Corrective Action Plans

Finding 416 (2023-001)

Significant Deficiency 2023

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 Questioned Costs 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

Questioned Costs 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

Questioned Costs Allowable Costs / Cost Principles Reporting

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

Questioned Costs 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 1241198 (2022-001)

Material Weakness 2022

SIERRA SVING GRACE HMELESS PRJ

CA

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

Refer to the Attached Management's Formal Response and Corrective Action Plan.

View Audit 415297

Finding 1240570 (2022-002)

Material Weakness 2022

NUNAKAUYARMIUT TRIBE

AK

Allowable Costs / Cost Principles § 200.430

Finding 2022-002 Lack of Internal Control Over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Dora Mathew, Tribal executive Director Mary Carl, Tribal Financial Officer Corrective Action Plan: Nunakauyarmiut Tribe concurs with the finding and has strength...

Finding 2022-002 Lack of Internal Control Over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Dora Mathew, Tribal executive Director Mary Carl, Tribal Financial Officer Corrective Action Plan: Nunakauyarmiut Tribe concurs with the finding and has strengthened controls governing payroll and other expenditures charged to federal awards. The Tribe requires documentation demonstrating that payroll costs charged to a federal program are supported by actual work performed for that program and are necessary, reasonable, allocable, allowable, and consistent with the applicable award and Tribal policies. Timesheets and payroll records will be reviewed before payroll expenses are charged to federal awards. Finance will periodically reconcile payroll expenses to the general ledger, applicable grant or contract budgets, and supporting documentation. Unsupported or incorrectly allocated expenditures identified during review will be investigated and, when appropriate, corrected through properly documented accounting adjustments. Finance, Administration, supervisors, and program personnel will coordinate to ensure payroll and other costs are charged only to programs that benefited from the activity and that adequate supporting documentation is maintained. Proposed Completion Date: September 30, 2026.

View Audit 414987

Finding 1240567 (2022-003)

Material Weakness 2022

NUNAKAUYARMIUT TRIBE

AK

Allowable Costs / Cost Principles § 200.430

Finding 2022-003 Lack of Internal Control Over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Dora Mathew, Tribal executive Director Mary Carl, Tribal Financial Officer Corrective Action Plan: Nunakauyarmiut Tribe concurs with the finding and has implemen...

Finding 2022-003 Lack of Internal Control Over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Dora Mathew, Tribal executive Director Mary Carl, Tribal Financial Officer Corrective Action Plan: Nunakauyarmiut Tribe concurs with the finding and has implemented additional controls over expenditures charged to federal transportation awards. Payroll and other costs charged to transportation programs must be supported by documentation demonstrating the relationship of the expenditure to the applicable project or federal award. Employee time charged to transportation projects must reflect actual work performed and be supported by approved time and payroll documentation. Finance will reconcile transportation program expenditures to the general ledger, approved award budget, and supporting documentation. Costs that cannot be adequately supported or determined to be allocable to the applicable transportation award will not remain charged to that award. The Tribe will maintain supporting documentation for payroll, purchases, contracts, invoices, travel, and other expenditures associated with transportation awards to provide an adequate audit trail and demonstrate compliance with applicable award requirements. Proposed Completion Date: September 30, 2026.

View Audit 414987

Finding 1240034 (2022-008)

Material Weakness 2022

Akiachak Native Community

AK

Allowable Costs / Cost Principles Material Weakness Reporting § 200.430

Finding 2022-008 Lack of Internal Controls Over Activities Allowed or Unallowed and Allowable Costs/Costs Principles Name of Contact Person: Noelle George, Tribal Administrator Corrective Action Plan: Management will strengthen internal controls over payroll and review personnel files for adequate p...

Finding 2022-008 Lack of Internal Controls Over Activities Allowed or Unallowed and Allowable Costs/Costs Principles Name of Contact Person: Noelle George, Tribal Administrator Corrective Action Plan: Management will strengthen internal controls over payroll and review personnel files for adequate pay rate documentation. Proposed Completion Date: October 31, 2026.

View Audit 414656

Finding 1240033 (2022-007)

Material Weakness 2022

Akiachak Native Community

AK

Allowable Costs / Cost Principles Material Weakness Reporting

Finding 2022-007 Lack of Internal Controls Over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Noelle George, Tribal Administrator Corrective Action Plan: Improvements will be made to documentation procedures for payables and cash disbursements to accommo...

Finding 2022-007 Lack of Internal Controls Over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Noelle George, Tribal Administrator Corrective Action Plan: Improvements will be made to documentation procedures for payables and cash disbursements to accommodate the minimum requirements for grant regulations and audit purposes. Proposed Completion Date: October 31, 2026.

View Audit 414656

Finding 1239836 (2022-004)

Material Weakness 2022

Community Alliance with Family Farmers

CA

Reporting Allowable Costs / Cost Principles Cash Management

In 2026 CAFF will create a grant bridging document to monitor differences between revenue and expenses and progress against grant budgets. Grant reports in QuickBooks will reflect a full accounting each month for revenue earned and costs incurred (including allocated costs per cost allocation plan).

View Audit 414508

Finding 1239834 (2022-002)

Material Weakness 2022

Community Alliance with Family Farmers

CA

Subrecipient Monitoring Procurement, Suspension & Debarment Allowable Costs / Cost Principles

In 2026 CAFF will identify all required uniform compliance requirements under each grant and draft written policies and procedures to ensure we remain in compliance, focusing on the 12 basic compliance areas identified in the OMB Compliance Supplement published last year. This compliance document wi...

In 2026 CAFF will identify all required uniform compliance requirements under each grant and draft written policies and procedures to ensure we remain in compliance, focusing on the 12 basic compliance areas identified in the OMB Compliance Supplement published last year. This compliance document will name the individual accountable and the procedures needed to ensure compliance.

View Audit 414508

Finding 1236266 (2022-009)

Material Weakness 2022

Community Homeless Solutions

CA

Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Update procurement (purchasing) policies and incorporate Federal Requirements. This will require staff training of Federal Procurement Standards and establishing oversight procedures

View Audit 411850

Finding 1236265 (2022-008)

Material Weakness 2022

Community Homeless Solutions

CA

Allowable Costs / Cost Principles

Improve procedures related to costs (expenses) charged to Federal Awards - including documentation and records retention. This includes frequent reviews of records to ensure compliance with federal regulations and policies.

View Audit 411850

Finding 1236264 (2022-007)

Material Weakness 2022

Community Homeless Solutions

CA

Allowable Costs / Cost Principles Reporting

Implement a formal approval process for all federal expenditures - ensuring pre-approval, and available documentation are retained. Consider staff training for uniform guidance and continuing reviews and approvals to ensure compliance.

View Audit 411850

Finding 1236263 (2022-006)

Material Weakness 2022

Community Homeless Solutions

CA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Improve payroll allocations ensuring accuracy of actual time worked. Also, documentation should reflect work performed accurately.

View Audit 411850

Finding 1235974 (2022-003)

Material Weakness 2022

Metro Area Continuum of Care for the Homeless

NE

Allowable Costs / Cost Principles Cash Management Period of Performance

Finding Reference Number 2022: Approval and Support for Costs Description of Finding: For the Emergency Rental Assistance Program, adequate supporting documentation could not be provided for 8 of 60 transactions tested, and 16 of 60 transactions did not contain evidence of appropriate approval. The ...

Finding Reference Number 2022: Approval and Support for Costs Description of Finding: For the Emergency Rental Assistance Program, adequate supporting documentation could not be provided for 8 of 60 transactions tested, and 16 of 60 transactions did not contain evidence of appropriate approval. The audit reports questioned costs of less than $25,000. Statement of Concurrence or Nonconcurrence: Threshold CoC concurs with the finding. Corrective Action: Management will continue to follow and reinforce established internal controls for processing and approving costs charged to federal programs. Personnel responsible for processing and approving federal expenditures will receive additional training. Management will require adequate supporting documentation to be retained with each charge and evidence of appropriate review and approval before costs are charged to a federal program. This is similar to prior-year finding 2021. The corrective action above strengthens documentation retention, approval evidence, and staff training in response to the repeated issue. Name of Contact Person: Jason Feldhaus, Executive Director, jason@thresholdcoc.org Projected Completion Date: December 31, 2026 Questioned Costs: Less than $25,000, as reported by the auditors.

View Audit 411573

Finding 1229200 (2022-001)

Material Weakness 2022

CHINOOK PUBIC SCHOOLS

MT

Allowable Costs / Cost Principles Subrecipient Monitoring § 200.302 § 200.403

The District agrees with the finding regarding the need to maintain adequate supporting documentation and internal controls over expenditures charged to federal awards. The District recognizes that costs charged to Federal awards must be adequately documented and supported in accordance with 0MB Uni...

The District agrees with the finding regarding the need to maintain adequate supporting documentation and internal controls over expenditures charged to federal awards. The District recognizes that costs charged to Federal awards must be adequately documented and supported in accordance with 0MB Uniform Guidance, 2 CFR. and that expenditures must be properly reviewed and approved prior to payment. The District will strengthen its procedures to ensure that all expenditures, particularly those charged to Federal grants, have appropriate supporting documentation demonstrating the allowability and business purpose of the expenditure. The District will also ensure that evidence of supervisory review and approval is maintained prior to payment. Staff and supervisors will periodically review expenditure records to ensure documentation and approval requirements are being followed and maintained.

View Audit 410696

Finding 1228715 (2022-001)

Material Weakness 2022

Philadelphia Industrial Development Corporation

PA

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

Managements Corrective Action Plan: Individual(s) Responsible for Corrective Action Plan Tysha Dixon Director, Financial Reporting (215) 496-8168 Completed March 2023 Questioned Program: ALN #14.218 Community Development Block Grants (CDBG) Finding #2022-001 – Activities Allowed or Unallowed and All...

Managements Corrective Action Plan: Individual(s) Responsible for Corrective Action Plan Tysha Dixon Director, Financial Reporting (215) 496-8168 Completed March 2023 Questioned Program: ALN #14.218 Community Development Block Grants (CDBG) Finding #2022-001 – Activities Allowed or Unallowed and Allowance Costs / Cost Principles Information on Federal Program – CDBG Entitlement Grants Cluster, Community Development Block Grants – Entitlement Grants, 14.218, Philadelphia Department of Commerce, contract number 23-20489 Management’s Corrective Action Plan Management will continue to rely on its existing controls that are in place, including the ongoing communication with the City for any changes in transactions that require their approval. In the circumstances where management is pending a contract amendment from the City for loans requiring additional funding, management will determine if there are unrestricted funding sources to support the change in the approved amount of the loan until the amended contract is finalized.

View Audit 410388

Finding 1228640 (2022-007)

Material Weakness 2022

TOWN OF SPRING LAKE

NC

Allowable Costs / Cost Principles

SIGNIFICANT DEFICIENCY / NONMATERIAL NONCOMPLIANCE Finding 2022-007 Allowable Costs / Cost Principles Name of Contact Person: James C Overton, Finance Director Corrective Action: The Town has hired a purchasing agent and finance director who are working on implementing standard operating procedures ...

SIGNIFICANT DEFICIENCY / NONMATERIAL NONCOMPLIANCE Finding 2022-007 Allowable Costs / Cost Principles Name of Contact Person: James C Overton, Finance Director Corrective Action: The Town has hired a purchasing agent and finance director who are working on implementing standard operating procedures and policies targeting the procurement process to ensure that the Town obtains competitive bids on all federal and state grant projects, and that such bids are documented to comply with North Carolina General Statutes and the Uniform Grant Guidance procurement standards. The Town has also contracted with the North Carolina League of Municipalities to provide additional training to the Town‘s staff. Proposed Completion Date: December 31, 2026.

View Audit 410277

Finding 1228543 (2022-001)

Material Weakness 2022

THE LIGHTHOUSE, INC.

HI

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.512

Planned Corrective Action: The audited financial statements for FY2022 will be finalized before the end of the month, and shortly thereafter, the single audit reporting package will be transmitted to FAC. Name of Contact Person: Melby Albano, MHK HUD Housing Manager, and Greg Payton, CEO Projected C...

Planned Corrective Action: The audited financial statements for FY2022 will be finalized before the end of the month, and shortly thereafter, the single audit reporting package will be transmitted to FAC. Name of Contact Person: Melby Albano, MHK HUD Housing Manager, and Greg Payton, CEO Projected Completion Date: 12/31/2024

View Audit 410164

Finding 1228538 (2022-001)

Material Weakness 2022

LEEWARD KOKUA HOUSING INC

HI

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.512

Planned Corrective Action: The audited financial statements for FY2022 will be finalized before the end of the month, and shortly thereafter, the single audit reporting package will be transmitted to FAC. Name of Contact Person: Melby Albano, MHK HUD Housing Manager, and Greg Payton, CEO Projected C...

Planned Corrective Action: The audited financial statements for FY2022 will be finalized before the end of the month, and shortly thereafter, the single audit reporting package will be transmitted to FAC. Name of Contact Person: Melby Albano, MHK HUD Housing Manager, and Greg Payton, CEO Projected Completion Date: 12/31/2024

View Audit 410162

Corrective Action Plans

Filters