Corrective Action Plans

Finding 555674 (2021-007)

Material Weakness 2021

MA

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

Item 2021.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this...

Item 2021.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance. • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant’s period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail. • Review these procedures annually to ensure ongoing compliance with the grant’s period of performance.

View Audit 354288

Finding 555670 (2021-003)

Material Weakness 2021

Island Health, Inc.

MA

Allowable Costs / Cost Principles § 200.40 § 200.430

Item 2021.003 – Activities Allowed or Unallowed Recommendation We recommend that the Center consistently enforce its internal controls over payroll to ensure that the timesheet and payrates are reviewed and approved by the appropriate supervisor. Additionally, we recommend that the Center consisten...

Item 2021.003 – Activities Allowed or Unallowed Recommendation We recommend that the Center consistently enforce its internal controls over payroll to ensure that the timesheet and payrates are reviewed and approved by the appropriate supervisor. Additionally, we recommend that the Center consistently reinforces its internal controls over nonpayroll expenditures to ensure all expenditures were approved by the appropriate supervisor. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: Timesheet and payrate review and approval: • Standardize timesheet submission and approval process. • Utilize and electronic timesheet system to document the verification of employee payrates and ensure there is a detailed audit trail that records all submissions, review, and approval by supervisors. • Conduct regular audits to verify timesheets and payrates are reviewed and approved by supervisors. Nonpayroll Expenditures: • Evaluate and improve upon existing processes to ensure internal control over nonpayroll expenditures are working. This includes enforcement of approval policies with mandatory documentation and regular monitoring throughout the process for a clear audit trail. • Conduct regular audits to verify nonpayroll expenditures have been reviewed and approved by supervisors.

View Audit 354288

Finding 554491 (2021-012)

Material Weakness 2021

Washington County

OK

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

No corrective action taken.

View Audit 353149

Finding 554490 (2021-011)

Material Weakness 2021

Washington County

OK

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

No corrective action taken.

View Audit 353149

Finding 554366 (2021-003)

Material Weakness 2021

Kanawha Valley Collective Inc.

WV

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

Audit Finding Reference: Federal Award Findings and Questioned Costs: 2021-03 (Single audit submission) Planned Corrective Action: The Kanawha Valley Collective, Inc. will develop internal policies and procedures designed to ensure a timely annual financial statement closing which will allow the req...

Audit Finding Reference: Federal Award Findings and Questioned Costs: 2021-03 (Single audit submission) Planned Corrective Action: The Kanawha Valley Collective, Inc. will develop internal policies and procedures designed to ensure a timely annual financial statement closing which will allow the required single audit to be completed in a timelier manner. Name of Contact Person: Traci Strickland Anticipated completion date: June 30, 2025

View Audit 352974

Finding 554365 (2021-002)

Material Weakness 2021

Kanawha Valley Collective Inc.

WV

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

Audit Finding Reference: Federal Award Findings and Questioned Costs: 2021-02 (Reporting) Planned Corrective Action: The Kanawha Valley Collective, Inc. will implement enhanced reconciliation and documentation procedures that timely identify and allow for the correction of differences between the ac...

Audit Finding Reference: Federal Award Findings and Questioned Costs: 2021-02 (Reporting) Planned Corrective Action: The Kanawha Valley Collective, Inc. will implement enhanced reconciliation and documentation procedures that timely identify and allow for the correction of differences between the accounting recordkeeping and the grant reporting documentation. Name of Contact Person: Traci Strickland

View Audit 352974

Finding 554207 (2021-009)

Material Weakness 2021

Consortium of Universities for the Advancement of Hydrologic Science, Inc.

MA

Cash Management Allowable Costs / Cost Principles Eligibility § 200.307

Finding Reference Number: MW2021-009 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021: CUAHSI used a single payment gateway for registration on CUAHSI events and was able to accurately ...

Finding Reference Number: MW2021-009 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021: CUAHSI used a single payment gateway for registration on CUAHSI events and was able to accurately document and produce grant-specific totals for audit year 2021 program income. CUAHSI staff missed the NSF filing deadline for declaring federal fiscal year 2021 program income by one day (submitted November 16th, 2021). Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI continues to use a single payment gateway for events and registration fees which supports segregation of payments per event and per grant. Program income has been reported to NSF accurately and on time beginning in 2023 and appropriate staff and policies are in place to ensure future compliance. Name of Contact Person: 􀁸 Maureen S. Ako, Director of Finance 􀁸 Telephone: (339)221-5400 􀁸 Email: msabino@cuahsi.org Projected Completion Date: NA; is complete

View Audit 352801

Finding 554202 (2021-004)

Material Weakness 2021

Consortium of Universities for the Advancement of Hydrologic Science, Inc.

MA

Allowable Costs / Cost Principles Material Weakness Reporting § 200.512

Finding Reference Number: MW2021-004 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021 NA Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI is curre...

Finding Reference Number: MW2021-004 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021 NA Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI is currently delinquent on the filing of audits from fiscal years 2021-2023. The organization is treating audit filings as the top priority and is working carefully through the audit backlog with qualified auditors that are currently engaged for audits 2021-2022. The delays in filing will continue into calendar year 2025, at which time it is expected that the audit package for the year ended December 31, 2024, will be filed on time to the Federal Audit Clearinghouse. Changes to CUAHSI’s accounting system, personnel, duties, and processes help ensure future audit preparation and support are streamlined, accurate, and timely. Name of Contact Person: 􀁸 Maureen S. Ako, Director of Finance 􀁸 Telephone: (339)221-5400 􀁸 Email: msabino@cuahsi.org Projected Completion Date: 2025-09-30

View Audit 352801

Finding 553802 (2021-002)

None 2021

Niagara Area Management Corporation

NY

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

Niagara Area Management Corporation has hired a new Chief Financial Officer and Director of Finance. NAMC has also engaged a new public accounting firm. It is NAMC policy to submit the annual audited financial statements and the data collection form to the Federal Audit Clearinghouse within 9 months...

Niagara Area Management Corporation has hired a new Chief Financial Officer and Director of Finance. NAMC has also engaged a new public accounting firm. It is NAMC policy to submit the annual audited financial statements and the data collection form to the Federal Audit Clearinghouse within 9 months after year-end.

View Audit 352433

Finding 553726 (2021-004)

Significant Deficiency 2021

Falmouth-Pendleton County Airport Board

OH

Equipment & Real Property Management Matching / Level of Effort / Earmarking Special Tests & Provisions

Finding Reference Number: 2021-004 Description of Finding: Lack of Internal Control Over Compliance – Unfamiliarity with Federal Compliance Requirements Statement of Concurrence or Nonconcurrence: The Board of the Falmouth Pendleton County Airport agrees with the audit finding. Corrective ...

Finding Reference Number: 2021-004 Description of Finding: Lack of Internal Control Over Compliance – Unfamiliarity with Federal Compliance Requirements Statement of Concurrence or Nonconcurrence: The Board of the Falmouth Pendleton County Airport agrees with the audit finding. Corrective Action: In future years, when receiving federal funds, management will contact the appropriate Federal agency and inquire about Uniform Guidance compliance requirements for federal funds. Name of Contact Person: Dan Bell, Board Chairman, k62airport@gmail.com (859) 816-8879 Projected Completion Date: On or before June 30, 2025

View Audit 352320

Finding 553725 (2021-003)

Significant Deficiency 2021

Falmouth-Pendleton County Airport Board

OH

Allowable Costs / Cost Principles Reporting

Finding Reference Number: 2021-003 Description of Finding: Non-Compliance with Uniform Guidance Reporting Requirements – Audit Not Filed Timely with Federal Audit Clearinghouse Statement of Concurrence or Nonconcurrence: The Board of the Falmouth Pendleton County Airport agrees with the audit fi...

Finding Reference Number: 2021-003 Description of Finding: Non-Compliance with Uniform Guidance Reporting Requirements – Audit Not Filed Timely with Federal Audit Clearinghouse Statement of Concurrence or Nonconcurrence: The Board of the Falmouth Pendleton County Airport agrees with the audit finding. Corrective Action: In future years, when receiving federal funds, management will complete the audit with sufficient time to timely submit to the Federal Audit Clearinghouse. Name of Contact Person: Dan Bell, Board Chairman, k62airport@gmail.com (859) 816-8879 Projected Completion Date: On or before June 30, 2025

View Audit 352320

Finding 544469 (2021-004)

Material Weakness 2021

City of Stonecrest, Georgia

GA

Questioned Costs Allowable Costs / Cost Principles § 200.300 § 200.306 § 200.308 § 200.309 § 200.403

Name of the Contact Person Responsible for the Corrective Action Plan: Gia Scruggs, City Manager Corrective Action Plan: The private contractor engaged in 2017 to provide government management and operations services staffed the engagement with less than 40 staff including 5 consultants. The City, s...

Name of the Contact Person Responsible for the Corrective Action Plan: Gia Scruggs, City Manager Corrective Action Plan: The private contractor engaged in 2017 to provide government management and operations services staffed the engagement with less than 40 staff including 5 consultants. The City, since the termination of the services contract effective December 31, 2021, has 79 staff involved in City management and operations roles including 5 elected officials. The additional staff, including an additional 5 in accounting/finance, affords the City the capacity to effectively account for and report on restricted funds received in connection with state and federal grant programs. The City Manager staff has grown by an additional 3 staff persons from the contractor level that was assigned in 2021 to monitor grants providing sufficient City staff for current grant programs to be monitored and grant conditions complied with. As the City continues to be eligible for additional state and federal grants, a Grants Administrator position has been added to staff organization and the plan is to organize a grants management team devoted to reporting and compliance assurance as well as seeking to apply for state and federal grant and program funds. Anticipated Completion Date: City Finance Department staff, together with the City Manager, are presently monitoring compliance and reporting relating to state and federal grants and program support. Third-party contractors will no longer be used for these tasks, and as more restricted funds are received by the City, the grants management team will be organized. Presently, the City has only one federal grant program and one state program. The corrective actions have been implemented and are presently operative and in place

View Audit 351144 Questioned Costs: $1

Finding 530197 (2021-001)

Significant Deficiency 2021

Huntsville Memorial Hospital

TX

Questioned Costs Allowable Costs / Cost Principles Cash Management

U.S. Department of Health and Human Services 2021-001 Provider Relief Fund – Assistance Listing No. 93.498 Recommendation: We recommend that management implement a system that allows for easy identification of any copies of invoices paid. Explanation of disagreement with audit finding: There is no d...

U.S. Department of Health and Human Services 2021-001 Provider Relief Fund – Assistance Listing No. 93.498 Recommendation: We recommend that management implement a system that allows for easy identification of any copies of invoices paid. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Huntsville Community Hospital, Inc. now operates under a full digitized accounting and payables system which allows them to pull any historical invoice copies as needed. Name(s) of the contact person(s) responsible for corrective action: Paul Hanson, CFO Planned completion date for corrective action plan: Huntsville Community Hospital, Inc. now operates under a full digitized accounting and payables system.

View Audit 348302 Questioned Costs: $1

Finding 530131 (2021-003)

Material Weakness 2021

Astria Health

WA

Allowable Costs / Cost Principles § 200.403

Finding Number 2021-003: Allowable Costs/Cost Principles - Material Weakness in Internal Control Over Compliance and Instance of Material Noncompliance. Program: U.S. Department of Health and Human Services - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution. Response and Correc...

Finding Number 2021-003: Allowable Costs/Cost Principles - Material Weakness in Internal Control Over Compliance and Instance of Material Noncompliance. Program: U.S. Department of Health and Human Services - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution. Response and Corrective Action Plan: Management agrees with the finding. The Organization will review and modify policies and procedures over the program to ensure management implements policies and procedures to ensure there is understanding of the terms and conditions of Federal awards. Anticipated Completion Date: by December 31, 2024. Responsible Person: Matthew Matthiesen, CFO.

View Audit 348226

Finding 526799 (2021-012)

Material Weakness 2021

Muskogee County

OK

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303 § 200.403

Assistance Listing Number 21.019 Noncompliance Over Major Federal Program Coronavirus Relief Fund Activities Allowed or Unallowed and Allowable Costs/Cost Principles Chairman Board of County Commissioners: Muskogee County has hired an internal grant administrator to assist in keeping the county comp...

Assistance Listing Number 21.019 Noncompliance Over Major Federal Program Coronavirus Relief Fund Activities Allowed or Unallowed and Allowable Costs/Cost Principles Chairman Board of County Commissioners: Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to ensure that all grant funds are properly expended within the allowable period of performance. It should be noted that OMES did not review any of the submitted information to determine eligibility prior to sending reimbursements for items that have now been determined questionable. County Clerk: Documentation was scanned into the Purchase Order's images and once the Purchase Order was paid, the images were then deleted by the Board of County Commissioners secretary. Images were later recovered by the software system and since the incident, restrictions have been implemented to no longer allow deletions.

View Audit 345861 Questioned Costs: $1

Finding 526798 (2021-011)

Material Weakness 2021

Muskogee County

OK

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

Assistance Listing Number21.019 Lack of Internal Controls Over Major Federal Programs Coronavirus Relief Fund Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to ens...

Assistance Listing Number21.019 Lack of Internal Controls Over Major Federal Programs Coronavirus Relief Fund Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to ensure that all grant funds are properly expended.

View Audit 345861

Finding 526797 (2021-010)

Material Weakness 2021

Muskogee County

OK

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

Assistance Listing Number 21.019 Lack of County-Wide Controls Over Major Federal Programs Coronavirus Relief Fund Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to...

Assistance Listing Number 21.019 Lack of County-Wide Controls Over Major Federal Programs Coronavirus Relief Fund Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to ensure that all grant funds are properly expended.

View Audit 345861

Finding 526774 (2021-008)

Significant Deficiency 2021

Kittson County

MN

Allowable Costs / Cost Principles

Contact Person – Aimee Sugden, County Administrator Corrective Action Plan – The County will review policies and procedures over grant disbursement approval. Completion Date – January 1, 2025

View Audit 345806

Finding 526769 (2021-005)

Significant Deficiency 2021

Kittson County

MN

Allowable Costs / Cost Principles

Contact Person – Aimee Sugden, County Administrator Corrective Action Plan – The County will review policies and procedures over grant disbursement approval. Completion Date – January 1, 2025

View Audit 345806

Finding 526705 (2021-004)

Material Weakness 2021

City of McKeesport

PA

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.412

CONDITION: For the calendar year 2021, the City of McKeesport submitted a listing to the Department of Treasury, of eligible expenses for the Coronavirus State and Local Fiscal Recovery Federal Funding. This listing contained the ShotSpotter as referenced in Finding 2021-004 which was already reimb...

CONDITION: For the calendar year 2021, the City of McKeesport submitted a listing to the Department of Treasury, of eligible expenses for the Coronavirus State and Local Fiscal Recovery Federal Funding. This listing contained the ShotSpotter as referenced in Finding 2021-004 which was already reimbursed to the City as part of the Community Development Block Grant (CDBG) Program by the Department of Housing and Urban Development. CRITERIA: In accordance with Section 2 CFR 200.412 of the Uniform Guidance, federal expenses are prohibited from being charged to more than one federal program. MANAGEMENT’S CORRECTIVE ACTION PLAN: Management of the City will review this eligible expense charged to the Coronavirus State and Local Fiscal Recovery Federal Funding Program, confirm that this is an expense that was already reimbursed by the Department of Housing and Urban Development for the benefit of the City’s CDBG Grant Program, and if so, consult with a representative from the Department of Treasury as to the procedure required to amend the quarterly report filings required to be filed with the Department of Treasury to ensure compliance with Section 2 CFR 200.214 of the Uniform Guidance. The timeframe for completion of this process is effective immediately.

View Audit 345703 Questioned Costs: $1

Finding 526704 (2021-002)

Material Weakness 2021

City of McKeesport

PA

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

• CONDITION: During the calendar year 2021, the City did not utilize a formal general ledger system of accounting to track the financial activity (financial position and results of operations) for several ‘Funds’ held at the City. The activity of these funds is either 1) maintained in spreadsheet f...

• CONDITION: During the calendar year 2021, the City did not utilize a formal general ledger system of accounting to track the financial activity (financial position and results of operations) for several ‘Funds’ held at the City. The activity of these funds is either 1) maintained in spreadsheet fashion similar to a checkbook used in personal finances, 2) recorded partially (expenses only with no revenue), or 3) not tracked at all. As these funds are not maintained using the City’s accounting software package, management does not have the ability to efficiently generate financial reports necessary to provide management with the proper fiscal oversight. This condition included the American Rescue Plan Act (ARPA) funding known as the Coronavirus State and Local Fiscal Recovery Fund. However, it should be noted that City personnel were able to prepare spreadsheets to document which expenditures were utilized to prepare the necessary quarterly reporting requirements to the Department of Treasury. • CRITERIA: Prudent internal control procedures in the areas of general ledger management and financial reporting include maintaining a formal general ledger system of accounting to track the activity of all ‘Funds’ maintained by the City. In specific as it relates to federal programs, Section 2 CFR 200.403(g) of the Uniform Guidance requires that federal costs must be adequately documented which would include the maintaining a formal general ledger system of accounting for all ‘Funds’ of the City. • MANAGEMENT’S CORRECTIVE ACTION PLAN: Management of the City will assess the current workload and expertise of the City’s business office personnel in an effort to determine a feasible timeframe to continue the process of creating a formal general ledger system of accounting for all City ‘Funds’ that are not already entered into the software accounting system. The timeframe for completion of this review will occur during the first nine months of calendar year 2025 with the intention of having the City be in full compliance with Section 2 CFR 200.403(g) of the Uniform Guidance which requires federal costs to be adequately documented which would include the maintaining of a formal general ledger system of accounting for all ‘Funds’ of the City.

View Audit 345703

Finding 526697 (2021-001)

Material Weakness 2021

City of McKeesport

PA

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

CONDITION (Continued): As a result, the financial position and results of operations as shown throughout the calendar year were inaccurately stated. However, it should be noted that the Community Development Department of the City and other City personnel maintain separate financial reporting for t...

CONDITION (Continued): As a result, the financial position and results of operations as shown throughout the calendar year were inaccurately stated. However, it should be noted that the Community Development Department of the City and other City personnel maintain separate financial reporting for these federal funds, independent of the aforementioned ‘Fund’ general ledgers sufficient to ascertain the revenues and expenditures of the federal programs. CRITERIA: Prudent internal control procedures in the areas of general ledger management and financial reporting include the reconciliation of all general ledger account balances to underlying supporting documentation monthly with independent oversight and approval as part of the process. In specific as it relates to federal programs, Section 2 CFR 200.403(g) of the Uniform Guidance requires that federal costs must be adequately documented which would include the applicable general ledgers of the City. MANAGEMENT’S CORRECTIVE ACTION PLAN: Management of the City will review the recommended options as presented by the Audit Firm’s recommendation for feasibility considering current manpower, expertise, and budgetary constraints. In addition, the City plans to ensure that written procedures for all accounting functions are implemented, reviewed and updated as necessary with the objective of ensuring that all balance sheet account balances are supported by the underlying documentation available at the City. The timeframe for completion of this review will occur during the first nine months of calendar year 2025 with the intention of having the City be in full compliance with Section 2 CFR 200.403(g) of the Uniform Guidance which requires federal costs to be adequately documented which would include the applicable general ledgers of the City.

View Audit 345703

Finding 524394 (2021-003)

Material Weakness 2021

Quileute Tribal School

WA

Allowable Costs / Cost Principles Subrecipient Monitoring Material Weakness § 200.303

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limit...

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limited to essential staff and activities. Due to the limited staff not all documentation and certifications were obtained. Further, prior to the emergency order key positions in the finance and administration departments were vacant. Currently all finance and administration departments are staffed. The School has implemented electronic procurement and timekeeping systems. These systems provide clarity in the approval process of procurement and timekeeping transactions. The transition from paper to digital formats provides enhanced internal controls to ensure that transactions are documented and approved. Training relating to the Federal and School procurement and timekeeping requirements will be provided. Implementation date: June 30, 2025

View Audit 343636

Finding 522674 (2021-016)

Material Weakness 2021

Ottawa County

OK

Questioned Costs Allowable Costs / Cost Principles § 200.403

The county will work to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.

View Audit 341985 Questioned Costs: $1

Finding 522672 (2021-017)

Material Weakness 2021

Ottawa County

OK

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

The county will work to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.

View Audit 341985

Corrective Action Plans

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