Corrective Action Plans

Finding 383643 (2021-003)

Material Weakness 2021

IN

Allowable Costs / Cost Principles Reporting

Management continues to evaluate the current controls related to reporting to ensure amounts are appropriately stated. Though the decrease was significant, we have adequate expenses and lost revenues to support funding reported for Periods 1 and 2.

View Audit 296677

Finding 382376 (2021-009)

Material Weakness 2021

Children's Home of Kingston

NY

Questioned Costs Allowable Costs / Cost Principles

2021-009 – Allocations of Salaries of Other Costs; In February 2024, J.E. Ryan & Associates determined the allocation methodology most appropriate for our Agency is to use square footage. Where appropriate and possible, employees will be directly charged to their funding source (project code). Quart...

2021-009 – Allocations of Salaries of Other Costs; In February 2024, J.E. Ryan & Associates determined the allocation methodology most appropriate for our Agency is to use square footage. Where appropriate and possible, employees will be directly charged to their funding source (project code). Quarterly time studies will be implemented as of April 2024 for employees who work across multiple programs and provide direct care. For employees working in Maintenance, Food Services, Human Resources, Finance, and IT, square footage allocation will be utilized. During the upcoming fiscal year, the Controller will review, on a monthly or quarterly basis, the incurred expenses compared to the UAC approved budget.

View Audit 296079

Finding 380907 (2021-008)

Material Weakness 2021

Love County Health Center D/b/a Mercy Health Love County

OK

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Finding 2021-008 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy to ensure reported amounts agreed with under...

Finding 2021-008 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy to ensure reported amounts agreed with underlying supporting documentation. In addition the underlying supporting documentation contained errors. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process to a ensure the report agrees with the under lying supporting documentation. Anticipated Completion Date: Ongoing

View Audit 295601

Finding 380906 (2021-007)

Material Weakness 2021

Love County Health Center D/b/a Mercy Health Love County

OK

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

Finding 2021-007 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were bei...

Finding 2021-007 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were being reduced by Medicare's reimbursement or claimed on other grants. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process to ensure amounts claimed for this program are reduced by amounts reimbursed or obligated by another source and include a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission Anticipated Completion Date: Ongoing

View Audit 295601

Finding 380905 (2021-006)

Material Weakness 2021

Love County Health Center D/b/a Mercy Health Love County

OK

Allowable Costs / Cost Principles Reporting Procurement, Suspension & Debarment § 200.303

Finding 2021-006 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA# 93.498 Finding Summary: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were...

Finding 2021-006 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA# 93.498 Finding Summary: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were being in the proper period. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. Anticipated Completion Date: Ongoing

View Audit 295601

Finding 380904 (2021-005)

Material Weakness 2021

Love County Health Center D/b/a Mercy Health Love County

OK

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues ...

Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues was reviewed and approved. Accordingly, the errors in the lost revenue calculation spreadsheet were not identified by management. In addition, the Hospital did not have an internal control process in place to ensure a review and approval of the Period 1 Report was performed by someone other than the preparer of the report. Responsible Individuals: Scott Callender Corrective Action Plan : The Hospital will implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. Anticipated Completion Date: Ongoing

View Audit 295601

Finding 377355 (2022-003)

Material Weakness 2021

Red Wind Consulting INC

CO

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.43

Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of allowable costs. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document ...

Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of allowable costs. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document in writing, the process and review it with department leaders. Additionally, staff members working in areas concerning this process will be trained to ensure process adherence.

View Audit 295151

Finding 375834 (2021-004)

Significant Deficiency 2021

California Asian Pacific Chamber of Commerce

CA

Allowable Costs / Cost Principles Significant Deficiency § 200.400

Description of Finding: The allocation of payroll costs to programs are done manually instead of done based on entity-wide timesheets Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: The ERP system...

Description of Finding: The allocation of payroll costs to programs are done manually instead of done based on entity-wide timesheets Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: The ERP system will include electronic timesheets for daily charging to specific grants, as well as more visibility into the proper separation of direct, indirect, and unallowable costs per the CFR. An indirect cost pool allocation structure will be designed and implemented to properly allocate the allowable indirect costs to each work effort. Detailed paper timesheets will be provided in the interim for all employees to ensure compliance with the requirements and provide proper support for all grant costs. Monthly reviews by the Project Directors/Managers plus Accounting will be performed to identify any potential cost charging issues and corrective action(s) required. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Susan Wright, Controller, 256-689-7055, swright@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: March 2024 for detailed paper timesheets, December 2024 for ERP system

View Audit 294918

Finding 375833 (2021-003)

Material Weakness 2021

California Asian Pacific Chamber of Commerce

CA

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.400

Description of Finding: Expenditure detail does not support the amounts billed Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian acknowledges the serious nature of this finding and the pote...

Description of Finding: Expenditure detail does not support the amounts billed Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian acknowledges the serious nature of this finding and the potential for damage to relationships with the grantors and Federal entities. The Interim Controller and Director of Finance are working to secure an ERP system which will allow for better cost collection, reporting and reviews of the grant-related expenses for accuracy, reliability, and reconciliation. Subcontractor invoices will be required to provide specific information related to the grant, scope of work and any other pertinent details for proper charging in the accounting system. Detailed paper timesheets will be provided in the interim for all employees to ensure compliance with the requirements and provide proper support for all grant costs. Monthly reviews by the Project Directors/Managers plus Accounting will be performed to identify any potential cost charging issues and corrective action(s) required. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: March 2024 for detailed paper timesheets, December 2024 for ERP system

View Audit 294918 Questioned Costs: $1

Finding 375524 (2021-004)

Significant Deficiency 2021

Lincoln Road Benevolent Corporation D/b/a Olenes Pop Vidrine Gardens

LA

HUD Housing Programs Allowable Costs / Cost Principles

Recommendation: We recommend that the management agent reimburse the entity for the overpayment of payroll expenses and implement additional controls to ensure that these fees are properly calculated in the future. Views of Responsible Officials and Planned Corrective Action: The management agent...

Recommendation: We recommend that the management agent reimburse the entity for the overpayment of payroll expenses and implement additional controls to ensure that these fees are properly calculated in the future. Views of Responsible Officials and Planned Corrective Action: The management agent reimbursed the entity the $1,620. They have also contracted with an outside payroll organization to administer payroll.

View Audit 294568

Finding 375498 (2021-017)

Material Weakness 2021

Okmulgee County

OK

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.403

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

View Audit 294536 Questioned Costs: $1

Finding 375497 (2021-016)

Material Weakness 2021

Okmulgee County

OK

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

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

View Audit 294536

Finding 375496 (2021-015)

Material Weakness 2021

Okmulgee County

OK

Internal Control / Segregation of Duties Subrecipient Monitoring Questioned Costs § 200.303

Management will work together to design and implement procedures to address county wide controls over federal programs and to ensure compliance with grant agreements.

View Audit 294536

Finding 375420 (2021-004)

Material Weakness 2021

Municipality of Morovis

PR

Subrecipient Monitoring Reporting Allowable Costs / Cost Principles § 200.302 § 200.403

We concur with the finding. The pandemic caused by the outbreak of COVID-19 disrupted and delayed many accounting and reporting processes during the fiscal years 2020 and 2021 since the Municipality had to shut down operations for various months. Consequently, several projects and tasks calendarized...

We concur with the finding. The pandemic caused by the outbreak of COVID-19 disrupted and delayed many accounting and reporting processes during the fiscal years 2020 and 2021 since the Municipality had to shut down operations for various months. Consequently, several projects and tasks calendarized were postponed or delayed, including certain reports and controls required by the Federal Regulations. As of the date of this Corrective Action Plan, the transaction detail of the Disaster Grant costs incurred on fiscal year ending on June 30, 2021 was produced, under alternate methods, from the Finance Department’s accounting system and submitted to the external auditor. Expected Implementation Date: The transaction details applicable to financial statements of fiscal periods ended June 30, 2021 were completed. Transactions detail analysis during the following fiscal years were already completed. Responsible Person: Finance Department Director and Federal Program Director.

View Audit 294483

Finding 375419 (2021-003)

Material Weakness 2021

Municipality of Morovis

PR

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.302 § 200.403

We concur with the finding. The pandemic caused by the outbreak of COVID-19 disrupted and delayed many accounting and reporting processes during the fiscal years 2020 and 2021 since the Municipality had to shut down operations for various months. Consequently, several projects and tasks calendarized...

We concur with the finding. The pandemic caused by the outbreak of COVID-19 disrupted and delayed many accounting and reporting processes during the fiscal years 2020 and 2021 since the Municipality had to shut down operations for various months. Consequently, several projects and tasks calendarized were postponed or delayed, including certain reports and controls required by the Federal Regulations. As of the date of this Corrective Action Plan, the transaction detail of CDL costs incurred on fiscal year ending on June 30, 2021 was produced, under alternate methods, from the Finance Department’s accounting system and submitted to the external auditor. Expected Implementation Date: The transaction details applicable to financial statements of fiscal periods ended June 30, 2021 were completed. Transactions detail analysis during the following fiscal years were already completed.Responsible Person: Finance Department Director and Federal Program Director.

View Audit 294483

Finding 375383 (2021-011)

None 2021

Cleveland County

OK

Allowable Costs / Cost Principles Eligibility Questioned Costs

21.019 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Requirements - Coronavirus Relief Fund The Cleveland County Board of County Commissioners (BOCC) will implement policies and procedures to ensure compliance with applicable grant requirements. Specifically,...

21.019 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Requirements - Coronavirus Relief Fund The Cleveland County Board of County Commissioners (BOCC) will implement policies and procedures to ensure compliance with applicable grant requirements. Specifically, the BOCC will ensure grant funds are expended on allowed costs as set forth by the grant. Anticipated Completion Date: On Going April 2021 Responsible Contact Person: Rod Cleveland,Chairman BOCC

View Audit 294443 Questioned Costs: $1

Finding 374692 (2021-001)

Significant Deficiency 2021

Tuscumbia City Board of Education

AL

Allowable Costs / Cost Principles Reporting Significant Deficiency

Recommendations: The Board should strive to submit the Single Audit Reporting Package to the federal audit clearinghouse no later than nine months after the fiscal year end. Views of Responsible Officials and Planned Corrective Actions: The Board will strive to submit its Single Audit Reporting Pac...

Recommendations: The Board should strive to submit the Single Audit Reporting Package to the federal audit clearinghouse no later than nine months after the fiscal year end. Views of Responsible Officials and Planned Corrective Actions: The Board will strive to submit its Single Audit Reporting Package to the federal audit clearinghouse no later than nine months after the fiscal year end for all future funds received from the federal government.

View Audit 294382

Finding 372281 (2021-003)

Material Weakness 2021

Hope for Prisoners, Inc.

NV

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

Original ‐ HOPE for Prisoners CEO presently reviews and approves all RFR forms in wri􀀂ng prior to submission. Management will request speciﬁc Board members to provide addi􀀂onal oversight by reviewing the submi􀀁ed RFR to compare it to the monthly ﬁnancial reports already being provided. Final ‐ Ho...

Original ‐ HOPE for Prisoners CEO presently reviews and approves all RFR forms in wri􀀂ng prior to submission. Management will request speciﬁc Board members to provide addi􀀂onal oversight by reviewing the submi􀀁ed RFR to compare it to the monthly ﬁnancial reports already being provided. Final ‐ Hope for Prisoners’ CEO presently reviews and approves all RFR forms in wri􀀂ng prior to submission. Oversight by speciﬁc board members will be provided through a review of the submi􀀁ed RFR to compare it to the monthly ﬁnancial reports already being provided.

View Audit 293572

Finding 371940 (2021-005)

Material Weakness 2021

Martin University

IN

Allowable Costs / Cost Principles

Internal control and compliance with the higher education emergency relief fund and procedures should be improved student financial aid cluster program. Corrective action: The University has implemented a policy that requires a complete review of the internal controls over the compliance of the HEER...

Internal control and compliance with the higher education emergency relief fund and procedures should be improved student financial aid cluster program. Corrective action: The University has implemented a policy that requires a complete review of the internal controls over the compliance of the HEERF programs and to make sure that all required areas of compliance supplement are achieved. The updated policy was provided to the Grants Risk Management Services Division of DOE on 12/14/2023 Person responsible: Qiana Hall, Associate VP of Enrollment Services Anticipated Completion Date: March 31, 2024

View Audit 293212

Finding 371930 (2021-007)

Significant Deficiency 2021

First Nations Community Healthsource, Inc.

NM

Questioned Costs Allowable Costs / Cost Principles

2021-007—Allowable Costs/Cost Principles Corrective Action: The CFO will implement internal measures, including creating a schedule of activities with due dates, progress reports, and staff meetings, to monitor and ensure that the amounts charged to federal programs are allowable and properly approv...

2021-007—Allowable Costs/Cost Principles Corrective Action: The CFO will implement internal measures, including creating a schedule of activities with due dates, progress reports, and staff meetings, to monitor and ensure that the amounts charged to federal programs are allowable and properly approved. Corrective action steps will be identified and implemented as needed. The grant/contract staff will review the grant budgets, including line-item allocations, to determine allowable expenses. The CFO will verify the monthly expenses are allowable and approve the drawdown budgets of the grants accordingly. Person Responsible: Until the CFO position is filled, Angela Holden (Controller), Annmol Anand (Senior Accountant), and Margie King and Pablo Valdez (Grants and Contracts staff) will be responsible for completing the corrective actions. Completion Date: These actions will be implemented within the first 30 days of the audit completion. The completion date will be September 30, 2024.

View Audit 293199 Questioned Costs: $1

Finding 371311 (2021-013)

Material Weakness 2021

City of Bethel, Alaska

AK

Allowable Costs / Cost Principles § 200.303 § 200.403

Finding 2021‐013 Gift Cards – Activities Allowed or Unallowed; Allowable Costs/Cost Principles – Noncompliance and Material Weakness in Internal Controls over Compliance Corrective Action Plan Management will review current policies and will ensure that policies and procedures are adhered to ensure ...

Finding 2021‐013 Gift Cards – Activities Allowed or Unallowed; Allowable Costs/Cost Principles – Noncompliance and Material Weakness in Internal Controls over Compliance Corrective Action Plan Management will review current policies and will ensure that policies and procedures are adhered to ensure that proper reconciliations are done. Expected Completion Date Fiscal Year 2025.

View Audit 292985

Finding 371310 (2021-012)

Material Weakness 2021

City of Bethel, Alaska

AK

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Finding 2021‐012 Expenditure Approval – Activities Allowed and Unallowed, Allowable Costs – Material Weakness in Internal Control over Compliance Corrective Action Plan Management will implement policies and procedures to ensure expenditures are reviewed timely and approved prior to posting. Expecte...

Finding 2021‐012 Expenditure Approval – Activities Allowed and Unallowed, Allowable Costs – Material Weakness in Internal Control over Compliance Corrective Action Plan Management will implement policies and procedures to ensure expenditures are reviewed timely and approved prior to posting. Expected Completion Date Fiscal Year 2025.

View Audit 292985

Finding 371309 (2021-011)

Material Weakness 2021

City of Bethel, Alaska

AK

Allowable Costs / Cost Principles § 200.403

Finding 2021‐011 Expenditure Documentation – Activities Allowed and Unallowed, Allowable Costs/Cost Principles – Noncompliance and Material Weakness in Internal Control over Compliance Corrective Action Plan Management will implement policies and procedures to ensure supporting documentation over ex...

Finding 2021‐011 Expenditure Documentation – Activities Allowed and Unallowed, Allowable Costs/Cost Principles – Noncompliance and Material Weakness in Internal Control over Compliance Corrective Action Plan Management will implement policies and procedures to ensure supporting documentation over expenditures are retained. Expected Completion Date Fiscal Year 2025.

View Audit 292985

Finding 371304 (2021-006)

Material Weakness 2021

City of Bethel, Alaska

AK

Allowable Costs / Cost Principles § 200.303 § 200.430

Finding 2021‐006 Payroll Documentation – Activities Allowed and Unallowed, Allowable Costs/Cost Principles – Noncompliance and Material Weakness in Internal Control over Compliance Corrective Action Plan Management will review current employee pay rates within the payroll module and ensure that rate...

Finding 2021‐006 Payroll Documentation – Activities Allowed and Unallowed, Allowable Costs/Cost Principles – Noncompliance and Material Weakness in Internal Control over Compliance Corrective Action Plan Management will review current employee pay rates within the payroll module and ensure that rates agree to the most current pay rate as is specified in the employee’s current personnel action form. Expected Completion Date Fiscal Year 2025.

View Audit 292985

Finding 370814 (2021-002)

Significant Deficiency 2021

Dallas County System of Services, Inc.

AL

Allowable Costs / Cost Principles Reporting

Description of Finding Significant weakness in allocation of administrative costs for financial reporting. In the past, DCSOS has elected to use the 10% de minimis allocation for indirect administrative costs for all Federal grants. For State funded grants, administrative costs were a part of the ...

Description of Finding Significant weakness in allocation of administrative costs for financial reporting. In the past, DCSOS has elected to use the 10% de minimis allocation for indirect administrative costs for all Federal grants. For State funded grants, administrative costs were a part of the budget where possible. As the organization has grown quickly in the past 3 years, a systematic process to allocate costs has not been developed and consequently, during the audit process, there was not an ‘explainable allocation’ method to review. DCSOS agrees with this audit finding. Statement of Concurrence or Nonconcurrence: Due to the rapid growth of the organization and limited staffing, a method of calculating and allocating indirect (administrative) costs has not been developed. It is noted through the audit that the absence of following the Uniform Guidance (2 CFR200) could distort the cost to run each program. Therefore, DCSOS agrees with the audit finding. Corrective Action: For the future grant application process, DCSOS will develop a formal method of allocating indirect costs to each program using an explainable method. This process will be implemented in the future grant year 2025. Proposed Completion Date: September 30, 2024 Person Responsible for Corrective Action: Financial Officer

View Audit 292503

Corrective Action Plans

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