reporting on any future programs such as Coronavirus State and Local Fiscal Recovery Fund.

View Audit 354454

Finding 555744 (2022-003)

Significant Deficiency 2022

Behavioral Health Services, Inc.

CA

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.430

Audit Finding Description: Documentation for exempt employees' hours was unavailable or incomplete. Corrective Action Plan: 1. Problem Statement: • During testing over payroll, the auditors noted exempt employee salary expense that was not supported with accurate time records. • Root cause: Manageme...

Audit Finding Description: Documentation for exempt employees' hours was unavailable or incomplete. Corrective Action Plan: 1. Problem Statement: • During testing over payroll, the auditors noted exempt employee salary expense that was not supported with accurate time records. • Root cause: Management lacks policy over tracking time on the timesheet for the exempt employees. Since exempt employees are compensated monthly, it is not required for the exempt employees to record time in their timesheet. 2. Corrective Actions: • Review and Assessment: We have conducted a thorough review of the finding to understand its root cause and identify areas for improvement. • Policy and Procedure Enhancements: We will update relevant policies or procedures to strengthen systems and prevent recurrence. • Training and Education: Employees involved in the process will undergo additional training to ensure they fully understand compliance requirements and best practices. • Monitoring and Oversight: Management will implement regular monitoring and periodic internal audits to ensure continued compliance and effectiveness of the corrective actions. Name of responsible person: Andrea L. Jones, Chief Financial Officer Anticipated completion date: June 30, 2026

View Audit 354388 Questioned Costs: $1

Finding 555743 (2022-002)

Significant Deficiency 2022

Behavioral Health Services, Inc.

CA

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.430

Audit Finding Description: Documentation for exempt employees' hours was unavailable or incomplete. Corrective Action Plan: 1. Problem Statement: • During testing over payroll, the auditors noted exempt employee salary expense that was not supported with accurate time records. • Root cause: Manageme...

Audit Finding Description: Documentation for exempt employees' hours was unavailable or incomplete. Corrective Action Plan: 1. Problem Statement: • During testing over payroll, the auditors noted exempt employee salary expense that was not supported with accurate time records. • Root cause: Management lacks policy over tracking time on the timesheet for the exempt employees. Since exempt employees are compensated monthly, it is not required for the exempt employees to record time in their timesheet. 2. Corrective Actions: • Review and Assessment: We have conducted a thorough review of the finding to understand its root cause and identify areas for improvement. • Policy and Procedure Enhancements: We will update relevant policies or procedures to strengthen systems and prevent recurrence. • Training and Education: Employees involved in the process will undergo additional training to ensure they fully understand compliance requirements and best practices. • Monitoring and Oversight: Management will implement regular monitoring and periodic internal audits to ensure continued compliance and effectiveness of the corrective actions. Name of responsible person: Andrea L. Jones, Chief Financial Officer Anticipated completion date: June 30, 2026

View Audit 354388 Questioned Costs: $1

Corrective Action Plans

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