Corrective Action Plans

Finding 858 (2023-003)

Significant Deficiency 2023

MI

Allowable Costs / Cost Principles

The District concurs with the finding. The District will implement procedures to ensure compliance requirements of the program.

View Audit 1639

Finding 706 (2023-001)

Significant Deficiency 2023

Bicentennial Apartments, Inc.

WY

Allowable Costs / Cost Principles Subrecipient Monitoring Significant Deficiency

Management’s Response: Cable rates paid by tenants were increased recently to help cover more of the costs. We have contacted the carrier for a copy of the current contract, upon receipt we are going to opt out of the contract per the provisions of said contract. When reviewing a different contract ...

Management’s Response: Cable rates paid by tenants were increased recently to help cover more of the costs. We have contacted the carrier for a copy of the current contract, upon receipt we are going to opt out of the contract per the provisions of said contract. When reviewing a different contract (same provider) with another project it states that we will have to give a 90-day notice prior to the expiration of the then-current term. If this is the case, it will be May 20th, 2024, to terminate on July 20th 2024.

View Audit 1355

Finding 687 (2023-001)

Significant Deficiency 2023

Chittenango Central School District

NY

Subrecipient Monitoring Allowable Costs / Cost Principles HUD Housing Programs

During a desktop monitoring review with the New York State Department of Education, the District was made aware of the requirement to maintain the required time certification forms. Steps have been taken to capture all required signatures on payroll charged to the related grants. Projected completio...

During a desktop monitoring review with the New York State Department of Education, the District was made aware of the requirement to maintain the required time certification forms. Steps have been taken to capture all required signatures on payroll charged to the related grants. Projected completion date is estimated to be January 31, 2024.

View Audit 1321

Finding 642 (2023-002)

Significant Deficiency 2023

Moraine Valley Community College District Number 524

IL

Subrecipient Monitoring Cash Management Allowable Costs / Cost Principles § 200.303 § 200.305

Identifying Number: 2023-002 Finding: For one out of two subrecipient payments tested, the College did not submit payment within 30 days after receipt of the billing from the subrecipient. Corrective Action Planned: The College will update its subrecipient invoice payment procedure to establish st...

Identifying Number: 2023-002 Finding: For one out of two subrecipient payments tested, the College did not submit payment within 30 days after receipt of the billing from the subrecipient. Corrective Action Planned: The College will update its subrecipient invoice payment procedure to establish stronger internal controls related to tracking subrecipient invoice approval routing. The College will ask each subrecipient to include the Manager of Grants Accounting and Compliance on any requests for reimbursements. If a subrecipient’s invoice meets Moraine Valley’s criteria for performance and fiscal compliance, the Manager of Grants Accounting and Compliance will monitor the approval process to make sure it is properly approved by the grant’s Principal Investigator, the Director of Resource Development, and the Manager of Grants Accounting and Compliance. This additional monitoring will help ensure all subrecipient invoices are paid within 30 days of receipt. If the invoice does not meet the College’s criteria including all proper supporting documentation, the invoice will be returned to the subrecipient for corrections. Anticipated Completion Date: June 30, 2024 Responsible Person: Darren Howard, Manager of Grants Accounting and Compliance Howardd46@morainevalley.edu

View Audit 1222

Finding 573 (2023-002)

Significant Deficiency 2023

East China School District

MI

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

Management will work with various departments to review current policies and procedures related to federal grant awards. We will focus on the related controls necessary to avoid transactions paid in advance that extend passed the expenditure period. Grant procedures will include review, approval a...

Management will work with various departments to review current policies and procedures related to federal grant awards. We will focus on the related controls necessary to avoid transactions paid in advance that extend passed the expenditure period. Grant procedures will include review, approval and consideration during the grant planning process.

View Audit 1118

Finding 544 (2023-001)

None 2023

Tawas Area Schools

MI

Questioned Costs Allowable Costs / Cost Principles

The District understands the issue and will reclassify the excess expenses charged to the ESSER grant and include/incur other allowable expenses in those charged to the grant.

View Audit 1068 Questioned Costs: $1

Finding 425 (2023-001)

Significant Deficiency 2023

Shands Jacksonville Medical Center, INC

FL

Allowable Costs / Cost Principles Cash Management Eligibility

Views of responsible officials and planned corrective actions: The Financial and Data Analytics Director conducts spot testing of each bi-weekly payroll expenditure report received from Human Resources for eligible PRF reporting. Evidence of testing is retained. Responsible Officials: Dean C. Cocchi...

Views of responsible officials and planned corrective actions: The Financial and Data Analytics Director conducts spot testing of each bi-weekly payroll expenditure report received from Human Resources for eligible PRF reporting. Evidence of testing is retained. Responsible Officials: Dean C. Cocchi, Vice President and CFO Completion Date: March 31, 2022

View Audit 896

Finding 416 (2023-001)

Significant Deficiency 2023

National Crime Victim Law Institute

OR

Allowable Costs / Cost Principles Significant Deficiency

National Crime Victim Law Institute respectfully submits the following corrective action plan for the year ended May 31, 2023. Contact Person of National Crime Victim Law Institute: Julie Hester, Director of Administration and Operations 1130 SW Morrison Street, Suite 240, Portland, Oregon 97205 N...

National Crime Victim Law Institute respectfully submits the following corrective action plan for the year ended May 31, 2023. Contact Person of National Crime Victim Law Institute: Julie Hester, Director of Administration and Operations 1130 SW Morrison Street, Suite 240, Portland, Oregon 97205 Name and Address of Independent Public Accounting Firm: McDonald Jacobs, P.C. 520 SW Yamhill, Suite 500, Portland, Oregon 97204 Audit Period: June 1, 2022 through May 31, 2023. The finding from the May 31, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Finding # 2023-001 Type: Federal award, Significant deficiency regarding allowable costs Finding For three months tested, amounts charged to the grant for allocated rent expenses were inaccurate or did not agree to the accounting records, resulting in insignificant over and under billings. Recommendation: Contract billings should be reconciled to the accounting records and a review of the reconciliation should be completed before invoicing the government agency. Corrective Action: NCVLI has engaged the services of a contract accounting firm for fiscal year 2023-24. This accounting firm will assist with monthly financial transactions, maintaining accounting records and assisting with billings. This firm will work closely with the Director of Administration & Operations (DAO). Among the benefits of this additional layer of support for accounting work is a new process for rent allocations which ensures calculations are reviewed and affirmed by multiple people. Rent allocations are generated by the accounting firm and reviewed by the DAO prior to generation of billings. Billings will then be generated by the DAO with assistance from the accounting firm and will continue to be reviewed and approved by the Executive Director prior to submission to federal agencies. As an additional check, regular internal review of monthly payroll and rent allocations will be conducted by a member of the management team other than the DAO to ensure supporting documentation and reports from accounting system align and support allocations. Anticipated Completion Date: September 2023

View Audit 868

Finding 401 (2023-001)

Significant Deficiency 2023

Community Health Care, Inc.

IA

Allowable Costs / Cost Principles Reporting

CHC agrees it did not allocate its Iowa Medicaid Wrap-Around payments to the Dental and Pediatric Services lines correctly. As the additional context states in the audit report, CHC agrees the departmental allocation did not affect its overall financial statements for the 2020, 2021, and 2022 quart...

CHC agrees it did not allocate its Iowa Medicaid Wrap-Around payments to the Dental and Pediatric Services lines correctly. As the additional context states in the audit report, CHC agrees the departmental allocation did not affect its overall financial statements for the 2020, 2021, and 2022 quarters and did not affect its ability to fully obligate the distributed funds, with its corrected lost revenues reflecting $2,589,831 in lost revenues. CHC has a strong record of grant compliance demonstrated by its consistent compliance with its financial statement audits and its clean record of compliance with its HRSA surveyors. We take our grant compliance seriously and have adequate internal controls in place to maintain current and future federal grants. We will strengthen our departmental allocation methodology of the Iowa Medicaid wrap-around payments with the following: • Re-educating its current accounting staff on the correct allocation methodology for Iowa Medicaid wrap-around payments. • Ensuring its dental payor wraparound payments are allocated correctly to its internal dental departments. This process will be monitored and completed through its monthly account reconciliation process and quarterly departmental reporting processes. • Ensuring its medical payor wraparound payments are allocated correctly to its internal medical departments. This will be done by utilizing a consistent allocation methodology based upon patient visits. This process will be monitored and completed through its monthly account reconciliation process and quarterly departmental reporting processes. The timing of the implemented corrective actions began in 2023 and has been re-enforced with its accounting staff in the first 2 quarters of 2023. As CHC has been able to fill its open accounting positions and train appropriately, I do not anticipate further Iowa Medicaid wrap allocation deficiencies. As such I consider all remediation steps to be implemented and complete.

View Audit 836

Finding 361 (2023-003)

Significant Deficiency 2023

Sebeka Public Schools

MN

Allowable Costs / Cost Principles Cash Management Eligibility

Contact Person – Superintendent; Corrective Action Plan – The District has established a procedure for review of journal entries; Completion Date – Completed

View Audit 736

Finding 342 (2022-002)

Significant Deficiency 2023

Arrive Ministries

MN

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Finding 2022-002 - Documentation of Internal Control to Support Approvals of Payroll Charged to Federal Program. ...

Finding 2022-002 - Documentation of Internal Control to Support Approvals of Payroll Charged to Federal Program. Recommendation: The Organization implemented a process to maintain documentation of the Executive Director’s approval for all pay periods. Corrective Action: We have already implemented a process for retaining the emails approving payroll period time cards by the Director and Executive Director. Corrective Action owner: Jennifer Haskett, Senior Accountant Completion Date: 11/1/2022

View Audit 718

Finding 341 (2022-001)

Significant Deficiency 2023

Arrive Ministries

MN

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

CORRECTIVE ACTION PLAN September 25, 2023 Arrive Ministries respectfully submits the following corrective action plan for the year ended March 31, 2023. Arrive Ministries concurs with the findings and recommendations listed below. Name and address of independent public accounting firm: BERGANKDV, LT...

CORRECTIVE ACTION PLAN September 25, 2023 Arrive Ministries respectfully submits the following corrective action plan for the year ended March 31, 2023. Arrive Ministries concurs with the findings and recommendations listed below. Name and address of independent public accounting firm: BERGANKDV, LTD. 220 Park Avenue South St. Cloud, Minnesota Audit period: APRIL 1, 2022 TO MARCH 31, 2023 The findings from the September 5, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FEDERAL AWARD Assistance Listing Number: 19.510 Federal Program Name: U.S. Refugee Admissions Program Name of Federal Agency: Department of State Finding 2022-001 - Time and Effort Reporting Recommendation: The Organization implement a process to track employee’s time and effort worked on federal programs. Corrective Action: We have implemented a process for employees to certify their time charged to federal programs on a monthly basis. We then adjust the financials as needed. Corrective Action owner: Jennifer Haskett, Senior Accountant Completion Date: 12/1/2022

View Audit 718

Finding 305 (2023-002)

Significant Deficiency 2023

Vermont Student Assistance Corporation

VT

Cash Management Allowable Costs / Cost Principles § 200.303

Recommendation: We recommend management perform a documented review of the federal drawdowns to ensure the benefits reimbursement rate is timely updated in accordance with the requirements of new grant awards. Explanation of disagreement with audit finding: There is no disagreement with the audit fi...

Recommendation: We recommend management perform a documented review of the federal drawdowns to ensure the benefits reimbursement rate is timely updated in accordance with the requirements of new grant awards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has directed the Finance Department to review all draw down worksheets to insure that draw down parameters agree with all grant proposal, budget and award documents. Name(s) of the contact person(s) responsible for corrective action: Bruce Hicken, Controller Planned completion date for corrective action plan: No later than October 31, 2024.

View Audit 579

Finding 70 (2023-002)

Significant Deficiency 2023

Freestore Foodbank, Inc. and Affiliates

OH

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Criteria: According to 45 CFR 260.34, a religious organization that received Federal TANF funds shall not, in providing program services or benefits, discriminate against a TANF applicant or recipient on the basis of religion, a religious belief, a refusal to hold a religious belief, or a refusal to...

Criteria: According to 45 CFR 260.34, a religious organization that received Federal TANF funds shall not, in providing program services or benefits, discriminate against a TANF applicant or recipient on the basis of religion, a religious belief, a refusal to hold a religious belief, or a refusal to actively participate in a religious practice. To ensure compliance with this requirement, Freestore Foodbank Inc. and Affiliates require all local distributors receiving commodities to sign a local distributor agreement. Condition: CSH noted two instances (in a sample of 40 local distributor agreements) where food was distributed to religious organizations that do not abide by 45 CFR 260.34. Planned Corrective Action: In one instance, management issued food to an agency which had an expired local distributor agreement. Going forward, controls will be put in place by 9/30/23 to better track agency agreements to ensure all agencies receiving food have up-to-date agreements. The second instance involved the request for TANF food to be distributed to an organization who was not participating in the program. While the organization was correctly set up in our database, food was requested to be distributed. Management will improve training for staff and run periodic reports to ensure food is going to the proper organizations. Management will also set up periodic compliance meetings with program managers to develop best practices for each of the grants by 10/31/23.

View Audit 63

Finding 67 (2023-001)

Significant Deficiency 2023

Clackamas County Childrens Commission

OR

Allowable Costs / Cost Principles

Corrective Action: The error identified related to a recurring accounts payable invoice template that is available to, and pending in, future accounting periods and posted monthly. The recurring invoice template was not updated at the time the distribution code was changed for current allocation ra...

Corrective Action: The error identified related to a recurring accounts payable invoice template that is available to, and pending in, future accounting periods and posted monthly. The recurring invoice template was not updated at the time the distribution code was changed for current allocation rates. The template has since been updated. We will continue to review the transactions prior to posting in the accounting system to correct any errors. Anticipated Completion Date: August 2023

View Audit 62

Finding 1225676 (2022-007)

Material Weakness 2022

Quileute Tribal School

WA

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

Condition/Context: For 3 of the 3 samples selected for testing, the School did not provide support for review and approval of the monthly bank reconciliations Corrective action taken: Quileute Tribal School will establish effective internal controls for the monthly bank reconciliations and adhere to...

Condition/Context: For 3 of the 3 samples selected for testing, the School did not provide support for review and approval of the monthly bank reconciliations Corrective action taken: Quileute Tribal School will establish effective internal controls for the monthly bank reconciliations and adhere to the internal controls. Person responsible for corrective action: Bob Harmon, Superintendent NOTE: In addition, Quileute Tribal School has engaged an independent CPA firm to assist with account reconciliations and audit readiness to help ensure that financial information is complete, accurate, and properly reported. Implementation Date: July 30, 2026

View Audit 408537

Finding 1225675 (2022-006)

Material Weakness 2022

Quileute Tribal School

WA

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

Condition/Context: For 1 of the 3 samples selected for testing, the school did not provide support for review and approval of the Character Investigations. Corrective action taken: Quileute Tribal School will establish effective internal controls for the Character Investigations compliance requireme...

Condition/Context: For 1 of the 3 samples selected for testing, the school did not provide support for review and approval of the Character Investigations. Corrective action taken: Quileute Tribal School will establish effective internal controls for the Character Investigations compliance requirement and adhere to the internal controls. Person responsible for corrective action: Bob Harmon, Superintendent Implementation Date: July 30, 2026

View Audit 408537

Finding 1224463 (2022-004)

Material Weakness 2022

Monticello Housing Authority

NY

HUD Housing Programs Special Tests & Provisions Allowable Costs / Cost Principles

2022-004 – Deficiencies Noted in Documentation of Controls - Housing Choice Voucher Participant Files - Significant Deficiency Auditor Recommendations: The Authority should establish a checklist for the Housing Choice Voucher Coordinator to use during the recertification process to document the proc...

2022-004 – Deficiencies Noted in Documentation of Controls - Housing Choice Voucher Participant Files - Significant Deficiency Auditor Recommendations: The Authority should establish a checklist for the Housing Choice Voucher Coordinator to use during the recertification process to document the procedures performed to ensure all compliance requirements are met. We recommend a complete review of all Housing Choice Voucher Program tenant file regulations to ensure compliance with these policies. Response: The Executive Director will actively oversee all financial aspects of the agency. Additionally, the director will ensure that finances are current and accurate monthly. A complete review of all Housing Choice Voucher Program tenant file regulations will be performed to ensure compliance with these policies. Timeframe: By completion of the 2027 FYE audit Individual responsible for correction: Mr. Marc Starling, Executive Director

View Audit 407735

Finding 1224365 (2022-003)

Material Weakness 2022

Russellville Hospital, Inc.

AL

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303 § 200.512

The hospital will work with an outside consultant with more in-depth understanding of the reporting requirements prior to additional submissions. We are also catching up on the audit submissions and will remain on task with timely submission. Anticipated completion date: 09/30/2026

View Audit 407672

Finding 1224134 (2022-004)

Material Weakness 2022

STRESS & TRAUMA TREATMENT CENTER INC

IL

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

Condition: During our testwork, we noted three employees were missing time and effort certifications. Plan: The Organization is implementing written policies and procedures over time and effort reporting to ensure proper documentation is always maintained or complete in all instances to properly dis...

Condition: During our testwork, we noted three employees were missing time and effort certifications. Plan: The Organization is implementing written policies and procedures over time and effort reporting to ensure proper documentation is always maintained or complete in all instances to properly distribute salary and benefit costs for employees who work in whole or in part on grant program activity in accordance with the Uniform Guidance. This includes having the documentation reviewed and formally approved by a supervisor. Anticipated Date of Completion: December 31, 2026 Name of Contact Person: Matt Buckman, Executive Director

View Audit 407517

Finding 1223029 (2022-002)

Material Weakness 2022

DELRIDGE NEIGHBORHOODS DEVELOPMENT ASSOCIATION

WA

Allowable Costs / Cost Principles Eligibility HUD Housing Programs

Finding 2022-002 Significant Deficiency in Internal Controls Over Compliance – HOME Investment Partnerships Program Finding: The audit identified a tenant file in which a HOME-assisted unit was not properly identified on the Household Eligibility Certification form, resulting in rental charges that ...

Finding 2022-002 Significant Deficiency in Internal Controls Over Compliance – HOME Investment Partnerships Program Finding: The audit identified a tenant file in which a HOME-assisted unit was not properly identified on the Household Eligibility Certification form, resulting in rental charges that exceeded allowable limits under HOME program requirements. Corrective Action Plan: DNDA agrees with the finding and has implemented procedures to strengthen compliance monitoring and tenant file review processes. To address this finding, management has taken the following actions: o Corrected the identified tenant file and reviewed the circumstances that led to the error. o Implemented additional review procedures for Household Eligibility Certification forms to verify unit designation, household income calculations, and applicable rent restrictions. o Established a secondary review process for HOME-assisted units to ensure compliance requirements are accurately reflected in tenant records. o Provided additional training and guidance to staff responsible for tenant certifications and compliance monitoring. o Incorporated periodic compliance reviews into ongoing property management oversight activities. Responsible Party: Shannon Woodard – Interim Executive Director, Danielle Clark-Burfening – Housing Director, Misty Wilson – Area Supervisor (3rd Party Property Management – United Marketing, Inc.), Bonita Salyers – Regional Portfolio Assistant (3rd Party Property Management – United Marketing, Inc.) Implementation Date: Corrective actions began upon identification of the finding. Expected Completion Date: Implemented December 18, 2025, Quarterly Verification of Compliance by Danielle Clark-Burfening Monitoring: Management will conduct periodic reviews of HOME-assisted tenant files and certification documents to verify continued compliance with HUD and HOME program requirements.

View Audit 406594

Finding 1222697 (2022-005)

Material Weakness 2022

Veterans Transition Center of California

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management § 200.307

View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA5, management agrees with the finding. Corrective actions will be ...

View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA5, management agrees with the finding. Corrective actions will be implemented in subsequent fiscal years, including the establishment of policies and procedures to ensure that program income is tracked by contract and expended in accordance with applicable federal requirements.

View Audit 406305

Finding 1222695 (2022-003)

Material Weakness 2022

Veterans Transition Center of California

CA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.403 § 200.405 § 200.430

View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA3, management agrees with the finding. Corrective actions will be ...

View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA3, management agrees with the finding. Corrective actions will be implemented in subsequent fiscal years. Unallowable costs will be identified and documented in the Accounting Policies and Procedures Manual and communicated to the Finance Department and the Organization’s employees. The CFO will regularly communicate these requirements to directors and staff through weekly and monthly meetings to ensure a clear understanding of allowable versus unallowable costs. In addition, quarterly budget-to-actual analyses will be prepared and reviewed to monitor expenditure and ensure costs remain within approved budget limitations.

View Audit 406305

Finding 1222694 (2022-002)

Material Weakness 2022

Veterans Transition Center of California

CA

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

Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA2, management agrees with the finding. Corrective actions will be implemented in subsequent fisca...

Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA2, management agrees with the finding. Corrective actions will be implemented in subsequent fiscal years. CFDA numbers for new federal awards will be identified, along with the applicable compliance requirements in accordance with the OMB Compliance Supplement (Matrix of Federal Compliance Requirements). Policies and procedures will be established for each applicable compliance requirement and will be communicated to employees responsible for monitoring and ensuring compliance.

View Audit 406305

Finding 1216731 (2022-001)

Material Weakness 2022

STEPS to Recovery Homes

AZ

Subrecipient Monitoring Allowable Costs / Cost Principles

Management of the Organization will restructure all classes in the functional classing system, as well as utilize the project function, and consistently apply expenditures such that system reports accurately reflect income and expenditures by program / grant.

View Audit 403176

Corrective Action Plans

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