Corrective Action Plans

Finding 390162 (2022-002)

Material Weakness 2022

MO

Questioned Costs Allowable Costs / Cost Principles Reporting

Management concurs with the audit finding. Capital Region Medical Center has sufficient unreimbursed lost revenues to replace the unallowable expenses reported. Capital Region Medical Center federal grant processes will begin to follow the University of Missouri grant policies beginning January 1,...

Management concurs with the audit finding. Capital Region Medical Center has sufficient unreimbursed lost revenues to replace the unallowable expenses reported. Capital Region Medical Center federal grant processes will begin to follow the University of Missouri grant policies beginning January 1, 2024.

View Audit 301078 Questioned Costs: $1

Finding 390130 (2022-004)

Significant Deficiency 2022

Public Law Center

CA

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.320 § 200.403

1. The Center will retain evidence of competitive bidding, unless an emergency or other situation precluding the delay of competitive bidding has arisen (in which case, the Center will retain the evidence and rationale justifying the sole source contract). The Center will retain verification of susp...

1. The Center will retain evidence of competitive bidding, unless an emergency or other situation precluding the delay of competitive bidding has arisen (in which case, the Center will retain the evidence and rationale justifying the sole source contract). The Center will retain verification of suspension and debarment for all potential contract service providers. The Center notes that one of the contracts selected for testing arose during an emergency situation (flooding). 2. CFO will ensure that all invoices and supporting documentation are retained. ED and/or Director of Legal Services (depending on amount of expenditure, both may be required) will approve electronic payments in Bill.com. Approval of expenses paid with paper checks will be indicated by signature of checks after reviewing accompanying support.

View Audit 301014 Questioned Costs: $1

Finding 390129 (2022-003)

Significant Deficiency 2022

Public Law Center

CA

Questioned Costs Allowable Costs / Cost Principles § 200.430

Personnel costs will be charged to the program based on actual time recorded in the organization’s case management software. Hours will be audited quarterly to ensure accuracy and completeness. The Center notes that the grantor, the State Bar of California, never requested the Center to charge payro...

Personnel costs will be charged to the program based on actual time recorded in the organization’s case management software. Hours will be audited quarterly to ensure accuracy and completeness. The Center notes that the grantor, the State Bar of California, never requested the Center to charge payroll expenses to the program based on actual time documents, nor had they ever noted this discrepancy during their periodic audits of the program.

View Audit 301014 Questioned Costs: $1

Finding 389474 (2022-004)

Significant Deficiency 2022

Northeast Missouri Area Agency on Aging

MO

Allowable Costs / Cost Principles Cash Management § 200.302

Recommendation: We recommend the Agency draft and adopt written procedures in accordance with Uniform Guidance requirements. Action Taken: Management agrees with the finding and adopted the appropriate policies and procedures in December 2023.

View Audit 300445

Finding 388416 (2022-001)

Material Weakness 2022

Christus Health

TX

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

Finding 2022-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: ...

Finding 2022-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: July 1, 2020 to June 30, 2022 Corrective Action Planned: Management agrees that certain expenses to the COVID department were not reviewed and approved at the order entry level in specific cases. Although evidence of review was not retained for every charge to the COVID department, we believe the appropriateness of the charge was reasonable. Additionally, based on monthly review of departmental expenses and full-time equivalent (FTE) analysis at the facility level, we believe that these expenditures are subject to the appropriate level of review to identify unexpected variances. As it relates to the COVID Activity Code, this code was created as a means to track certain COVID hours worked, but was not configured to calculate the amounts associated with those hours, resulting in the need to make reasonable estimates. Even using the base pay rate at the time the hours were incurred would not have been accurate since it would omit adjustments for shift differentials, weekend hours, and overtime. We performed internal analyses and reviewed the results of samples selected by the auditors and concluded that the risk of a material overcharge to the program was minimal. Further, we have almost $40 million of unused lost revenues after our final PRF submission for Period 5, such that any questioned costs would easily be covered by other eligible uses of PRF funds. We have reviewed our processes related to the retention of expense documentation to improve audit evidence should this program ever be awarded in future periods. Responsible party: Lee Sonne, Vice President of Finance and Controller Implementation Date: Procedures were reviewed and analysis completed along with the Period 5 portal filing in September 2023.

View Audit 300148 Questioned Costs: $1

Finding 387785 (2022-001)

Material Weakness 2022

MacHne Naarim

NY

Procurement, Suspension & Debarment Allowable Costs / Cost Principles School Nutrition Programs

Hayim Prero, as lead person for the SFSP program for Machne Naarim, will ensure that all expenditures show proper approval before purchases are made. This recommendation was made in the fall of 2022 and went into effect in the summer of 2023. As this was the procedure until now, however, there was n...

Hayim Prero, as lead person for the SFSP program for Machne Naarim, will ensure that all expenditures show proper approval before purchases are made. This recommendation was made in the fall of 2022 and went into effect in the summer of 2023. As this was the procedure until now, however, there was no signature to verify the approval, and this took minimal time to correct. As part of yearly training, the director of each site will be directed to ensure that there is a signature indicating proper approval for all expenditures before purchases are made. This will also be verified for all the sites by the Machne Naarim bookkeeping staff when the invoices are submitted to Machne Naarim for verification of the integrity of their programs.

View Audit 299842

Finding 387583 (2022-001)

None 2022

Kit Carson County

CO

Allowable Costs / Cost Principles Special Tests & Provisions

County had additional funds available in Other Allowable Costs to offset the premuim pay to exempt workers. County will not offer premium pay to employees classified as exempt.

View Audit 299705

Finding 387254 (2022-007)

Significant Deficiency 2022

Board of Education of Prince George's County Maryland

MD

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

The School System concurs with the auditor’s findings and recommendations. The Infants and Toddlers Supervisor will conduct monthly reviews of outstanding purchase orders in Oracle, addressing issues promptly with the Business Operation Officer/Financial Analyst. Professional development sessions ...

The School System concurs with the auditor’s findings and recommendations. The Infants and Toddlers Supervisor will conduct monthly reviews of outstanding purchase orders in Oracle, addressing issues promptly with the Business Operation Officer/Financial Analyst. Professional development sessions will be attended to enhance invoice scrutiny for allowable expenses within the grant period. Quarterly reminders and Financial Quarterly Review meetings will be instituted for supervisors, ensuring timely action on outstanding purchase orders. Following will be implemented: 1. Infants and Toddler Supervisor will hold monthly meetings with the Financial Analyst and the secretarial staff to ensure consistent actions are taken when generating purchase orders and processing invoices. 2. The Infants and Toddler secretary will review invoice dates against contracts and purchase orders to ensure they fall within grant timelines before submitting them to the supervisor for signature. 3. Infants and Toddler Supervisor will confirm that purchases made with grant funds are allowable and within the designated grant period. The Supervisor will cross-reference invoice dates against grant periods before signing and sending to accounts payable. 4. The infants and Toddler Supervisor will confirm the work being invoiced has been completed and vendor details are checked, and dates verified. 5. Grant Accountants will provide transaction detail reports (at least quarterly). The Infant and Toddlers Coordinating Supervisor will review and sign-off on the quarterly transaction reports. 6. The Financial Analyst will meet monthly with the Infants and Toddler Supervisor and Coordinating Supervisor to ensure grant allowable expenses are adhered to and invoicing is updated and falls within grant-specific timelines.

View Audit 299515

Finding 387239 (2022-005)

Significant Deficiency 2022

Board of Education of Prince George's County Maryland

MD

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.430

The School System concurs with the auditor’s findings and recommendations. As an on-going effort, the process for creating pay elements for specialized compensation will be monitored for accuracy during the creation stages. Electronic alerts generated in the oracle system will be re-employed to no...

The School System concurs with the auditor’s findings and recommendations. As an on-going effort, the process for creating pay elements for specialized compensation will be monitored for accuracy during the creation stages. Electronic alerts generated in the oracle system will be re-employed to notify appropriate finance personnel when new elements are created by the Payroll Department to ensure the distribution accuracy of salary expenses along with applicable fringes to the appropriate grant accounts. This will prevent manual journal entry realignment postings of large data sets of salary and fringes to the primary assignment costing versus accounts created specifically for specialized pay that is approved in the respective grant application as an allowable cost.

View Audit 299515

Finding 387010 (2022-008)

Material Weakness 2022

Workforce Development Board Work4wv Region 1, Inc.

WV

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

2022-008 Allocation of Grant Expenses U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement policies and procedures to ensure that all expenses are for actual expenses incurred, and that timely reconciliations are performed to ...

2022-008 Allocation of Grant Expenses U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement policies and procedures to ensure that all expenses are for actual expenses incurred, and that timely reconciliations are performed to ensure the expenses are properly charged to the correct assistance listing number and grant. Action Taken: The Board has developed a process to correctly allocate expenditures to the correct funding stream. At each month’s end, all employees complete an allocation spreadsheet. When all spreadsheets are completed, approved, and turned in, the Board determines the allocation of payroll and expenditures. Expenditures that occurred in March will be allocated using the allocation chart for February. Also, this procedure is backup for each cash request that is submitted for funding. Also, this is reviewed for the reconciliation between the cash request and the Board’s accounting software.

View Audit 299381

Finding 387006 (2022-004)

Material Weakness 2022

Workforce Development Board Work4wv Region 1, Inc.

WV

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.303 § 200.309

2022-004 Period of Performance U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement internal controls and policies to ensure that supporting documentation is maintained for all transactions, and that a member of management who...

2022-004 Period of Performance U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement internal controls and policies to ensure that supporting documentation is maintained for all transactions, and that a member of management who is knowledgeable of the period of performance is reviewing and approving all transactions prior to payment. Action Taken: For each accounting procedure, internal controls have been put in place. The Board’s payroll processing goes through three levels of approval before it is processed. The expenditures process goes through three levels of approval before the bill is paid. The Board is verifying that each report or process is approved by at least three levels of approval and within a timely manner. Expenditure checks are issued every two weeks. The approval of these checks is also approved by an officer of the Board of Directors. Any out of the ordinary practices have both the approval of the Executive Director and an officer of the Board of Directors. With the past issues of this Board, the Board added an internal control for the sake of period of performance, for reports that are submitted to Workforce WV. In addition, these reports will be reviewed and approved by one of the managers of the Board within the time the report is due.

View Audit 299381 Questioned Costs: $1

Finding 387004 (2022-002)

Material Weakness 2022

Workforce Development Board Work4wv Region 1, Inc.

WV

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

2022-002 Activities Allowed or Unallowed U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all charges to federal programs are adequately reviewed and approved prior to payment, and that a...

2022-002 Activities Allowed or Unallowed U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all charges to federal programs are adequately reviewed and approved prior to payment, and that adequate supporting documentation for all federal program charges is maintained. Action Taken: The Board is taking adequate action to review and approve all charges to the federal programs. The Board’s steps have been reviewed with Workforce WV and has been approved our procedures. Supporting documentation is kept both in physical and electronic forms. Each check the Board distributes has an approved purchase order attached, (if applicable), invoice, or if it is a monthly recurring charge, statement or bill attached and once the bill is entered into our system and the bill is paid, the check has the Executive Director’s initials and date showing it is approved in our accounting system. Also, if the expenditures are questionable, we will receive approval before submission of the bill from our liaison in the Workforce WV office.

View Audit 299381 Questioned Costs: $1

Finding 386546 (2022-004)

Material Weakness 2022

Neuse River Council of Governments D/b/a Eastern Carolina Council

NC

Allowable Costs / Cost Principles Cash Management Material Weakness

The Council agrees with this finding. The Council has hired a new Finance Director with the appropriate skills, knowledge, and experience to oversee the Finance Department. The Finance Director has identified and corrected internal control issues.

View Audit 298859

Finding 386542 (2022-001)

Material Weakness 2022

County of Coos, New Hampshire

NH

Questioned Costs Allowable Costs / Cost Principles

Corrective Action Plan: The nursing home payroll staff compiled a list of staff beginning in March 2020, where there was a workforce-related actual expense to prevent, prepare for or respond to coronavirus during the reporting period. To complete the Provider Relief Fund expenses for Payroll/General...

Corrective Action Plan: The nursing home payroll staff compiled a list of staff beginning in March 2020, where there was a workforce-related actual expense to prevent, prepare for or respond to coronavirus during the reporting period. To complete the Provider Relief Fund expenses for Payroll/General and Administrative Expenses, this extensive payroll expense list needed to be sorted & tabulated to meet the PRF report. In the process, a portion of 5 weeks of covid expense were included twice causing double expense, an additional $41,046.24. This was a clerical error by the Director of Finance. To correct this issue moving forward, a secondary reviewer needs to inspect the compilation of payroll expenses and formulas in the spreadsheet before submitting. Due to the excessive amount of lost revenues in all reporting periods, the reporting of expenses was not needed, but reported for historical information. The Director of Finance called the HRSA helpdesk on 2/5/2024 as soon as this error was noted. HRSA replied that unless CCNH receives a letter, they will not reopen this reporting period and they will not reopen a reporting period for an outside auditor finding. Name of Responsible Person: Carrie Klebe Anticipated Implementation Date of Corrective Action: The above actions will take effect immediately.

View Audit 298844 Questioned Costs: $1

Finding 386434 (2022-002)

Material Weakness 2022

Elkhart and St. Joseph Counties Head Start Consortium

IN

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

Finding 2022-002 – Head Start Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Brenda Overton Contact Phone Number: 574.393.5866 Views of Responsible Official: We concur with the finding. Description of Corrective Act...

Finding 2022-002 – Head Start Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Brenda Overton Contact Phone Number: 574.393.5866 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all vouchers are reviewed by a secondary individual, all supporting backup is maintained for each claim, and all payroll amounts agree to approved contracts. Anticipated Completion Date: April 2024

View Audit 298779 Questioned Costs: $1

Finding 386269 (2022-006)

Significant Deficiency 2022

Churches United for the Homeless

MN

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

Department of Treasury Federal Financial Assistance Listing/ALN 21.027 COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Allowable Costs and Allowable Activities Significant Deficiency in Internal Control over Compliance Finding Summary: The Organization’s internal controls did not have ade...

Department of Treasury Federal Financial Assistance Listing/ALN 21.027 COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Allowable Costs and Allowable Activities Significant Deficiency in Internal Control over Compliance Finding Summary: The Organization’s internal controls did not have adequate internal controls to ensure costs are properly approved. Responsible Individuals: Robben Luhning and Susan Koesterman. Corrective Action Plan: Direct costs of internally generated items will need to be added to the current approval platform and/or process. Anticipated Completion: December 31, 2023.

View Audit 298678

Finding 386268 (2022-005)

Material Weakness 2022

Churches United for the Homeless

MN

Allowable Costs / Cost Principles Material Weakness

Department of Treasury Federal Financial Assistance Listing/ALN 21.027 COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Allowable Costs and Allowable Activities Material Weakness in Internal Control over Compliance Finding Summary: The Organization’s internal controls did not have adequate...

Department of Treasury Federal Financial Assistance Listing/ALN 21.027 COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Allowable Costs and Allowable Activities Material Weakness in Internal Control over Compliance Finding Summary: The Organization’s internal controls did not have adequate internal controls to ensure payroll costs and invoice allocations are properly calculated. Responsible Individuals: Robben Luhning and Susan Koesterman. Corrective Action Plan: During 2022, a new payroll system was implemented that should rectify the issue. Anticipated Completion: December 31, 2023.

View Audit 298678

Finding 385640 (2022-006)

Material Weakness 2022

Perry County

MS

Allowable Costs / Cost Principles Material Weakness

Corrective Action Planned: Information received from Paymode is not always clear and concise as to what payment is for. We will do our best to comply. Anticipated Completion Date: Unknown Name of Contact Person Responsible for Corrective Action: Ashly Tingle, Comptroller

View Audit 298350

Finding 384783 (2022-003)

Significant Deficiency 2022

Arizona Health Care Association, Inc.

AZ

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Significant Deficiency § 200.303 § 200.430

Coronavirus State and Local Fiscal Recovery Funds _ Assistance Listing No. 21.027 Recommendation: We recommend that the Association adopt a formal policy for tracking employee time and effort supporting grant expenses. Additionally, management should summarize the actual time employees spend on gran...

Coronavirus State and Local Fiscal Recovery Funds _ Assistance Listing No. 21.027 Recommendation: We recommend that the Association adopt a formal policy for tracking employee time and effort supporting grant expenses. Additionally, management should summarize the actual time employees spend on grant award programs and adjust the budgeted cost allocations to reflect the actual time spent. A second person knowledgeable of grant award requirements should review the time and effort summaries for proper completion and recording. This will help ensure that internal contols over compliance are established and will help ensure that cost charged to grant award programs are supported and allowable. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Staff now complete a Time and Effort Certification form from the State of Arzona for each pay period to reflect time spent on each grant. Name(s) of the contact person(s) responsible for corrective action: Frank Caruso, Director of Finance and Operations. Planned completion date for corrective action plan: Already corrected, January 2023.

View Audit 297894

Finding 384588 (2022-002)

Significant Deficiency 2022

Family Service Association of Howard County

IN

Questioned Costs Allowable Costs / Cost Principles § 200.403

Significant Deficiency in Internal Control Over Compliance and Noncompliance – A. Activities Allowed or Unallowed and B. Allowable Costs/Cost Principles Recommendation: The auditor recommended FSA implement procedures for all employees who have payroll claimed under federal programs to maintain de...

Significant Deficiency in Internal Control Over Compliance and Noncompliance – A. Activities Allowed or Unallowed and B. Allowable Costs/Cost Principles Recommendation: The auditor recommended FSA implement procedures for all employees who have payroll claimed under federal programs to maintain detailed timecards or time studies to support hours worked under each federal program. Planned Corrective Actions: Family Service Association of Howard County, Inc. (FSA) will implement procedures and maintain time cards and time studies for employees who have payroll claimed under the federal programs to be in compliance of federal grants beginning April 2024.

View Audit 297675 Questioned Costs: $1

Finding 384392 (2022-006)

Material Weakness 2022

City of West Fargo

ND

Allowable Costs / Cost Principles Material Weakness Reporting

Activities Allowed or Unallowed Material Weakness in Internal Control Over Compliance Federal Agency Name: Department of Treasury Pass‐Through Entity: North Dakota Office of Management and Budget Assistance Listing Number: 21.027 Program Name: COVID-19 – Coronavirus State and Local Fiscal Recovery F...

Activities Allowed or Unallowed Material Weakness in Internal Control Over Compliance Federal Agency Name: Department of Treasury Pass‐Through Entity: North Dakota Office of Management and Budget Assistance Listing Number: 21.027 Program Name: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Finding Summary: During the course of the engagement, it was noted that the City has no formal review process for the allocation of payroll costs to federal awards, which could result in a material misstatement of the City’s schedule of expenditures of federal awards. Corrective Action Plan: The City will review its internal control processes over compliance to ensure that payroll costs allocated to federal awards are adequately reviewed. Responsible Individuals: Dustin Scott, City Administrator Anticipated Completion Date: December 31, 2023

View Audit 297513

Finding 384385 (2022-017)

Significant Deficiency 2022

The City of Frederick, Maryland

MD

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

Moving forward, email correspondence used in the approval process shall be maintained by Weinberg Center management in the same manner as physical invoices or timesheets.

View Audit 297486

Finding 384383 (2022-015)

Material Weakness 2022

The City of Frederick, Maryland

MD

Questioned Costs Allowable Costs / Cost Principles Material Weakness

New financial grant accountant has been assigned to work with departments to ensure proper accounting of expenditures.

View Audit 297486 Questioned Costs: $1

Finding 384374 (2022-006)

Significant Deficiency 2022

The City of Frederick, Maryland

MD

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

Staff allocations are reviewed regularly to ensure they are based on work assignments. We are now tracking changes to allocations for historical reference.

View Audit 297486

Finding 384372 (2022-004)

Significant Deficiency 2022

The City of Frederick, Maryland

MD

Internal Control / Segregation of Duties Special Tests & Provisions Allowable Costs / Cost Principles

Outreach staff are now updating all patient intakes once per calendar year or upon site visit to ensure information is up to date. Responsibilities have been modified with employees assigned specifically to focus on operations, compliance and consistency.

View Audit 297486

Corrective Action Plans

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