Corrective Action Plans

Finding 20598 (2022-002)

Significant Deficiency 2022

Alliance for Community Empowerment, Inc.

CT

Questioned Costs Allowable Costs / Cost Principles

Head Start ? Assistance Listing No. 93.600 Recommendation: Alliance for Community Empowerment, Inc. should formalize review over employee coding and allocations to ensure that allocations are based on actual time and effort. Explanation of disagreement with audit finding: There is no disagreement wi...

Head Start ? Assistance Listing No. 93.600 Recommendation: Alliance for Community Empowerment, Inc. should formalize review over employee coding and allocations to ensure that allocations are based on actual time and effort. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The entry of all department coding will be reviewed by the Payment Coordinator by running a new hire report to ensure all new and returning employees are allocated to the proper department code. Name of the contact person responsible for corrective action: Indi Hayes Planned completion date for corrective action plan: 04/24/2023 If the Department of Health and Human Services has questions regarding this plan, please call Indi Hayes at 475.476.7440.

View Audit 20358 Questioned Costs: $1

Finding 20597 (2022-001)

Significant Deficiency 2022

Alliance for Community Empowerment, Inc.

CT

Questioned Costs Allowable Costs / Cost Principles Period of Performance

Head Start ? Assistance Listing No. 93.600 Community Services Block Grant ? Assistance Listing No. 93.569 Recommendation: We recommend Alliance for Community Empowerment, Inc. design controls to ensure an adequate review process is in place to review the period of costs incurred to ensure costs are ...

Head Start ? Assistance Listing No. 93.600 Community Services Block Grant ? Assistance Listing No. 93.569 Recommendation: We recommend Alliance for Community Empowerment, Inc. design controls to ensure an adequate review process is in place to review the period of costs incurred to ensure costs are charged to grants in the proper period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All expenditures will be reviewed and recorded in the proper period of performance. The correction was put into place during the audit and all expenditures have been reviewed during entry and at the point of signature from the Finance Director. Name of the contact person responsible for corrective action: Indi Hayes Planned completion date for corrective action plan: 4/24/2023

View Audit 20358 Questioned Costs: $1

Finding 20583 (2022-002)

None 2022

Tuskegee University

AL

Questioned Costs Allowable Costs / Cost Principles § 200.430

Finding 2022-002 ? Allowable Cost/ Cost Principles Planned Corrective Action: In November 2022, the University removed all unallowable salary and related fringe benefits costs off the affected grants, returned funds to USDA through the ASAP drawdown process, and corrected the SEFA. Additionally, the...

Finding 2022-002 ? Allowable Cost/ Cost Principles Planned Corrective Action: In November 2022, the University removed all unallowable salary and related fringe benefits costs off the affected grants, returned funds to USDA through the ASAP drawdown process, and corrected the SEFA. Additionally, the Office of Human Resources (HR) and Office of Grants and Contracts (OGCA) have implemented and strengthen monthly review procedures for Personnel Action Forms. In January 2023, Human Resources granted the OGCA query and view access to the Person?s Pay Distribution Module for employees working on grants and contracts. This will allow the OGCA staff to compare the PAFs to HR and Payroll data and identify errors, if any, for correction. Upon receipt of PAFs in the OGCA, the following steps will occur: A. (1) Verify that the faculty and or staff can be specifically identified with the sponsored project; (2) Verified the position in the budget and/or have the prior written approval of the funding agency; (3) Compare the grant period to the personnel action form (PAF) start and end date; and (4) ensure that required approved signatures (Principal Investigator, Department Head and/or Dean) are present. C. Once the above conditions have been met, the Financial Analyst signs the PAF, forward to the Budget Officer and the VP for Business Affairs/CFO, for approval. The approved document is then submitted to the Office of the President and finally, Human Resources for review, approval, and compliance with university employment guidelines and policies. Once approved, HR enters the PAF into the Colleague System. An employment contract is generated as applicable. D. Monthly Review of the Grants General Ledger Summary Report (GLSA) and the General Ledger Trial Balance (GLTB) and or General Ledger Budget Status (GLBS) are completed by the Grants Financial Analysts. This monthly review is to verify that amounts charged are allowable and accurately posted to the correct departmental account and object codes. Payroll charges are compared to the PAFs. E. The OGCA, HR, and Payroll Offices collaborate on any discrepancies or errors and resolve immediately. Anticipated Date of Completion: Corrective action completed as of the date of this report. Person Responsible for Corrective Action Plan: Mr. Dexter Odom, Chief Financial Officer

View Audit 20254 Questioned Costs: $1

Finding 20565 (2022-001)

Material Weakness 2022

Decatur Hospital Authority D/b/a Wise Health System and Affiliates

TX

Questioned Costs Allowable Costs / Cost Principles Reporting

Corrective Action Plan for Finding 2022-001 We are in receipt of the Findings Required to be Reported by Uniform Guidance, regarding questioned costs and material instance of noncompliance with respect to Activities Allowed/Unallowed and Allowable Costs/Cost Principles. Decatur Hospital Authority?s...

Corrective Action Plan for Finding 2022-001 We are in receipt of the Findings Required to be Reported by Uniform Guidance, regarding questioned costs and material instance of noncompliance with respect to Activities Allowed/Unallowed and Allowable Costs/Cost Principles. Decatur Hospital Authority?s Chief Financial Officer, Todd Scroggins, is responsible to oversee and implement the corrective action plan. In its Provider Relief period three and period four reporting submissions for the year ended December 31, 2022, the Authority?s reports included the activity of the Authority and their Nursing Home Facilities (Nursing Homes). The reported activity included other PRF expenses, nursing home infection control expenses and lost revenues. There are four separate nursing home management companies that provide services to the Authority?s seven Nursing Homes. There were approximately $358,571 in nursing home infection control expenses that were unable to be reconciled to eligible expenses for one of the Nursing Homes. The Authority provided the Nursing Homes with templates to use to provide the Authority with the necessary information for the reporting as the reporting was complete on the TIN of the Authority. The Authority relied on the accuracy of the information provided by the Nursing Homes. The Authority was not aware of the findings in the audit of period 1 and period 2 at the time the Authority submitted period 3 reporting. Therefore, the inaccurate reconciliation of eligible infection control expenses from period 2 was also used for reporting in period 3, which caused a recurrence in audit findings due to timing of audits and findings reported to the Authority. The Authority?s CFO will judgmentally perform detailed testing of reported costs and lost revenue from the Nursing homes in future reporting periods. In addition, the Authority?s CFO and management team will perform a detailed analysis of the reporting requirements in accordance with the final guidelines set by HRSA for future reporting periods. As deemed necessary, the Authority will modify the policies and procedures over federal grant reporting. The Authority?s CFO will oversee this to ensure that it is accomplished for future unreported periods as of this date. The corrective action plan will be implemented by December 31, 2023.

View Audit 27070 Questioned Costs: $1

Finding 20532 (2022-002)

Material Weakness 2022

City of Cambridge Massachusetts

MA

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management § 200.303

The City will establish the following procedures to ensure payment requests received from subrecipients are paid within 30 days of receipt of a complete request for reimbursement: 1. Department of Human Service Programs (DHSP) Contract Manager reviews invoices within 5 business days of receipt of re...

The City will establish the following procedures to ensure payment requests received from subrecipients are paid within 30 days of receipt of a complete request for reimbursement: 1. Department of Human Service Programs (DHSP) Contract Manager reviews invoices within 5 business days of receipt of request for reimbursement from subrecipient. a. If invoice is complete, original date of receipt is recorded. b. If invoice is incomplete, subrecipient is notified of items or documentation that is missing and receipt date is updated to reflect date of receipt of complete invoice. 2. Contract Manager approves payment request and submits to DHSP Fiscal staff for processing. 3. Fiscal staff processes and submits to Auditing Department as Priority payment.

View Audit 19296

Finding 20527 (2022-001)

Material Weakness 2022

Life & Discovery Inc. (dba Asian American Center of Frederick)

MD

Allowable Costs / Cost Principles Material Weakness Reporting § 200.430

Department of Health and Human Services FINDING ? FEDERAL AWARD PROGRAMS AUDITS 2022-001 Documentation of Personnel Expenses (Timesheets) Material Weakness Recommendation: Require all employees to complete a contemporaneous timesheet which includes all required Uniform Guidance requirements. A...

Department of Health and Human Services FINDING ? FEDERAL AWARD PROGRAMS AUDITS 2022-001 Documentation of Personnel Expenses (Timesheets) Material Weakness Recommendation: Require all employees to complete a contemporaneous timesheet which includes all required Uniform Guidance requirements. Action Taken: On January 1, 2023, an electronic time reporting function was put into effect through ADP (?Automatic Data Processing?), the company?s payroll processing system. This improvement allows employees to enter their time and select a cost center (?department code?) at the time of entry. It then routes the timesheet for approval by the supervisor before reaching the accounting department for payment initiation, resulting in an automated review and approval.

View Audit 20204

Finding 20526 (2022-001)

Significant Deficiency 2022

Boys & Girls Clubs of Metro Atlanta, Inc.

GA

Allowable Costs / Cost Principles Cash Management

Section III ? Major Federal Award Findings and Questioned Costs 2022-001 ? Allowable Costs/Activities Allowed The Organization agrees that turnover within program administration (2 separate principals in two years amidst the Covid pandemic) resulted in a lack of site visits and therefore reduced fid...

Section III ? Major Federal Award Findings and Questioned Costs 2022-001 ? Allowable Costs/Activities Allowed The Organization agrees that turnover within program administration (2 separate principals in two years amidst the Covid pandemic) resulted in a lack of site visits and therefore reduced fidelity between system data and actual headcounts of meals administered. Site visits resumed in fourth quarter of 2022. Further, an additional Grants Administrator was hired and added to the food program as a second principal, which will also provide an additional level of review. Going forward, meals will not be submitted for reimbursement if they cannot be properly documented and accounted for. Responsible Official: Chief Development Officer Anticipated Completion Date: 6/30/2023

View Audit 21513

Finding 20523 (2022-002)

Material Weakness 2022

The Carle Foundation

IL

Allowable Costs / Cost Principles Reporting § 200.303 § 200.430

Corrective Action Plan: SOR II grant leadership evaluated its process for preparing and reviewing time tracking for this award and has implemented procedures to ensure appropriate documentation of personnel costs are complete and accurate. Coordination with Payroll staff begin and was validated wi...

Corrective Action Plan: SOR II grant leadership evaluated its process for preparing and reviewing time tracking for this award and has implemented procedures to ensure appropriate documentation of personnel costs are complete and accurate. Coordination with Payroll staff begin and was validated with current pay period ending 9/23/23. Hourly staff are clocking into appropriate cost center and salaried staff are submitting hours to payroll to ensure appropriate time tracking Contact Person(s): Heather Hintz/Kathy Dams Anticipated Completion: 12/31/2023

View Audit 20202

Finding 20474 (2022-004)

Material Weakness 2022

South Arkansas Developmental Center for Children and Families, Inc.

AR

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

Contact Name: Barbara Staggs, CFO Contact Phone Number: 870-863-8194 Audit Period Ending: June 30, 2022 Audit Firm: FORVIS, LLP Federal Program: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution, Assistance Listing No. 93.498 Federal Agency: U.S. Department of Health and H...

Contact Name: Barbara Staggs, CFO Contact Phone Number: 870-863-8194 Audit Period Ending: June 30, 2022 Audit Firm: FORVIS, LLP Federal Program: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution, Assistance Listing No. 93.498 Federal Agency: U.S. Department of Health and Human Services Management concurs with finding and in future will get clarification from FORVIS regarding this type reporting to make sure it is done correctly.

View Audit 26769

Finding 20469 (2022-001)

Significant Deficiency 2022

City of Santa Barbara

CA

Procurement, Suspension & Debarment Allowable Costs / Cost Principles

2022-001 Corona Virus State and Local Recovery Funds? Assistance Listing No. 21.027 Recommendation: We recommend the City implement procedures to ensure that verification documentation for suspension and debarment is maintained to support the City's internal control over compliance. Explanation of d...

2022-001 Corona Virus State and Local Recovery Funds? Assistance Listing No. 21.027 Recommendation: We recommend the City implement procedures to ensure that verification documentation for suspension and debarment is maintained to support the City's internal control over compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Despite understanding of these requirements, the City failed to document verification of suspension and debarment findings. We have taken immediate action to incorporate standards to ensure that these measures are documented and maintained appropriately moving forward. Name(s) of the contact person(s) responsible for corrective action: Jessica Yates, Accounting Supervisor Planned completion date for corrective action plan: June 2023

View Audit 26059

Finding 20464 (2022-002)

Material Weakness 2022

Town of Edinburgh

IN

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

FINDING 2022-002 Contact Person Responsible for Corrective Action: Scott Finley Contact Phone Number: 812-526-3511 Contact E-mail: sfinley@edinburgh.in.us View of responsible official: The town concurs with the Section III finding identified. Description of Corrective Action Plan: For SRF disburseme...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Scott Finley Contact Phone Number: 812-526-3511 Contact E-mail: sfinley@edinburgh.in.us View of responsible official: The town concurs with the Section III finding identified. Description of Corrective Action Plan: For SRF disbursements related to construction, the town?s engineers review the pay applications and are sent to the town for review. The pay app is submitted to the council for review and approval. Upon approval, the Clerk-Treasurer signs the pay app and submits it to SRF for disbursement. Moving forward, the town council president will sign the pay app rather than the Clerk-Treasurer. For SRF Disbursements related to engineering, the invoice is reviewed by the Town Manager and Clerk- Treasurer and then submitted to SRF for disbursement. Moving forward, these invoices will be processed similarly to the construction pay apps. These invoices will be reviewed by the Town Manager and Clerk- Treasurer and then submitted to the council for approval. After council approval they will be submitted to SRF for disbursement. The town will also request that the engineers add a signature page to their invoices so they can be signed off on. Anticipated Completion Date: Process will be implemented immediately.

View Audit 24560

Finding 20460 (2022-005)

Material Weakness 2022

Jefferson County Government

CO

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

FISCAL YEAR OF FINDING: 2022 AUDITOR FINDING: 2022-005 Eligibility. We noted the following issues in the 40 cases tested: 1. Four instances in which income was incorrectly calculated based on information maintained in case file. 2. One instance in which there was inadequate documentation to support ...

FISCAL YEAR OF FINDING: 2022 AUDITOR FINDING: 2022-005 Eligibility. We noted the following issues in the 40 cases tested: 1. Four instances in which income was incorrectly calculated based on information maintained in case file. 2. One instance in which there was inadequate documentation to support eligibility determination within the case file. 3. One instance in which the Colorado Works Referral form was not processed timely. 4. Two instances in which the County' eligibility authorization notes for the period selected did not agree to CHATS. Recommendation: We recommend that the County continue to strengthen the internal controls surrounding the eligibility process, specifically continuing the use and monitoring of case reviews to help identify potential areas for additional training. CLIENT PLANNED ACTION: Jefferson County agrees with the findings. There continues to be improvement each year in the overall findings, which demonstrates that the strategies previously implemented had the desired impact. However, the continued findings require additional action steps. Jefferson County will continue and implement the following actions to address and prevent future errors. ? The CCAP supervisor will continue reviewing available reports in CHATS to target untimely closures and follow up on potential erroneous case closures. Reports include the RE301, RE224, and RE115. Any case needing action will be assigned for completion within 5 business days and reviewed to ensure corrections were completed. ? Monthly case reviews will continue, at three levels, to assess case and payment accuracy. o The Jeffco Human Services Internal Quality Assurance (IQA) team will review 1% of the caseload monthly, utilizing the state mandated list. o The State Program Integrity Office will review cases monthly to monitor case and payment accuracy. o CCAP Supervisor and/or Lead Worker will review cases as follows: - The CCAP Supervisor will complete a minimum of two case reviews per worker per month. The number and type of review may be adjusted based on individual staff performance. Income and parent fee calculations will be targeted using the primary activity report in CHATS. The Lead Worker will fulfill this function if the Supervisor is out of the office. - 5% of all applications and redeterminations will be reviewed by the CCAP Supervisor or Lead Worker prior to approval. Jefferson County?s Internal Auditor has also been trained on the eligibility process and may review cases prior to approval to support the team. Eligibility Specialists will utilize a pre-authorization checklist when submitting the selected cases for review. The checklist was developed and implemented to assist workers in accurately entering and checking their data entry and eligibility determination. New CCAP Eligibility Specialists will have 100% of cases reviewed prior to approval until accuracy rates reach 95%, at which point preauthorization reviews will be reduced incrementally based on performance. o All responses to IQA or State Program Integrity regarding corrections or resolutions to cases will be documented and provided to the CCAP Supervisor/Program Manager within 2-5 business days, depending on the identified deadline, and will include screen shots verifying corrections prior to submittal. o Monthly meetings between the Division Director, Program Integrity Manager, Program Integrity Supervisor, Quality Assurance Supervisor, CCAP Program Manager, and CCAP Supervisor will continue in order to discuss performance and progress related to quality assurance and program integrity. Prior to the meeting, the Internal Quality Assurance (IQA) team will provide monthly reports for review and analysis. During the meetings, data and trends will be reviewed utilizing the aforementioned reports, which include error type, accuracy, and error increase/reduction over the year. In addition, training needs for staff will be discussed based on the supervisory, Internal Quality Assurance (IQA), and State level review findings and monitoring strategies will be developed to address areas of concern. ? Monthly review data is incorporated into all individual and leadership performance milestones. Milestones are the county?s employee performance management system. Continued errors or lack of progress and improvement will be addressed via the county Employee Relations coaching and disciplinary framework. ? Effective January 1, 2023, Jefferson County launched an updated model for service delivery and workload management utilizing an internal system, GenApp. The utilization of GenApp: o Improved document storage, o Increased oversight related to workload and timeliness as all pending actions can be viewed by type, date received and due date, o Simplified workload coverage due to employee leave or vacancies, o Removed inconsistencies in customer service, o Improved available reports. ? The Colorado Works Referral inbox has been prioritized by the CCAP Supervisor/Lead Worker for review and timely completion. ? Supplementary income training will be developed and delivered starting in October 2023 and continue on a quarterly basis to provide a review of income rules, calculation, common errors, and answer questions. CLIENT RESPONSIBLE PARTY: Tara Noble (Program Manager) and Monie Salgado (CCAP Supervisor) COMPLETION DATE: October 2023

View Audit 22844

Finding 20456 (2022-001)

Material Weakness 2022

Florida Health Sciences Center, INC

FL

Questioned Costs Allowable Costs / Cost Principles § 200.303

Existing processes were revised to ensure all billings to the HRSA uninsured program were in compliance with federal guidelines and regulations. Additionally, management established a work group to review inpatient accounts incorrectly billed to HRSA to ensure the amounts are properly refunded.

View Audit 22522 Questioned Costs: $1

Finding 20428 (2022-001)

Material Weakness 2022

Opp City Board of Education

AL

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303 § 200.326

Item 2022-001 ? Special Tests and Provisions ? Wage Rate Requirements Recommendation: 2 CFR 200.303 requires the non-Federal entity to ?(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Feder...

Item 2022-001 ? Special Tests and Provisions ? Wage Rate Requirements Recommendation: 2 CFR 200.303 requires the non-Federal entity to ?(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award.? 2 CFR 200.326 and 29 CFR Part 5, Labor Standards Provisions Applicable to Contracts Governing Federally Financed and Assisted Construction (DOL Regulations) require the contractor or subcontractor to submit to the nonfederal entity weekly, for each week in which any contract work is performed, a copy of the payroll and a statement of compliance (certified payrolls). We recommend the strengthening of controls to ensure the prevailing wage rate clauses are included in the contracts and that certified payrolls are received for each week in which construction work is performed. The Chief School Financial Officer, Linda Harper, should review documentation for inclusion of the prevailing wage rate clauses in construction contracts as part of the bid process prior to expenditures being made. She should also review all invoices received from contractors and subcontractors to ensure that the certified payroll information is received for all weeks for which construction work is performed. Action Taken: Management has reviewed the requirements of 2 CFR Section 200.303 and 2 CFR 200.326 relating to wage rate requirements and agrees with the recommendation. Management has already communicated with all contractors and subcontractors regarding the wage rate requirements and has implemented additional procedures, effective January 1, 2023, stating that the Chief School Financial Officer, Linda Harper, will review documentation for inclusion of the prevailing wage rate clauses in construction contracts as part of the bid process prior to expenditures being made. She will also review all invoices received from contractors and subcontractors to ensure that the certified payroll information is received for all weeks for which construction work is performed.

View Audit 28288

Finding 20413 (2022-002)

Material Weakness 2022

North East Community Action Corporation and Subsidiaries

MO

Questioned Costs Allowable Costs / Cost Principles Eligibility

2022-002 Noncompliance;Activities Allowed/Unallowed; Allowable Costs/Activities; Eligibility A. Comments on Findings and Recommendations: We concur with the auditor?s suggestions regarding lack of controls and adequate supporting documentation over gift cards and attribute the deficiencies to ...

2022-002 Noncompliance;Activities Allowed/Unallowed; Allowable Costs/Activities; Eligibility A. Comments on Findings and Recommendations: We concur with the auditor?s suggestions regarding lack of controls and adequate supporting documentation over gift cards and attribute the deficiencies to an error in determination of gift cards and proper treatment, as a result of turnover in program management. B. Actions Taken or Planned: Current management continues to evaluate process and procedures to ensure accurate recording, tracking, reporting and monitoring of program expenses, in order to provide adequate documentation to support compliance with grant requirements . Changes have been initiated to improve processes and documentation over assistance payments, including gift cards. Anticipated completion date: In Process Contact information for this finding: Vicky Pritchett, Finance Director, 573-324-2231

View Audit 26264 Questioned Costs: $1

Finding 20404 (2022-001)

Significant Deficiency 2022

Yolo County Transportation District

CA

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

Federal Grantor: US Department of Transportation, Federal Transit Administration, Federal Transit Formula Grants, Direct Award, All Award under Assistance List (AL) Number 20.507 Effect: Expenses were misallocated to individual routes and purposes, resulting in an overclaim of Woodland preventative ...

Federal Grantor: US Department of Transportation, Federal Transit Administration, Federal Transit Formula Grants, Direct Award, All Award under Assistance List (AL) Number 20.507 Effect: Expenses were misallocated to individual routes and purposes, resulting in an overclaim of Woodland preventative maintenance expenses of $12,268 under grant CA-2022-204. Auditor Recommendation: We recommend the District develop written procedures for allocating expenses to routes and purposes used to claim expenses under federal grants, including what data should be input into the allocation spreadsheet, the formulas used to allocate each type of expense to routes, which expenses should be allocated to each route and purpose (operating, preventive maintenance, etc.) and which expenses may not be allocated to certain routes and purposes. A summary tab should be added to the spreadsheet to sum amounts for each route computed on separate tabs on the spreadsheet to make it easier to reconcile total operating expenses, preventive maintenance, insurance, communications and other expenses to the general ledger. The District should also contact the FTA to discuss how to address the $12,268 amount overclaimed. YCTD Contact Person Responsible for the Corrective Action: Leo Levenson, Inteirm CFO, Llevenson@yctd.org. Management Response and Corrective Action Plan: YCTD concurs with the finding and recommendation. YCTD has already contacted the FTA regional office and followed their guidance on how to return the $12,268 amount overclaimed. YCTD will formalize new written procedures and summary spreadsheet tabs as recommended by the auditor, with a target date for completion of March 31, 2023.

View Audit 24662

Finding 20392 (2022-004)

Material Weakness 2022

Wickenburg Community Hospital

AZ

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Finding 2022-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Hospital did not properly include 340B reve...

Finding 2022-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Hospital did not properly include 340B revenues and final audit adjustments in net patient service revenue. In addition, the Hospital did not properly report payor categories for quarters in which the net patient service revenues were negative. Responsible Individuals: Patti Clavette, Chief Financial Officer; Jackie Lundblad, Chief Executive Officer Corrective Action Plan: Management will modify the lost revenue reported on future reports, if any, to reflect an accurate total lost revenue amount. In addition, a formal review and approval process will be implemented to ensure calculations are in accordance with applicable requirements and a member of management will be identified to review all reporting requirements for federal grants and awards to ensure the Hospital is in compliance with the requirements. Anticipated Completion Date: September 30, 2023

View Audit 21564

Finding 20391 (2022-006)

Significant Deficiency 2022

Wickenburg Community Hospital

AZ

Questioned Costs Allowable Costs / Cost Principles Cash Management

Finding 2022-006 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Compliance Requirement: Allowable Costs Finding Summary: Management calculated the applicant?s contribution as 25% of the funds requested ...

Finding 2022-006 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Compliance Requirement: Allowable Costs Finding Summary: Management calculated the applicant?s contribution as 25% of the funds requested for reimbursements instead of first applying the full contribution to the requested reimbursement. Responsible Individuals: Patti Clavette, Chief Financial Officer; Jackie Lundblad, Chief Executive Officer Corrective Action Plan: Management will properly adjust subsequent requests for reimbursement under the grant agreement for the remaining portion of the applicant?s contribution. In addition, management will evaluate controls in place to ensure conditions of future grants are met in order to prevent further noncompliance or question costs. Anticipated Completion Date: September 30, 2023

View Audit 21564 Questioned Costs: $1

Finding 20384 (2022-004)

Material Weakness 2022

Morris Area Public School 2769

MN

Allowable Costs / Cost Principles Material Weakness School Nutrition Programs

Finding Summary: During the course of our engagement, we noted instances where documentation was not retained supporting payroll expenditures and invoices were paid in an incorrect amount that was charged to the federal Child Nutrition Cluster program. Responsible Individuals: Shane Monson, Superint...

Finding Summary: During the course of our engagement, we noted instances where documentation was not retained supporting payroll expenditures and invoices were paid in an incorrect amount that was charged to the federal Child Nutrition Cluster program. Responsible Individuals: Shane Monson, Superintendent. Corrective Action Plan: The District will review and strengthen the controls surrounding the review and approval of allowable costs to ensure they are supported, approved of, and calculations are accurate. Anticipated Completion Date: June 30, 2023

View Audit 20655

Finding 20379 (2022-001)

Significant Deficiency 2022

Junior Achievement of Arizona, Inc.

AZ

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

Management has implemented procedures to verify that the expenditures that are requested for reimbursement are not duplicated and are allowable under the Uniform Guidance. Review procedures have been added to help ensure that only allowable salaries expenses are included in reimbursement requests an...

Management has implemented procedures to verify that the expenditures that are requested for reimbursement are not duplicated and are allowable under the Uniform Guidance. Review procedures have been added to help ensure that only allowable salaries expenses are included in reimbursement requests and that all voided checks are omitted.

View Audit 19855 Questioned Costs: $1

Finding 20378 (2022-002)

Significant Deficiency 2022

Housing Authority of the Township of Neptune

NJ

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.423 § 200.438 § 200.473

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Bart Cook,...

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Bart Cook, Executive Director, is responsible for implementing this corrective action by September 30, 2023.

View Audit 19315 Questioned Costs: $1

Finding 20377 (2022-001)

Significant Deficiency 2022

Peacehealth Networks

WA

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

As noted within the portal filing summary for the general reporting Period 1, the Corporation?s consolidated lost revenue totaled $141,363,926. Payments from the PRF for Period 1 totaled $53,982,121 for the consolidated parent and $14,810,675 for St. John?s Medical Center Period 2 targeted report. A...

As noted within the portal filing summary for the general reporting Period 1, the Corporation?s consolidated lost revenue totaled $141,363,926. Payments from the PRF for Period 1 totaled $53,982,121 for the consolidated parent and $14,810,675 for St. John?s Medical Center Period 2 targeted report. As a result, there were sufficient qualifying lost revenues to receive and earn all PRF funds received, regardless of the reporting error identified and described in the ?condition found? section above. Therefore, management believes no repayment of PRF funds received would be required. Management is implementing a process to add additional review steps prior to finalizing future reporting submissions.

View Audit 19419

Finding 20375 (2022-003)

Material Weakness 2022

The Be Kind People Project Foundation

AZ

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

2022-003 Material Weakness in Internal Control over Compliance with Activities Allowed or Unallowed and Allowable Costs/ Cost Principles Condition: The Organization did not retain the required documentation to support the review of expenditures. Cause: The Organization had turnover and limited st...

2022-003 Material Weakness in Internal Control over Compliance with Activities Allowed or Unallowed and Allowable Costs/ Cost Principles Condition: The Organization did not retain the required documentation to support the review of expenditures. Cause: The Organization had turnover and limited staffing available. Management?s Response and Corrective Action Plan: Changing the personnel involved has solved much of the problem, also the full awareness of what needs to be retained has also been explained to management. If/ when funds from federal sources are used, those expenditures will be reviewed monthly. Specifically, this will mean: ? Maintain EIDL-sourced funds in separate bank/ account. ? Have single authorization for any movement/ usage of funds in EIDL account. ? If/when funds from EIDL are used, have a written statement for purpose and documentation produced for use at the time of request. Responsible Individuals: ? Maintain separate account ? Marcia Meyer, CEO, in conjunction with Board Finance Committee ? Authorization for use of funds ? Marcia Meyer ? Maintenance of records for use ? JC Thompson ? Confirmation with use of funds per allowable uses per national guidelines ? Jennie Myers ? Reporting on monthly finance report ? Jennie Myers Anticipated Completion Date: This process is underway and will be visible at the fiscal year-end audit in June 2023.

View Audit 19100

Finding 20360 (2022-004)

Significant Deficiency 2022

Joseph's House and Shelter, Inc.

NY

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Finding 2022-004 ? Allowable Costs/Cost Principles--Significant Deficiency Recommendation: The Organization should put in place policies and procedures necessary to maintain detailed contemporaneous documentation supporting the allocation of payroll and related expenses to individual programs in a...

Finding 2022-004 ? Allowable Costs/Cost Principles--Significant Deficiency Recommendation: The Organization should put in place policies and procedures necessary to maintain detailed contemporaneous documentation supporting the allocation of payroll and related expenses to individual programs in a manner that accurately reflects the work performed. Views of Responsible Officials and Planned Corrective Actions: The Executive Director worked with the Director of Grants and Finance to review and revise the agency?s accounting policies and procures. To ensure proper oversight, all procedures and reports will be reviewed by the Board?s Finance Committee, followed by a final review and approval of the Full Board of Directors of Joseph?s House & Shelter. One project of note was a collaborative effort undertaken by the Executive Director, a new Director of HR and Administration, the Human Resources Manager, and the Director of Grants and Finance to roll out a more detailed time keeping system that is used to track employee time spent per program. This data is then subsequently directly coded and uploaded into the accounting software. This process ensures on an ongoing basis that the allocation of payroll and related expenses will accurately reflect the work being performed and has significantly improved timely and precise grant claims. This was implemented in Q2 2023.

View Audit 18957

Finding 20359 (2022-003)

Material Weakness 2022

Joseph's House and Shelter, Inc.

NY

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

Finding 2022-003 ? General Oversite ? Material Weakness Recommendation: We recommend that the Organization create policies and procedures to ensure proper oversight of the financial reporting function. In addition, we would recommend the Organization to consider the costs and benefits of restruct...

Finding 2022-003 ? General Oversite ? Material Weakness Recommendation: We recommend that the Organization create policies and procedures to ensure proper oversight of the financial reporting function. In addition, we would recommend the Organization to consider the costs and benefits of restructuring the finance department. This could include allocating additional resources to hire additional employees, reallocation of responsibilities within the organization and less reliance on the contracted accounting services. View of Responsible Officials and Planned Corrective Actions: The Executive Director has worked with the Director of Grants and Finance to review and revise the agency?s accounting policies and procures. To ensure proper oversight, all procedures and reports will be reviewed by the Board?s Finance Committee, followed by a final review and approval of the Full Board of Directors of Joseph?s House & Shelter. Beginning in Q1 2022, agency leadership took necessary action to begin restructuring the Finance Department following a change in staffing with the contracted accounting service. In Q2 2022, the agency promoted a long-tenured staff member to the newly-created Director of Grants and Finance position, which separated and removed all finance duties from the Director of Administration. To support the Director of Grants and Finance, a full time Grants and Finance Specialist staff position was created in Q3 of 2022. The organization has scaled back reliance on the contracted accounting service and has ensured that all claims, with the implementation of personnel time tracking systems, are submitted through our Finance Department. We continue to use a contracted accounting service for higher-level accounting duties and for on-going advisement that supplements, instead of replaces, the work of internal staff. We are confident these changes have improved the agency?s ability to provide adequate management oversight in the financial reporting process. This was completed in Q2 of 2023.

View Audit 18957

Corrective Action Plans

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