Corrective Action Plans

Finding 554818 (2024-002)

Significant Deficiency 2024

MN

HUD Housing Programs Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Monitoring Deposits over FDIC Limits Recommendation: We recommend that management develop procedures to ensure requirements are monitored, documented, and reviewed to ensure compliance with the HUD regulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with ...

Monitoring Deposits over FDIC Limits Recommendation: We recommend that management develop procedures to ensure requirements are monitored, documented, and reviewed to ensure compliance with the HUD regulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has designed internal controls to ensure deposits held over FDIC limits are monitored quarterly to ensure consistency with the minimally acceptable ratings as established by the Government National Association. Name(s) of contact person(s) responsible for corrective action: Nicole Chwala.

View Audit 353384

Finding 554817 (2024-001)

Significant Deficiency 2024

Chaska Manor Dba: Talheim

MN

Questioned Costs HUD Housing Programs Procurement, Suspension & Debarment

Replacement Reserve Deposits Recommendation: We recommend that management develop procedures to ensure replacement reserve deposits are updated timely to ensure compliance with the HUD regulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit fi...

Replacement Reserve Deposits Recommendation: We recommend that management develop procedures to ensure replacement reserve deposits are updated timely to ensure compliance with the HUD regulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has developed processes to verify replacement reserve deposits are updated based on the regulatory agreement annually. Name(s) of contact person(s) responsible for corrective action: Nicole Chwala. Planned completion date for corrective action plan: Corrective action has been taken in March 2025.

View Audit 353384 Questioned Costs: $1

Finding 554816 (2024-001)

Significant Deficiency 2024

Trinity Terrace

WI

Questioned Costs HUD Housing Programs Procurement, Suspension & Debarment

Replacement Reserve Deposits Recommendation: We recommend that management develop procedures to ensure replacement reserve deposits are updated timely to ensure compliance with the HUD regulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit fi...

Replacement Reserve Deposits Recommendation: We recommend that management develop procedures to ensure replacement reserve deposits are updated timely to ensure compliance with the HUD regulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has developed processes to verify replacement reserve deposits are updated based on the regulatory agreement annually. Name(s) of contact person(s) responsible for corrective action: Nicole Chwala. Planned completion date for corrective action plan: Corrective action has been taken in February 2025.

View Audit 353383 Questioned Costs: $1

Finding 554793 (2024-002)

Material Weakness 2024

City of Columbus, Ohio

OH

Allowable Costs / Cost Principles § 200.303 § 200.430

The City concurs with the finding and will take the following actions in response:Development’s Fiscal Team shall continue the process developed in response to the 2023 finding, with one modification: instead of a quarterly ‘true up’ process, Development shall perform a monthly ‘true up’ process. T...

The City concurs with the finding and will take the following actions in response:Development’s Fiscal Team shall continue the process developed in response to the 2023 finding, with one modification: instead of a quarterly ‘true up’ process, Development shall perform a monthly ‘true up’ process. This provides the opportunity for more frequent fiscal review of work logs and quicker identification of non-compliance by programmatic staff and supervisors. If a work log is not signed by the employee and/or supervisor, fiscal staff shall notify the employee and supervisor of the issue and request it be signed as soon as possible. Only after the work log is signed by both employee and supervisor shall it be included in the monthly true up. If the employee and/or supervisor is non-responsive to the request to sign the work log, the Deputy Director of Housing Strategies shall be notified and requested to address the issue as soon as possible; Development’s fiscal team shall continue to review signature timeliness as a part of the monthly ‘true up’ process. If fiscal identifies work logs signed by either employee and/or supervisor outside of the allotted time per the Department’s work log policy, fiscal shall notify the Deputy Director of Housing Strategies and request the issue be addressed as soon as possible; and The Compliance Officer shall provide a written reminder to all applicable staff and supervisors to sign the work log in a timely manner and shall perform a periodic review of the work logs throughout the year. Work log review shall also be included in internal monitoring done by the Compliance Officer. Documentation of reviews will be retained per the Department’s record retention schedule.

View Audit 353379

Finding 554759 (2024-019)

Significant Deficiency 2024

State of Oregon

OR

Allowable Costs / Cost Principles Special Tests & Provisions Reporting § 200.303

2024-019 Oregon Department of Human Services Improve controls and compliance over long-term care facility auditsManagement Response: We agree with this recommendation and will make these changes on the July 1, 2025 cost report template. We will be adding a line item to distinguish between Total Admi...

2024-019 Oregon Department of Human Services Improve controls and compliance over long-term care facility auditsManagement Response: We agree with this recommendation and will make these changes on the July 1, 2025 cost report template. We will be adding a line item to distinguish between Total Administration overtime and Administrator only overtime. .Anticipated Completion Date: July 1, 2025 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director

View Audit 353343

Finding 554755 (2024-015)

Significant Deficiency 2024

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles § 200.1 § 200.400

2024-015 Oregon Department of Human Services/Oregon Health Authority Strengthen review over direct costs charged to the program Management Response: We agree with this recommendation. Interest related to past due amounts will be charged to general funds only. Expenditures will be reviewed both by st...

2024-015 Oregon Department of Human Services/Oregon Health Authority Strengthen review over direct costs charged to the program Management Response: We agree with this recommendation. Interest related to past due amounts will be charged to general funds only. Expenditures will be reviewed both by staff and approving parties to ensure only allowable expenditures are charged to the federal grants. The questioned costs of $68 will be refunded and reported to CMS on the CMS 64. The agency will ensure that future contracts that include any incentive funds for surveys will be structured such that incentives are billed under separate coding that will be charged to general funds only. The questioned costs of $28,801 will be refunded and reported to CMS on the CMS 64 Anticipated Completion Date: April 30, 2025 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director

View Audit 353343 Questioned Costs: $1

Finding 554754 (2024-014)

Significant Deficiency 2024

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles § 200.400

2024-014 Oregon Department of Human Services/Oregon Health Authority Implement control procedures around cost allocation system inputs Management Response: We agree with this recommendation. The Office of Financial Services will review the existing controls in Cost Allocation system and identify are...

2024-014 Oregon Department of Human Services/Oregon Health Authority Implement control procedures around cost allocation system inputs Management Response: We agree with this recommendation. The Office of Financial Services will review the existing controls in Cost Allocation system and identify areas that need additional or new control procedures to ensure system inputs are appropriately identified and processed. In addition, we will review the noted errors and make appropriate corrections. Anticipated Completion Date: June 30,, 2025 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director

View Audit 353343 Questioned Costs: $1

Finding 554752 (2024-012)

Significant Deficiency 2024

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

2024-012 Oregon Health Authority Ensure MMIS rates are accurate and updated timely Management Response: We agree with this recommendation. The conversion factor (CF) for Calendar Year (CY) 2023 was not properly updated in December 2022. The proposed CMS CF value of 86.7850 was incorrectly applied to...

2024-012 Oregon Health Authority Ensure MMIS rates are accurate and updated timely Management Response: We agree with this recommendation. The conversion factor (CF) for Calendar Year (CY) 2023 was not properly updated in December 2022. The proposed CMS CF value of 86.7850 was incorrectly applied to the Medicaid Management Information System (MMIS) instead of the finalized CMS CF value of 85.585. This error occurred due to confusion surrounding an earlier final rule announcement related to the outpatient prospective payment system (OPPS). Recent CMS OPPS publications have simplified the process of identifying the correct final conversion factor. For CY 2023, payments were processed using the proposed CF of 86.7850 rather than the finalized CF of 85.585, as it was the only rate available at the time. No adjustments have been made to date. To address this issue, we are partnering with our software vendor Gainwell to identify the total number of outpatient claims affected by the incorrect CF. We will then develop a timeline, communicate to impacted parties and prepare to implement a Standard Mass Adjustment Process (SMAP) to correct all impacted outpatient claims identified by Gainwell, which were processed with the wrong CF for CY 2023. Please see the timeline below for OHA actions. • Identify all CY 2023 outpatient claims that are impacted by the wrong conversion factor by May 20, 2025. • Change rate from 86.7850 to 85.585 by May 20, 2025. • Communicate with providers about the changes and next steps by May 20, 2025. • Implement a verification and validation process to confirm rates are accurately and delivered on time, completion deadline Dec. 31, 2025. Anticipated Completion Date: April 1, 2026 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director

View Audit 353343 Questioned Costs: $1

Finding 554740 (2024-032)

Significant Deficiency 2024

State of Oregon

OR

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

2024-032 Department of Justice Ensure program expenditures are supported Management Response: The Oregon Department of Justice agrees with the finding and provides the following information regarding the cause of this error and corrective action planned for implementation by June 30, 2025, which wil...

2024-032 Department of Justice Ensure program expenditures are supported Management Response: The Oregon Department of Justice agrees with the finding and provides the following information regarding the cause of this error and corrective action planned for implementation by June 30, 2025, which will be implemented by the Interim Financial Services Manager Richard Rylander. This error was caused through a lack of secondary validation of expenditures which resulted in incorrect expenditures being entered into the system. The correction action plan will update the Secondary Review of Expenditures and Batch Entry Process to ensure that the secondary review identifies and prevents errors which caused the finding above. Anticipated Completion Date: June 30, 2025 Contact person: Richard Rylander, Interim Financial Services Manager

View Audit 353343 Questioned Costs: $1

Finding 554737 (2024-023)

Significant Deficiency 2024

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.303

2024-023 Oregon Department of Human Services Strengthen controls over program expenditures Management Response: We agree with this recommendation. Department management acknowledges the finding and has already initiated actions to address the concerns. Quarterly collaboration meetings including TANF...

2024-023 Oregon Department of Human Services Strengthen controls over program expenditures Management Response: We agree with this recommendation. Department management acknowledges the finding and has already initiated actions to address the concerns. Quarterly collaboration meetings including TANF and TADVS policy, business security unit, business operations, and office of financial services began in July 2024. Issues and resolutions are discussed during these quarterly meetings; as a result, guidance for staff has been developed, and regular internal audits take place throughout the year. Business operations team in partnership with TANF policy will send out communication reminding staff of the process when a check is reported as lost, and the steps that must happen prior to a replacement check being issued. In addition, policy and business operations will attend meetings with those who have a leadership role in the system to approve payments and share the transmittal along with a discussion on ways to mitigate duplicate payments in the future. Child Welfare reviewed and corrected the transaction identified in this audit. Although the SPOTS card was reimbursed on July 21, 2023, the request in OR-Kids was not canceled on that day causing the transaction to hit the SFMA. During the audit, the error was discovered and Federal Policy and Resources worked with Office of Financial Services (OFS) to correct the reimbursement on February 26, 2025. The transaction was canceled in the OR-Kids system through financial cycle on February 26, 2025. OFS entered the correction in SFMA to reflect the reduction to TANF funding, which processed through OR-Kids on February 27, 2025, and interfaced to SFMA on the evening of February 27, 2025. Anticipated Completion Date: 12/31/2025 Contact Person: Eva Ruiz, TANF program manager

View Audit 353343 Questioned Costs: $1

Finding 554718 (2024-002)

Significant Deficiency 2024

Tri-County Senior Citizens and Housing, Inc.

CO

HUD Housing Programs Internal Control / Segregation of Duties Special Tests & Provisions § 200.303

Finding 2024-002: Lower Income Housing Assistance Program - Section 8 New Construction and Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development ...

Finding 2024-002: Lower Income Housing Assistance Program - Section 8 New Construction and Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development (Repeat of Finding 2023-002 and 2022-002) Compliance Requirements: Cash Management, Eligibility, Reporting, Special Tests and Provisions Type of finding: Internal Control Over Compliance (significant deficiency) Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to ensure a review process is established through adequate segregation of duties. The Organization should consider assessing and realigning the duties and responsibilities of administrative staff allowing the administrator to act in a more supervisory position. Action Taken: At this time, we do not have an administrative assistant/Activities Coordinator. Administrator works closely with the bookkeeper. Administrator and Executive Director will schedule every third recertification for review. Executive Director does review of the financial statements on a monthly basis when they are emailed over just before Policy Board meetings. During audit last year, we understood that reporting and eligibility did not have to happen at each interval but a review by another party in office every few re-certifications, as well as reviewing cash management. If there are any questions regarding this plan, please call the responsible party at (719) 852-5778. Sincerely yours, Monica Wolfe Executive Director Tri-County Senior Citizens and Housing, Inc.

View Audit 353337

Finding 554704 (2024-002)

Significant Deficiency 2024

Gettysburg Area School District

PA

Allowable Costs / Cost Principles

Finding 2024-002 - Allowable Costs/Cost Principles - Time and Effort Certifications Condition: A sample of payroll transactions were selected for testing that included the various ESSER programs. There were two teachers that were supported in whole with Federal funds included in the sample with n...

Finding 2024-002 - Allowable Costs/Cost Principles - Time and Effort Certifications Condition: A sample of payroll transactions were selected for testing that included the various ESSER programs. There were two teachers that were supported in whole with Federal funds included in the sample with no time and effort certifications maintained to support the portion of time and effort dedicated to the program. Corrective Action Taken or Planned: Time and Effort Certification will be maintained by the Curriculum and Instruction Department covering Title Funds for the 2024-2025 fiscal year and thereafter. The person responsible for the corrective action plan is Belinda M. Wallen, Business Manager/Board Secretary, and the anticipated completion date will be for the fiscal year ended June 2025. Sincerely, Belinda M. Wallen Business Manager

View Audit 353324

Finding 554613 (2024-019)

Significant Deficiency 2024

State of Oregon

OR

Allowable Costs / Cost Principles Special Tests & Provisions Reporting § 200.303

2024-019 Oregon Department of Human Services Improve controls and compliance over long-term care facility auditsManagement Response: We agree with this recommendation and will make these changes on the July 1, 2025 cost report template. We will be adding a line item to distinguish between Total Admi...

2024-019 Oregon Department of Human Services Improve controls and compliance over long-term care facility auditsManagement Response: We agree with this recommendation and will make these changes on the July 1, 2025 cost report template. We will be adding a line item to distinguish between Total Administration overtime and Administrator only overtime. .Anticipated Completion Date: July 1, 2025 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director

View Audit 353285

Finding 554609 (2024-015)

Significant Deficiency 2024

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles § 200.1 § 200.400

2024-015 Oregon Department of Human Services/Oregon Health Authority Strengthen review over direct costs charged to the program Management Response: We agree with this recommendation. Interest related to past due amounts will be charged to general funds only. Expenditures will be reviewed both by st...

2024-015 Oregon Department of Human Services/Oregon Health Authority Strengthen review over direct costs charged to the program Management Response: We agree with this recommendation. Interest related to past due amounts will be charged to general funds only. Expenditures will be reviewed both by staff and approving parties to ensure only allowable expenditures are charged to the federal grants. The questioned costs of $68 will be refunded and reported to CMS on the CMS 64. The agency will ensure that future contracts that include any incentive funds for surveys will be structured such that incentives are billed under separate coding that will be charged to general funds only. The questioned costs of $28,801 will be refunded and reported to CMS on the CMS 64 Anticipated Completion Date: April 30, 2025 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director

View Audit 353285 Questioned Costs: $1

Finding 554608 (2024-014)

Significant Deficiency 2024

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles § 200.400

2024-014 Oregon Department of Human Services/Oregon Health Authority Implement control procedures around cost allocation system inputs Management Response: We agree with this recommendation. The Office of Financial Services will review the existing controls in Cost Allocation system and identify are...

2024-014 Oregon Department of Human Services/Oregon Health Authority Implement control procedures around cost allocation system inputs Management Response: We agree with this recommendation. The Office of Financial Services will review the existing controls in Cost Allocation system and identify areas that need additional or new control procedures to ensure system inputs are appropriately identified and processed. In addition, we will review the noted errors and make appropriate corrections. Anticipated Completion Date: June 30,, 2025 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director

View Audit 353285 Questioned Costs: $1

Finding 554606 (2024-012)

Significant Deficiency 2024

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

2024-012 Oregon Health Authority Ensure MMIS rates are accurate and updated timely Management Response: We agree with this recommendation. The conversion factor (CF) for Calendar Year (CY) 2023 was not properly updated in December 2022. The proposed CMS CF value of 86.7850 was incorrectly applied to...

2024-012 Oregon Health Authority Ensure MMIS rates are accurate and updated timely Management Response: We agree with this recommendation. The conversion factor (CF) for Calendar Year (CY) 2023 was not properly updated in December 2022. The proposed CMS CF value of 86.7850 was incorrectly applied to the Medicaid Management Information System (MMIS) instead of the finalized CMS CF value of 85.585. This error occurred due to confusion surrounding an earlier final rule announcement related to the outpatient prospective payment system (OPPS). Recent CMS OPPS publications have simplified the process of identifying the correct final conversion factor. For CY 2023, payments were processed using the proposed CF of 86.7850 rather than the finalized CF of 85.585, as it was the only rate available at the time. No adjustments have been made to date. To address this issue, we are partnering with our software vendor Gainwell to identify the total number of outpatient claims affected by the incorrect CF. We will then develop a timeline, communicate to impacted parties and prepare to implement a Standard Mass Adjustment Process (SMAP) to correct all impacted outpatient claims identified by Gainwell, which were processed with the wrong CF for CY 2023. Please see the timeline below for OHA actions. • Identify all CY 2023 outpatient claims that are impacted by the wrong conversion factor by May 20, 2025. • Change rate from 86.7850 to 85.585 by May 20, 2025. • Communicate with providers about the changes and next steps by May 20, 2025. • Implement a verification and validation process to confirm rates are accurately and delivered on time, completion deadline Dec. 31, 2025. Anticipated Completion Date: April 1, 2026 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director

View Audit 353285 Questioned Costs: $1

Finding 554594 (2024-032)

Significant Deficiency 2024

State of Oregon

OR

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

2024-032 Department of Justice Ensure program expenditures are supported Management Response: The Oregon Department of Justice agrees with the finding and provides the following information regarding the cause of this error and corrective action planned for implementation by June 30, 2025, which wil...

2024-032 Department of Justice Ensure program expenditures are supported Management Response: The Oregon Department of Justice agrees with the finding and provides the following information regarding the cause of this error and corrective action planned for implementation by June 30, 2025, which will be implemented by the Interim Financial Services Manager Richard Rylander. This error was caused through a lack of secondary validation of expenditures which resulted in incorrect expenditures being entered into the system. The correction action plan will update the Secondary Review of Expenditures and Batch Entry Process to ensure that the secondary review identifies and prevents errors which caused the finding above. Anticipated Completion Date: June 30, 2025 Contact person: Richard Rylander, Interim Financial Services Manager

View Audit 353285 Questioned Costs: $1

Finding 554591 (2024-023)

Significant Deficiency 2024

State of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.303

2024-023 Oregon Department of Human Services Strengthen controls over program expenditures Management Response: We agree with this recommendation. Department management acknowledges the finding and has already initiated actions to address the concerns. Quarterly collaboration meetings including TANF...

2024-023 Oregon Department of Human Services Strengthen controls over program expenditures Management Response: We agree with this recommendation. Department management acknowledges the finding and has already initiated actions to address the concerns. Quarterly collaboration meetings including TANF and TADVS policy, business security unit, business operations, and office of financial services began in July 2024. Issues and resolutions are discussed during these quarterly meetings; as a result, guidance for staff has been developed, and regular internal audits take place throughout the year. Business operations team in partnership with TANF policy will send out communication reminding staff of the process when a check is reported as lost, and the steps that must happen prior to a replacement check being issued. In addition, policy and business operations will attend meetings with those who have a leadership role in the system to approve payments and share the transmittal along with a discussion on ways to mitigate duplicate payments in the future. Child Welfare reviewed and corrected the transaction identified in this audit. Although the SPOTS card was reimbursed on July 21, 2023, the request in OR-Kids was not canceled on that day causing the transaction to hit the SFMA. During the audit, the error was discovered and Federal Policy and Resources worked with Office of Financial Services (OFS) to correct the reimbursement on February 26, 2025. The transaction was canceled in the OR-Kids system through financial cycle on February 26, 2025. OFS entered the correction in SFMA to reflect the reduction to TANF funding, which processed through OR-Kids on February 27, 2025, and interfaced to SFMA on the evening of February 27, 2025. Anticipated Completion Date: 12/31/2025 Contact Person: Eva Ruiz, TANF program manager

View Audit 353285 Questioned Costs: $1

Finding 554572 (2024-003)

Significant Deficiency 2024

Trinity Services, Inc.

IL

Questioned Costs Allowable Costs / Cost Principles

The Organization will enhance its procedures and internal controls with respect to preparation and requests of funds. Grant agreements will be reviewed to confirm if expenditures being requested are allowed. The Organization will add a secondary level of review to ensure reimbursement requests are a...

The Organization will enhance its procedures and internal controls with respect to preparation and requests of funds. Grant agreements will be reviewed to confirm if expenditures being requested are allowed. The Organization will add a secondary level of review to ensure reimbursement requests are accurately stated.

View Audit 353273 Questioned Costs: $1

Finding 554571 (2024-002)

Significant Deficiency 2024

Trinity Services, Inc.

IL

Questioned Costs Allowable Costs / Cost Principles Reporting

The Organization will enhance its procedures and internal controls with respect to preparation and requests of funds. Grant agreements will be reviewed to confirm if expenditures being requested are allowed. The Organization will add a secondary level of review to ensure reimbursement requests are a...

The Organization will enhance its procedures and internal controls with respect to preparation and requests of funds. Grant agreements will be reviewed to confirm if expenditures being requested are allowed. The Organization will add a secondary level of review to ensure reimbursement requests are accurately stated.

View Audit 353273 Questioned Costs: $1

Finding 554570 (2024-001)

Significant Deficiency 2024

Trinity Services, Inc.

IL

Questioned Costs Allowable Costs / Cost Principles Reporting

The Organization will enhance its procedures and internal controls with respect to preparation and requests of funds. Grant agreements will be reviewed to confirm if expenditures being requested are allowed. The Organization will add a secondary level of review to ensure reimbursement requests are a...

The Organization will enhance its procedures and internal controls with respect to preparation and requests of funds. Grant agreements will be reviewed to confirm if expenditures being requested are allowed. The Organization will add a secondary level of review to ensure reimbursement requests are accurately stated.

View Audit 353273 Questioned Costs: $1

Finding 554540 (2024-002)

Significant Deficiency 2024

Falmouth Housing Authority

MA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.403

2024-002 – INTERNAL CONTROLS OVER COMPLIANCE – ALLOWABLE COSTS/COST PRINCIPLES Significant Deficiency Auditee’s Response and Planned Corrective Action FHA is retraining staff on procurement policy and reinforcing the requirement for pre-approval before payment. A checklist will be added to all invoi...

2024-002 – INTERNAL CONTROLS OVER COMPLIANCE – ALLOWABLE COSTS/COST PRINCIPLES Significant Deficiency Auditee’s Response and Planned Corrective Action FHA is retraining staff on procurement policy and reinforcing the requirement for pre-approval before payment. A checklist will be added to all invoices to confirm documentation is in place before submission for payment and a second signer will be responsible for signing invoices in the event of the absence of the Executive Director. Random monthly internal audits will be conducted to ensure continued compliance. Planned Implementation Date of Corrective Action: Immediate Person Responsible for Corrective Action: Benjamin Anako, Fiscal Officer

View Audit 353264

Finding 554534 (2024-004)

Significant Deficiency 2024

Portland Opportunities Industrialization Center, Inc.

OR

Allowable Costs / Cost Principles

Recommendation: We recommend management implement procedures to ensure billed amounts match allowable expenses for cost-reimbursable grants. Additionally, the percentage used to allocate payroll taxes and benefits should be periodically updated to align with actual expenses. Action Taken: The Orga...

Recommendation: We recommend management implement procedures to ensure billed amounts match allowable expenses for cost-reimbursable grants. Additionally, the percentage used to allocate payroll taxes and benefits should be periodically updated to align with actual expenses. Action Taken: The Organization agrees with the recommendation and is in the process of implementing appropriate procedures so that cost-reimbursable grants are accurately and timely billed. The procedures are expected to be implemented within next fiscal year. The questions costs will be resolved with the funding agency.

View Audit 353254

Finding 554530 (2024-005)

Material Weakness 2024

Inner City Health Center

CO

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.1 § 200.303

Recommendation: Our auditors recommended the Organization update their method of allocating expenditures to federal awards based on invoice date to ensure the incurred date is within the proper period of performance. Explanation of disagreement with audit finding: There is no disagreement with the ...

Recommendation: Our auditors recommended the Organization update their method of allocating expenditures to federal awards based on invoice date to ensure the incurred date is within the proper period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will review grant requirements and make sure that allowable costs are incurred and allocated to the grant within the grant period.

View Audit 353251 Questioned Costs: $1

Finding 554508 (2024-005)

Material Weakness 2024

Sandhills Medical Foundation, Inc.

SC

Allowable Costs / Cost Principles

In Finding 2024-005, it was reported that time and activity reports are not maintained for salaried employees. The Organization’s operating processes in place do not require salaried employees to certify time and efforts on a monthly basis. In response to Finding 2024-005, procedures will be establ...

In Finding 2024-005, it was reported that time and activity reports are not maintained for salaried employees. The Organization’s operating processes in place do not require salaried employees to certify time and efforts on a monthly basis. In response to Finding 2024-005, procedures will be established to maintain time and effort certifications by all salaried employees. Procedures will be established to ensure that salaried employees certify time and effort that coincide with the Organization’s payroll cycle (at least on a monthly basis).

View Audit 353175

Corrective Action Plans

Filters