Corrective Action Plans

Finding 20843 (2022-006)

Significant Deficiency 2022

MI

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

Finding 2022-006 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various ? Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through ...

Finding 2022-006 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various ? Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through Award Period: 1/1/2022-12/31/2022 Summary of the finding: Management did not retain evidence to support their review over the patient data submitted to Sponsor for the per diem billings from February 1, 2022 to December 31, 2022 was complete and accurate. Corrective action plan: The current attestation memo control will be replaced as follows: There are two categories of study activity that required review and approval by the appropriate individual (i.e., Principal Investigator, Clinical Research Manager (CRM) or a delegate): (1) at the time of enrollment to assure that the study participant met sponsor-defined eligibility requirements and (2) subsequent study activities that may include but are not limited to a study visit, data collection, follow-up phone call, questionnaire completion, laboratory testing, biospecimen collection, or some combination of these. Verification of eligibility at the time of enrollment will continue to be reviewed and approved by the study PI, CRM, or appropriate delegate per sponsor requirements. Documentation is maintained in study-specific binders, per FDA audit standards and internationally-accepted Good Clinical Practice principles to assure that only patients meeting the sponsor?s defined eligibility criteria are enrolled into the study. Review of study activities subsequent to the study participant enrollment will be conducted monthly by the CRM or their delegate. Sponsored Programs Administration (SPA) will prepare and send each CRM a Transaction Report downloaded from the institutional clinical trial management system for each federally funded study, at least quarterly, that includes a listing of study visits associated with enrolled study participants that occurred within the defined period of time. The CRM/delegate will review the report detail provided and, upon approval, sign, and date the report. To assure that the information in the report is consistent with what was submitted to third parties which generates reimbursement, the CRM/delegate will conduct an audit of a sample of patients from a random selection of studies included in the Transaction Report. Each sample will be verified against documentation maintained in the study binder. Audit results affirming document review will be recorded in an audit tracking log which will be retained with the study activity report in their Clinical Trial Office (CTO) file as evidence of their review of study activity for federally funded fixed fee/per patient studies. For those federally funded fixed fee/per patient studies that do not utilize the standard institutional clinical trial management system, a similar study activity report downloaded from the clinical trial management system utilized for the study will be used for review, signed and dated upon approval and kept in the CTO files as evidence of review. Individuals responsible for corrective action: Giacomo DeChellis, Sr. Director, Research Operations, Corewell Health East Timing of corrective action: September 1, 2023 and going forward.

View Audit 23232

Finding 20809 (2022-001)

Material Weakness 2022

Wenatchee School District No. 246

WA

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs, procurement, and restricted purpose requirements. Name, address, and telephone of District contact person: Karen Walters, Director of Accoun...

Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs, procurement, and restricted purpose requirements. Name, address, and telephone of District contact person: Karen Walters, Director of Accounting 235 Sunset Avenue Wenatchee WA, 98801 (509) 663-8161 Corrective action the auditee plans to take in response to the finding: This audit finding relates to unique rules associated with one-time, pandemic-necessitated funding. Additionally, the district fully expended all ECF funding during the 2021-2022 school year. Although we disagree with this finding, it is extremely unlikely the district will have to navigate these compliance expectations again. Regardless, the district will review its federal funding processes and procedures. The district will also review its procurement process to ensure contracts comply with state law. Anticipated date to complete the corrective action: December 31, 2023

View Audit 19488 Questioned Costs: $1

Finding 20778 (2022-002)

Significant Deficiency 2022

Transit Alliance Group, Inc.

GA

Allowable Costs / Cost Principles Subrecipient Monitoring Significant Deficiency

2022-002 Condition: Supporting documentation was missing for 1 out of 37 disbursements selected for allowable costs testing during the audit. Without adequate transportation logs, we were unable to determine if the reimbursed trips occurred. However, the projection of the error was less than the $2...

2022-002 Condition: Supporting documentation was missing for 1 out of 37 disbursements selected for allowable costs testing during the audit. Without adequate transportation logs, we were unable to determine if the reimbursed trips occurred. However, the projection of the error was less than the $25,000 reportable limit of questioned costs. Cause: The Organization?s controls did not provide for supporting documentation to be adequately retained. Recommendation: We recommend that internal control procedures on recordkeeping and filing should be clearly stated as part of the Organization policy. Management Response: We concur with the finding. The Organization?s internal control procedures have been inconsistent due to changes in the processing of DHS invoices, necessitating adjustments to the Organization?s records and filings after the fact because of errors and omissions relative to the use of the DHS software mandated (by DHS). This has resulted in numerous discrepancies between DHS and the Organization?s subcontractor documentation. On occasion, the discrepancy between the DHS software and the Organization?s internal control documents could not be reconciled. These reconciliations occurred after the DHS invoice was closed; consequently, the discrepancies could not be corrected. Corrective Action: The Organization will immediately implement an Organizational Policy that will require the reconciliation of the Organization?s internal documents based on subcontractor documentation and invoices prior to the closure of the DHS invoice to ensure both reconcile exactly. All discrepancies will be documented, and attempts will be made to resolve them completely. To ensure compliance with this Corrective Action, the Organization will immediately begin a search for an experienced consultant/consulting firm/qualified part-time staff person to manage the day-to-day bookkeeping requirements for the Organization to ensure that adjustments are made in a timely way and account balances are reviewed for completeness and accuracy. The day-to-day financial control processes will be implemented and followed by the consultant/consulting firm/part-time staff. The Organization will advertise for qualified consulting agencies/consultants/part-time staff and will select the best-qualified respondents to assist the Organization. Name of Responsible Person: Barbara Hurst

View Audit 26764

Finding 20760 (2022-004)

Significant Deficiency 2022

Henderson County Fiscal Court

KY

Allowable Costs / Cost Principles Reporting § 200.303

Prepared by: Brad Schneider, County Judge Executive Date Prepared: 12/5/2022 Person Responsible for Corrective Action Plan: Judge Executive and Staff Anticipated Completion Date: In process, once the October 6, 2022 guidance was provided by the State Auditor's office. Official's Response: We disagre...

Prepared by: Brad Schneider, County Judge Executive Date Prepared: 12/5/2022 Person Responsible for Corrective Action Plan: Judge Executive and Staff Anticipated Completion Date: In process, once the October 6, 2022 guidance was provided by the State Auditor's office. Official's Response: We disagree with the audit assessment that the county did not have an "effective internal control system" for compliance with Coronavirus State and Local Fiscal Recovery Fund Requirements. Faced with the unique situation surrounding these funds, the lack of any formal guidance from the State Auditor's Office on expending the funds before they arrived, and the often confusing and contradictory guidance provided by various state organizations and consultants, we believe Henderson County attempted to correctly and conscientiously handle these monies with the best information we had at the time. We found it interesting that shortly after the initial word from our auditors that we did not administer the funds properly, the State Auditor's Office then issued guidelines for counties. In our exit interview we were told the negative finding language covering our use of these funds would likely appear as findings in the audits of dozens of other counties who also made unwitting mistakes. We believe the after-the-fact guidelines and nearly universal adverse findings for counties indicate that it wasn't local officials who failed to do the proper thing but were, in fact, evidence the State Auditor's Office that failed to do its job. Simply put, if we'd been told in advance by state auditors specifically how they wanted these federal funds accounted for, we'd have done that. Minus that information, were left to figure it all out on our own as best we could. We respectfully believe our efforts should not be described as failures or non-compliance.

View Audit 21190

Finding 20681 (2022-003)

Significant Deficiency 2022

Children's Home Society of South Dakota

SD

Allowable Costs / Cost Principles § 200.303 § 200.430

Finding 2022-003 Allowable Costs, Allowable Activities, and Matching ? Significant Deficiency in Internal Control Over Compliance Federal/State Agency Name: Department of Justice and State of South Dakota Department of Public Safety Program Name: Crime Victim Assistance CFDA # 16.575, 2022-COMBO-000...

Finding 2022-003 Allowable Costs, Allowable Activities, and Matching ? Significant Deficiency in Internal Control Over Compliance Federal/State Agency Name: Department of Justice and State of South Dakota Department of Public Safety Program Name: Crime Victim Assistance CFDA # 16.575, 2022-COMBO-00022, 2022-COMBO-00011 Finding Summary: Audit testing over expenditures noted the following items: -Three instances were noted where hours used to allocate payroll to the grant differed from the actual hours worked and paid resulting in deficiencies in allowable costs, allowable activities, and matching. -One instance was noted where the hours used to allocate payroll to the grant differed from the actual hours worked and paid resulting in deficiencies in allowable costs and allowable activities. -One instance was noted where a non-payroll expenditure where costs charged to the grant that were paid within the service period but related to services outside of the service period resulting in deficiencies in allowable costs, allowable activities and matching. Responsible Persons: Shannon Clark, Chief Financial Officer; Lynn Peterson, Controller; Amy Carter, Program Director; Janice Lee, Finance Administrator Corrective Action Plan: This has been an ongoing issue and we are revising how our draws are prepared and reviewed. We plan to have one person familiar with the process prepare all the draws then a detailed review by the Controller before the draw will be submitted. Anticipated Completion Date: June 30, 2023

View Audit 27591

Finding 20679 (2022-001)

Significant Deficiency 2022

Aurora Comprehensive Community Mental Health Center, Inc.

CO

Allowable Costs / Cost Principles Cash Management Reporting

CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2022 AUDITOR FINDING: 2022-001 Finding: Reporting and Activities Allowed or Unallowed, Allowable Costs/Cost Principles CFDA No. 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution The Organization did not have...

CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2022 AUDITOR FINDING: 2022-001 Finding: Reporting and Activities Allowed or Unallowed, Allowable Costs/Cost Principles CFDA No. 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution The Organization did not have adequate internal controls in place to identify revenues reported did not agree to the underlying accounting records. The lost revenue reported in the Period 3 submission did not agree to accounting records. CLIENT PLANNED ACTION: The staff accountant will prepare the reporting information; the Controller will assist the staff accountant in reviewing the reporting guidelines as well as assist with populating the reports relative to accuracy and completion. The CFO will review the reports and data sources to ensure that the data aligns accurately to the reporting guidelines. CLIENT RESPONSIBLE PARTY: Loretta Buckman, CFO COMPLETION DATE: February 17, 2023

View Audit 26596

Finding 20674 (2022-003)

Material Weakness 2022

Butler Health System and Subsidiaries

PA

Questioned Costs Allowable Costs / Cost Principles Reporting

Views of Responsible Officials and Planned Corrective Actions ? Management acknowledges errors were made by contracted vendor for a subsidiary provider reporting submission. Management?s corrective action plan includes establishing appropriate review and approval process whereby the parent organiza...

Views of Responsible Officials and Planned Corrective Actions ? Management acknowledges errors were made by contracted vendor for a subsidiary provider reporting submission. Management?s corrective action plan includes establishing appropriate review and approval process whereby the parent organization is reviewing reporting submission of subsidiary organizations including those prepared by third-party vendors. In addition, future reporting submissions will be prepared with oversight by the parent organization to ensure corrections are made retroactive to the covered period of this audit.

View Audit 23696 Questioned Costs: $1

Finding 20658 (2022-002)

Significant Deficiency 2022

Southern Mono Healthcare District Dba Mammoth Hospital

CA

Allowable Costs / Cost Principles Significant Deficiency § 200.303

Finding 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 2 TIN #953154530 Federal Financial Assistance Listing #: #93.498 Finding Summa...

Finding 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 2 TIN #953154530 Federal Financial Assistance Listing #: #93.498 Finding Summary: The District?s lost revenue calculation claimed under the Provider Relief Fund program and the HHS reported submitted to the Department of Health and Human Services were not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Melanie Van Winkle, CFO Corrective Action Plan: A policy was developed on October 14, 2022, outlining the controls to be followed for filing reports with Federal Agencies. This policy reflects the procedures needed for proper internal controls to provide assurance that the District is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. All reporting after the creation of the policy has followed the policy. Unfortunately, this finding and policy were after the Provider Relief Fund reporting #2 was submitted. Anticipated Completion Date: Completed October 14, 2022 2

View Audit 20512

Finding 20634 (2022-004)

Material Weakness 2022

Rowan County, North Carolina

NC

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

Name of Contact Person: Anna Bumgarner, Finance Director Corrective Action/Management Response: The County interpretation of the interim rule for premium pay was incorrect. The interpretation was not realized until the auditor?s preliminary work was completed for the FY22 audit. When this error in i...

Name of Contact Person: Anna Bumgarner, Finance Director Corrective Action/Management Response: The County interpretation of the interim rule for premium pay was incorrect. The interpretation was not realized until the auditor?s preliminary work was completed for the FY22 audit. When this error in interpretation was pointed out to the County the former Finance Director provided the needed response on the ARPA quarterly report. The response on the quarterly report has corrected the item and no additional action is needed. Proposed Completion Date: April 2022

View Audit 28584

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

Corrective Action Plans

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