Corrective Action Plans

Finding 522473 (2021-010)

Significant Deficiency 2021

Saint Anthony Health Ministries and Subsidiaries

IL

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management § 200.303

Finding: Under Uniform Grant Guidance (2 CFR 200.303) requires nonfederal entities receiving Federal awards to establish and maintain internal controls designed to reasonably ensure compliance with Federal laws, regulations, and program compliance requirements. Effective internal controls should inc...

Finding: Under Uniform Grant Guidance (2 CFR 200.303) requires nonfederal entities receiving Federal awards to establish and maintain internal controls designed to reasonably ensure compliance with Federal laws, regulations, and program compliance requirements. Effective internal controls should include procedures to ensure that documentation to evidence the operation of internal controls, such as supervisory reviews. The Corporation did not have sufficient documentation that internal controls were in place and operating effectively for control activities required for assessment of activities allowed or unallowed and for allowable costs/cost principles. The Corporation also did not have sufficient documentation that internal controls were in place and operating effectively for monitoring procedures required for cash management and reporting compliance requirements. Corrective Actions Taken or Planned: Due to turnover of key positions responsible for grant submission, supporting documentation that was kept on these individuals’ computers was not saved, passed on, nor stored in a central storage location so that the new hires that were brought in to replace these individual as well as others in the department could view them. In August 2023, the hospital has provided education and training to the staff regarding identifying documentation and files related to the annual SEFA as well as establishing a central departmental drive to store the documentations so that others can locate them when necessary. Name of contact person responsible for corrective action: Jamie Mack, Vice President of Finance.

View Audit 341736

Finding 520683 (2021-003)

Material Weakness 2021

Russellville Hospital, Inc.

AL

Allowable Costs / Cost Principles HUD Housing Programs Material Weakness § 200.303 § 200.512

Finding 2021-003-Reporting, Non-compliance (Material Weakness) Going forward, the hospital will work with an outside consultant with more in-depth understanding of the reporting requirements prior to additional submissions. We are also catching up on the audit submissions and will remain on task wi...

Finding 2021-003-Reporting, Non-compliance (Material Weakness) Going forward, the hospital will work with an outside consultant with more in-depth understanding of the reporting requirements prior to additional submissions. We are also catching up on the audit submissions and will remain on task with timely submission. Anticipated completion date: 01/31/25.

View Audit 340379

Finding 519945 (2021-005)

Material Weakness 2021

Health & Education Housing Service, INC

MA

Internal Control / Segregation of Duties HUD Housing Programs Reporting

2021-005 - Reporting - Material Weakness Recommendation: Management should ensure timely completion of a Uniform Guidance audit, as required. Action Taken: Historically, Uniform Guidance Data Collection Form submissions were scheduled by the sponsor. In April 2019, the management agent experienc...

2021-005 - Reporting - Material Weakness Recommendation: Management should ensure timely completion of a Uniform Guidance audit, as required. Action Taken: Historically, Uniform Guidance Data Collection Form submissions were scheduled by the sponsor. In April 2019, the management agent experienced significant staff turnover including the Chief Financial Officer. The Entity's fiscal year fiscal year 2019 closed shortly thereafter. Management Agent Staff were unaware the required fiscal year 2019 and subsequent audit(s) had not been scheduled by the Sponsor; Covid 19 hit shortly thereafter. This issue went unaddressed throughout the pandemic, followed by the resignation of the Management Agent Accounting Manager in 2021, a position that remained vacant for nearly a year. The Management agent engaged with a CPA firm to conduct the 2019, 2020 and 2021 audits.

View Audit 339373

Finding 519942 (2021-002)

Material Weakness 2021

Health & Education Housing Service, INC

MA

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs

2021-002 - Allowable Costs/Cost Principles - Material Weakness Recommendation: We recommend that HES develop and implement procedures and controls to ensure management fee payment amounts are in accordance with the management agreement, and we recommend that funds be immediately returned to HES from...

2021-002 - Allowable Costs/Cost Principles - Material Weakness Recommendation: We recommend that HES develop and implement procedures and controls to ensure management fee payment amounts are in accordance with the management agreement, and we recommend that funds be immediately returned to HES from the management agent. Action Taken: This finding resulted from a single mischaracterized sponsor contribution, followed by the subsequent departure of competent accounting staff who could have corrected the issue. Corrective action was taken beginning in fiscal year 2022 when this issue was identified by competent accounting staff during which intercompany balances were reconciled and have been balanced routinely in subsequent fiscal years. The sponsor and management agent are in the process of developing a repayment plan.

View Audit 339373 Questioned Costs: $1

Finding 519154 (2021-001)

Material Weakness 2021

22nd District Agricultural Association

CA

Reporting Allowable Costs / Cost Principles Material Weakness

Reference Number: 2021-001 Name of Contact Person: Carlene Moore, CEO Corrective Action: As the 22nd DAA returned to financial stability, management hired and trained a combined 5 full-time employees to fill the needs in human resources and accounting departments. In the future, the 22nd DAA will ...

Reference Number: 2021-001 Name of Contact Person: Carlene Moore, CEO Corrective Action: As the 22nd DAA returned to financial stability, management hired and trained a combined 5 full-time employees to fill the needs in human resources and accounting departments. In the future, the 22nd DAA will engage subject matter experts when pursuing and obtaining any federal grant programs. Proposed Completion Date: December 31, 2022

View Audit 337708

Finding 518349 (2021-001)

Material Weakness 2021

The Center: Resources for Teaching and Learning

IL

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Audit Recommendation: Existing timesheet reconciliation procedures should be revised. The Organization should reconcile employee timesheets to amounts allocated to the grants on, at minimum, a quarterly basis, and ideally, on a monthly basis prior to the submission of vouchers or funding requests. P...

Audit Recommendation: Existing timesheet reconciliation procedures should be revised. The Organization should reconcile employee timesheets to amounts allocated to the grants on, at minimum, a quarterly basis, and ideally, on a monthly basis prior to the submission of vouchers or funding requests. Planned Corrective Actions: The Organization is reviewing and updating its procedures to reconcile the timesheets to the voucher requests monthly prior to submitting the voucher requests. The Organization accepts the recommendation. Anticipated Completion Date: December 31, 2024 Contact Person: Helen Gates, Accounting

View Audit 336734

Finding 514409 (2021-003)

Material Weakness 2021

Town of Newport

IN

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

FINDING 2021-003 Finding Subject: Water and Waste Disposal Systems for Rural Communities - Internal Controls Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the Town in order to ensure compliance with requirements related to th...

FINDING 2021-003 Finding Subject: Water and Waste Disposal Systems for Rural Communities - Internal Controls Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the Town in order to ensure compliance with requirements related to the grant agreement and the following compliance requirements: Activities Allowed or Unallowed, Allowable Costs/Cost Principles & Matching. Contact Person Responsible for Corrective Action: Rachel West, Clerk-Treasurer Contact Phone Number and Email Address: 765.492.8110 / newport.indiana@gmail.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Implement a system of checks and balances to ensure disbursements made are allowable and in accordance with contract provisions relating to grants. Include federal expenditures in monthly board minutes. Anticipated Completion Date: November 12, 2024

View Audit 332703

Finding 513959 (2021-001)

Material Weakness 2021

City of Williamsport

PA

Allowable Costs / Cost Principles Equipment & Real Property Management Special Tests & Provisions

During the audit period through 2022, there was a transition of fiscal and administrative personnel at the City of Williamsport. Due to findings of an internal financial investigation, the City communicated with appropriate parties and a grand jury was convened. The City has been an continues to be ...

During the audit period through 2022, there was a transition of fiscal and administrative personnel at the City of Williamsport. Due to findings of an internal financial investigation, the City communicated with appropriate parties and a grand jury was convened. The City has been an continues to be under state and federal criminal investigations since February of 2020. Numerous financial records, extending over a 10-year period, have been provided to investigators. In June of 2022, the City hired a consultant to provide fiscal oversight on an ongoing basis and reconcile, to the extent possible prior financial records. Since that time, the City has enhanced internal control and implemented policies to assure accurate financial reporting and compliance. The City anticipates a similar finding for the December 31, 2020, 2021, and 2022 audits, but with the exception of the results of the criminal investigations, expects to resolve this finding for the December 31, 2023 audit.

View Audit 332160

Finding 513237 (2021-003)

Material Weakness 2021

Republic of Palau

PW

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303

2021-003 Program concurs and working with MOF management to correct the finding On-going Glendalynn Ngirmeriil Executive Director Palau WIOA Office Contact: 680-488-2513 Email: gngirmeriil.wioa@gmail.com

View Audit 331185 Questioned Costs: $1

Finding 512304 (2021-002)

Material Weakness 2021

American Indian Community Center Association

WA

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs § 200.303

FINDING 2023-002 – Equipment & Real Property Management; Material Weakness in Internal Control over Compliance and Instance of Material Noncompliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and understands the importance of regular physica...

FINDING 2023-002 – Equipment & Real Property Management; Material Weakness in Internal Control over Compliance and Instance of Material Noncompliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and understands the importance of regular physical inventories. The Organization has designed an internal control process that will be implemented by August 30th, 2024. Contact Persons: Ryan Berendsen, Chief Operating Officer Delana Kromer, Controller

View Audit 330075 Questioned Costs: $1

Finding 508339 (2021-003)

Material Weakness 2021

Elle Foundation

LA

Questioned Costs Allowable Costs / Cost Principles

Corrective Action Planned: SSVF Policies and Procedure Guide will be updated at the agency CARF retreat to reflect the process of transactions related to SSVF and updated retention polices and documentation requirements. Contact Person: Cassandra Montgomery, Executive Director Anticipated Comple...

Corrective Action Planned: SSVF Policies and Procedure Guide will be updated at the agency CARF retreat to reflect the process of transactions related to SSVF and updated retention polices and documentation requirements. Contact Person: Cassandra Montgomery, Executive Director Anticipated Completion Date: Completed at the Agency CARF retreat during June 1-3, 2023.

View Audit 328912 Questioned Costs: $1

Finding 507871 (2021-003)

None 2021

Pontotoc County

OK

Questioned Costs Allowable Costs / Cost Principles

Per the auditor's recommendation, the County will design and implement a system of internal controls to ensure compliance with future grant requirments.

View Audit 328383 Questioned Costs: $1

Finding 507806 (2021-005)

Significant Deficiency 2021

Tazewell County, Illinois

IL

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

The County engaged an outside consultant to assist with compliance and reporting of the CSLFRF grant. Moving forward, management will ensure that a County employee, if working with a consultant or otherwise, be responsible for verifying compliance with all aspects of all federal grants.

View Audit 328309 Questioned Costs: $1

Finding 503666 (2021-001)

Significant Deficiency 2021

Public Defender Association

WA

Allowable Costs / Cost Principles Subrecipient Monitoring Significant Deficiency

Significant deficiency in internal control over compliance for allowable costs related to adequate documentation. Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: • This is primarily related to the absence of receipts for expen...

Significant deficiency in internal control over compliance for allowable costs related to adequate documentation. Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: • This is primarily related to the absence of receipts for expense items under $75. There are three items contributing to this finding: 1) Receipts that were not able to be located related to employees who had left the organization and did not provide receipts prior to departure - $96.12 of sample list. 2) Receipts that were simply not able to be found - $18.86 from sample list. 3) In general, PDA relies on our credit card platform for the repository of credit card receipts. The forum used during 2021 was “Elan”. Elan only retains receipts up to a maximum of 12 months from the date of spending. Due to the timing of the audit, in most cases 7-12 months had passed when the receipts were requested, and we were not able to extract from that system and therefore relied on employees’ records (see #1-2 above). • PDA’s policy is to retain and upload receipts for all spending, no minimum. • In May of 2022, PDA moved to a new credit card platform (“Center”), which retains receipts into perpetuity. Anticipated completion date: Quarter 1, 2024 Name(s) of the contact person(s) responsible for corrective action: Co-Executive Directors, Finance team

View Audit 325873

Finding 503188 (2021-104)

Material Weakness 2021

Apache County, Arizona

AZ

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Finding 2021-104 - Allocation of Coronavirus Relief Funds Funds (Material Weakness, Compliance Finding) CFDA Number: 21.019 Program Title: Coronavirus Relief Funds Federal Agency: U.S. Department of Treasury Award Year: 2020 Award Number: None Compliance Requirement: Allocated Costs Question Costs: ...

Finding 2021-104 - Allocation of Coronavirus Relief Funds Funds (Material Weakness, Compliance Finding) CFDA Number: 21.019 Program Title: Coronavirus Relief Funds Federal Agency: U.S. Department of Treasury Award Year: 2020 Award Number: None Compliance Requirement: Allocated Costs Question Costs: $2,460,485 Condition and context: The County used overall accounting data when allocating payroll and related expenses to the Coronavirus relief grant. The County first applied the grant funds to departments that met the definition of substantially dedicated employees. As there was remaining funds awarded the County applied the remaining funds to departments that would not meet the definition of substantially dedicated. These departments included the County attorney, constables, clerk of the court, probation and justice of the peace courts. The County did not maintain sufficient documentation to substantiate that employees within these departments were providing services relating to responding to the Covid-19 public health emergency. Expenses were not adequately defined by actual employee or pay period. Instead general payroll expenses were allocated from the departments identified. The total expenses allocated to the grant that did not meet the definition of substantially dedicated were $2,460,485. Recommendation: We recommend that the County establish policies and procedures to ensure that grant funds are used in accordance with grant agreements and other guidance. Adequate documentation should be maintained to ensure that expenses are substantiated and supported. Contact Name: Timothy Hinton, Finance Director Corrective Action Planned: The County’s allocation of funds followed the guidance provided by the State of Arizona. The County will review Federal guidance in determining how grant funds are to be allocated. Anticipated Completion Date: May 2024

View Audit 325282 Questioned Costs: $1

Finding 503185 (2021-103)

Material Weakness 2021

Apache County, Arizona

AZ

Special Tests & Provisions Allowable Costs / Cost Principles Material Weakness

Finding 2021-103 - Allocation of Forest Reserve Funds (Repeat Finding) (Material Weakness, Compliance Finding) CFDA Number: 10.665 Program Title: Schools and Roads – Grants to States Federal Agency: U.S. Department of Agriculture Award Year: 2021 Award Number: None Compliance Requirement: Special Te...

Finding 2021-103 - Allocation of Forest Reserve Funds (Repeat Finding) (Material Weakness, Compliance Finding) CFDA Number: 10.665 Program Title: Schools and Roads – Grants to States Federal Agency: U.S. Department of Agriculture Award Year: 2021 Award Number: None Compliance Requirement: Special Tests and Provisions Question Costs: None Condition and context: Forest reserve monies for Apache County were not properly disbursed for the benefit of public schools and public roads in accordance with A.R.S. 11-497. The County instead disbursed the entire annual allocation of $558,547 to public school districts. This finding is similar to prior year finding 2019-102. Recommendation: We recommend that the County stop violating state statute and distribute forest reserve monies in a manner that benefits both public schools and public roads as required by A.R.S. 11-497. Contact Name: Timothy Hinton, Finance Director Corrective Action Planned: The County Finance Director will review the needs the County’s roads and schools and make a recommendation to the board on an appropriate allocation of the forest reserve funds. Anticipated Completion Date: May 2024

View Audit 325282

Finding 502494 (2021-006)

Significant Deficiency 2021

College of the Marshall Islands

MH

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Allowable Costs/Cost Principle: The College partially agreed with the finding as stated. The College was not able to provide the documents to the external auditor in a timely manner; however, when the files were located the CMI missed the deadline to produce the documents. - Condition 1.1 - For ...

Allowable Costs/Cost Principle: The College partially agreed with the finding as stated. The College was not able to provide the documents to the external auditor in a timely manner; however, when the files were located the CMI missed the deadline to produce the documents. - Condition 1.1 - For item #s 1 and 2, CMI was not able to locate the documents requested by the external auditors in a timely manner during the audit fieldwork. For item #3, the College was not able to provide the documents to substantiate the number of credits being paid. Note: The College discovered all the documents relating to item #s 1,2 and 3 but were not available during the audit fieldwork. - Condition 1.2 - For one item amounting to $1,250 (21-PO-2096) the College was not able to locate the supporting documents during the audit fieldwork. Note: The College discovered the supporting documents but it was after the audit fieldwork was completed. - Condition 1.3 - One duplicate expenditure amounting to $2,119 (21-PO-1018) was charged to the program. September 30, 2022 Stevenson Kotton VPBAA Boni Sanchez IT Director

View Audit 324487 Questioned Costs: $1

Finding 502484 (2021-015)

Material Weakness 2021

College of the Marshall Islands

MH

Questioned Costs Allowable Costs / Cost Principles

Allowable Costs/Cost Principles: The College partially agrees with the finding. - Condition 1.1 - During the audit field work, the College was not able to provide the necessary documents requested by the external auditors. - Condition 1.2 - The College did not provide the necessary documents in ...

Allowable Costs/Cost Principles: The College partially agrees with the finding. - Condition 1.1 - During the audit field work, the College was not able to provide the necessary documents requested by the external auditors. - Condition 1.2 - The College did not provide the necessary documents in a timely manner to the external auditors during the audit fieldwork. Important Note: The College was able to locate the required documents BUT it was after the due date the external auditors requested for review and clarifications. The College recognizes the need to improve internal control policies and strengthen controls to ensure proper management and filing of all necessary documentation to support transactions. To fully utilize its document management system and all other College systems, regular training will be conducted to ensure proper and accurate use of its systems. September 30, 2022 Stevenson Kotton VPBAA Hatty Kabua Grant Coordinator

View Audit 324487 Questioned Costs: $1

Finding 502480 (2021-011)

Material Weakness 2021

College of the Marshall Islands

MH

Questioned Costs Allowable Costs / Cost Principles

Allowable Costs/Cost Principles: The College partially agrees with the findings. - Condition 1.1 - During the audit field work, the College was not able to provide the necessary documents requested by the external auditors. - Condition 1.2 - The College did not provide the necessary documents in...

Allowable Costs/Cost Principles: The College partially agrees with the findings. - Condition 1.1 - During the audit field work, the College was not able to provide the necessary documents requested by the external auditors. - Condition 1.2 - The College did not provide the necessary documents in a timely manner to the external auditors during the audit fieldwork. Important Note: The College was able to locate the required documents BUT it was after the due date the external auditors requested for review and clarifications. The College recognizes the need to improve internal control policies and strengthen controls to ensure proper management and filing of all necessary documentation to support transactions. To fully utilize its document management system and all other College systems, regular training will be conducted to ensure proper and accurate use of its systems. September 30, 2022 Stevenson Kotton VPBAA Pam Kaios UB Director

View Audit 324487 Questioned Costs: $1

Finding 502335 (2021-007)

Material Weakness 2021

Alfalfa County

OK

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.318 § 200.84

In each of our districts we will practice oversight and due diligence over the documentation of Disaster Grant expenditures. We will review documents to ensure labor rates and equipment rates were those approved FEMA. We will acknowledge our review by signing the documents.

View Audit 324377 Questioned Costs: $1

Finding 502334 (2021-006)

Material Weakness 2021

Alfalfa County

OK

Special Tests & Provisions Allowable Costs / Cost Principles Period of Performance § 200.303

We will research the compliancerequirements for each Major Federal Grant the County receives. Withthe compliance requirements in mind, we will establish policies and procedures to satisfy those requirements and practice oversight over federal grant activity.

View Audit 324377

Finding 502333 (2021-005)

Material Weakness 2021

Alfalfa County

OK

Internal Control / Segregation of Duties Subrecipient Monitoring Special Tests & Provisions

The Officers of Alfalfa County will meet to discuss the County-Wide Controls over the administration of Major Federal Programs. After discussing and gaining input from all those involved, written procedures will be approved and distributed.

View Audit 324377

Finding 499933 (2021-001)

Significant Deficiency 2021

Bon Secours Charity Health System, INC

DC

Allowable Costs / Cost Principles Reporting

Views of Responsible Officials and Planned Corrective Action Plan: BSCHS prepared the initial calculation of general and administrative expenses based on its understanding of the guidance in effect at the time of preparation. Management will check for updates to guidance and make necessary changes a...

Views of Responsible Officials and Planned Corrective Action Plan: BSCHS prepared the initial calculation of general and administrative expenses based on its understanding of the guidance in effect at the time of preparation. Management will check for updates to guidance and make necessary changes as appropriate.

View Audit 322874

Finding 498573 (2021-003)

Material Weakness 2021

Wishek Hospital Clinic Association D/b/a South Central Health

ND

Allowable Costs / Cost Principles § 200.303

Contact Person Megan Rath 2021-003 Corrective Action Plan The Association’s review and approval of expenses was undocumented. The Association will document the approval of the expenses claimed under federal programs in the future. Also, if future reports need to be submitted to HHS for Provider R...

Contact Person Megan Rath 2021-003 Corrective Action Plan The Association’s review and approval of expenses was undocumented. The Association will document the approval of the expenses claimed under federal programs in the future. Also, if future reports need to be submitted to HHS for Provider Relief Funds, a second reviewer will document approval of such reports. Completion Date The corrective action plan steps were implemented in part in 2022 with continued improvements planned to be in place by October 1, 2024.

View Audit 321318

Finding 498092 (2021-003)

Significant Deficiency 2021

Cavalier County Memorial Hospital Association

ND

Allowable Costs / Cost Principles Reporting

Finding # 2021-003 Response: The interim CFO has completed improvements in account review processes and procedures and has implemented recordkeeping improvements that improve the ability of the Organization to document, retain, and retrieve support for expenditures of federal awards. Responsible Pa...

Finding # 2021-003 Response: The interim CFO has completed improvements in account review processes and procedures and has implemented recordkeeping improvements that improve the ability of the Organization to document, retain, and retrieve support for expenditures of federal awards. Responsible Party: Jeffrey Hundman, Interim CFO Estimated Completion: 09/30/2024

View Audit 320758

Corrective Action Plans

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