Corrective Action Plans

Finding 391729 (2022-003)

Significant Deficiency 2022

MI

Cash Management Internal Control / Segregation of Duties § 200.302 § 200.305

March 27, 2024 2022-003: Significant Deficiency in Internal Control / Immaterial Noncompliance – Cash Management (repeat comment) Condition: 1) The Consortium requested funds in advance of when the related disbursements were made, 2) the basis for the advances (requests) were not supported by approp...

March 27, 2024 2022-003: Significant Deficiency in Internal Control / Immaterial Noncompliance – Cash Management (repeat comment) Condition: 1) The Consortium requested funds in advance of when the related disbursements were made, 2) the basis for the advances (requests) were not supported by appropriate documentation, and 3) authorization for requesting funds in advance not obtained. Corrective Action: We agree with the finding. The Consortium has carefully reviewed our policies and procedures and have made the necessary changes to ensure that cash draws are based on expenditures already incurred and they are supported by transactions recorded in the books and records of the Consortium. We believe the updated procedures will result in the reduction over time and ultimately the complete elimination of this issue. Contact Person: Shamar Herron: Sherron@mwse.org Anticipated Completion Date: December 2024 Respectfully, Shamar Herron

View Audit 302122

Finding 391219 (2022-006)

Material Weakness 2022

Lutheran Services in Iowa, Inc.

IA

Cash Management Allowable Costs / Cost Principles § 200.303

Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be revie...

Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be reviewed and approved by management prior to submission. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: 12/31/2023

View Audit 301846

Finding 391218 (2022-005)

Material Weakness 2022

Lutheran Services in Iowa, Inc.

IA

Cash Management Allowable Costs / Cost Principles § 200.303

Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be revie...

Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be reviewed and approved by management prior to submission. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: 12/31/2023

View Audit 301846

Finding 391214 (2022-004)

Significant Deficiency 2022

Lutheran Services in Iowa, Inc.

IA

Cash Management Allowable Costs / Cost Principles § 200.303

Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be revie...

Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be reviewed and approved by management prior to submission. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: 12/31/2023

View Audit 301846

Finding 391023 (2022-001)

Significant Deficiency 2022

Dr. Richard Izquierdo Health & Science Charter School

NY

Reporting Cash Management

The DR/HS staff will commit to the following- Improved fiscal oversight- Identifying specific expenditures for specific grants in a timely manner through usage of the accounting software and record revenue in the same period. Schedule sessions with the CSBM Finance team and Development Team to condu...

The DR/HS staff will commit to the following- Improved fiscal oversight- Identifying specific expenditures for specific grants in a timely manner through usage of the accounting software and record revenue in the same period. Schedule sessions with the CSBM Finance team and Development Team to conduct an analysis of revenue recognition and grant management to help identify any issues regarding financial reporting and revenue recognition

View Audit 301625

Finding 390819 (2022-001)

Material Weakness 2022

Child Start, Inc.

MT

Questioned Costs Allowable Costs / Cost Principles Cash Management

Management's Response: We concur with the recommendation, and the corrective action will be implemented as of March 6, 2024.

View Audit 301535 Questioned Costs: $1

Finding 390818 (2022-002)

Material Weakness 2022

Child Start, Inc.

MT

Cash Management Internal Control / Segregation of Duties

Management's Response: We concur with the recommendation, and the corrective action will be implemented as of March 6, 2024.

View Audit 301535

Finding 390817 (2021-001)

Material Weakness 2022

Child Start, Inc.

MT

Cash Management Internal Control / Segregation of Duties

Management's Response: We concur with the recommendation, and the corrective action will be implemented as of March 6, 2024.

View Audit 301535

Finding 389474 (2022-004)

Significant Deficiency 2022

Northeast Missouri Area Agency on Aging

MO

Allowable Costs / Cost Principles Cash Management § 200.302

Recommendation: We recommend the Agency draft and adopt written procedures in accordance with Uniform Guidance requirements. Action Taken: Management agrees with the finding and adopted the appropriate policies and procedures in December 2023.

View Audit 300445

Finding 388420 (2022-003)

Material Weakness 2022

Christus Health

TX

Questioned Costs Eligibility Period of Performance

Finding 2022-003 Identification of the federal program: Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.027 COVID – 19 Coronavirus State and Local Fiscal Recovery Funds. Pass-Through Award Numbers: Good Shepherd, pass-through Gregg County: SKM_C55822012711390 ...

Finding 2022-003 Identification of the federal program: Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.027 COVID – 19 Coronavirus State and Local Fiscal Recovery Funds. Pass-Through Award Numbers: Good Shepherd, pass-through Gregg County: SKM_C55822012711390 Trinity Mother Frances, Pass-through Smith County: Not available Santa Rosa, Pass-through the City of San Marcos: Not available Award Period of Performance: Good Shepherd, pass-through Gregg County, September 1, 2021 – November 30, 2021 Trinity Mother Frances, Pass-through Smith County, October 1, 2021 – November 30, 2021 Santa Rosa, Pass-through the City of San Marcos, March 03, 2021 through December 31, 2026 Corrective Action Planned: Management concurs with the finding and is in the process of performing a full audit of all expenditures reported to the respective pass-through agency. Upon completion of that review, we will seek guidance from the respective pass-through agency as to the appropriate corrective action. Responsible party: Lee Sonne, Vice President of Finance and Controller, jointly with the Melissa Crenwelge-Nedbalek Accounting Director responsible for Grant Reporting Implementation Date: Full audit of reported expenditures has begun in each ministry. Ultimate resolution is dependent on timing and results of meetings with the respective pass-thru agencies, but we expect to have procedures completed by June 30, 2024 to request the meeting with the pass-thru agencies.

View Audit 300148 Questioned Costs: $1

Finding 387010 (2022-008)

Material Weakness 2022

Workforce Development Board Work4wv Region 1, Inc.

WV

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

2022-008 Allocation of Grant Expenses U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement policies and procedures to ensure that all expenses are for actual expenses incurred, and that timely reconciliations are performed to ...

2022-008 Allocation of Grant Expenses U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement policies and procedures to ensure that all expenses are for actual expenses incurred, and that timely reconciliations are performed to ensure the expenses are properly charged to the correct assistance listing number and grant. Action Taken: The Board has developed a process to correctly allocate expenditures to the correct funding stream. At each month’s end, all employees complete an allocation spreadsheet. When all spreadsheets are completed, approved, and turned in, the Board determines the allocation of payroll and expenditures. Expenditures that occurred in March will be allocated using the allocation chart for February. Also, this procedure is backup for each cash request that is submitted for funding. Also, this is reviewed for the reconciliation between the cash request and the Board’s accounting software.

View Audit 299381

Finding 386546 (2022-004)

Material Weakness 2022

Neuse River Council of Governments D/b/a Eastern Carolina Council

NC

Allowable Costs / Cost Principles Cash Management Material Weakness

The Council agrees with this finding. The Council has hired a new Finance Director with the appropriate skills, knowledge, and experience to oversee the Finance Department. The Finance Director has identified and corrected internal control issues.

View Audit 298859

Finding 385644 (2022-007)

Material Weakness 2022

Greenfield Exempted Village School District

OH

Matching / Level of Effort / Earmarking Subrecipient Monitoring Cash Management

In this audit period the requirement for paying the prevailing wage was new and we have taken steps to ensure compliance. Even though both contractors paid prevailing wages, it was not in the written contracts.

View Audit 298366

Finding 384381 (2022-013)

Significant Deficiency 2022

The City of Frederick, Maryland

MD

Cash Management

Most funds are a pass through or on a reimbursement basis, therefore interest has always been de minimus. The City will re-evaluate.

View Audit 297486

Finding 384181 (2022-004)

Significant Deficiency 2022

College Unbound

RI

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding number: 2022-004 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 and 84.268 Award year: 2022 Corrective Action Plan: College Unbound hired two new positions, a Controller and a Bursar, who both started on 10/2/23 (the r...

Finding number: 2022-004 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 and 84.268 Award year: 2022 Corrective Action Plan: College Unbound hired two new positions, a Controller and a Bursar, who both started on 10/2/23 (the role was previously filled by a single temporary employee). Part of the Bursar’s scope of work is to work with Financial Aid to ensure that ledgers are correct. Reconciliation reports are also reviewed monthly to ensure accuracy and resolve discrepancies timely. Timeline for Implementation of Corrective Action Plan: Ongoing. Fully implemented by the end of FY24. Contact Person: Diana Perdomo, CFO

View Audit 297283

Finding 384055 (2022-001)

Significant Deficiency 2022

City of Davenport

WA

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

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Davenport January 1, 2022 through December 31, 2022 This schedule presents the corrective action the City is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations ...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Davenport January 1, 2022 through December 31, 2022 This schedule presents the corrective action the City is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2022-001 Finding caption: The City’s internal controls were not adequate to ensure compliance with the revenue diversion special test requirements. Name, address, and telephone of City contact person: Steve Goemmel, City Administrator City of Davenport P. O. Box 26 411 Morgan Street Davenport, WA 99122 Corrective action the auditee plans to take in response to the finding: The City’s airport fund balance was overstated due to a coding error by the Clerk/Treasurer in 2022. Every month the city pays the Washington State Department of Revenue excise tax for its utility funds, (Water/Sewer/Garbage funds) plus any revenue generated from the sale of graves at the cemetery, and leasehold tax on the airport hangar leases. The Clerk/Treasurer uses a spreadsheet template to calculate these liabilities. He inadvertently entered the calculated remittance into the airport fund rather than the garbage fund. The resulting error caused the city to overstate the expenditures in the airport fund and understated the expenditures in the garbage fund. The amount of the remittance that was paid to the Washington State Department of Revenue and the dollar amount remitted was correct and expended to the proper corresponding funds. This was also done on three small expenditures on the city’s credit card account. The expenditure amounts were paid but misassigned to the airport fund. All these expenditures were true and paid in a timely fashion. There was no misappropriation of funds. They were simply data entry mistakes to different funds numbers. No airport funds within any of our FAA grants were used to pay the Washington State Department of Revenue or other vendors. Under my direction, the Clerk/Treasurer has amended his calculation worksheet so that it does not include any expenditure to the Airport Fund. Airport Leasehold Tax is now paid to the Special Leasehold account of the Washington Department of Revenue. The City will institute a revised financial policy for credit card use so this doesn’t happen in the future. All credit card expenditures will be reviewed for accuracy in earnest. Anticipated date to complete the corrective action: June 1, 2024

View Audit 297143

Finding 383958 (2022-001)

Significant Deficiency 2022

Beth Israel Lahey Health, Inc.

MA

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Cash Management

Management Response and Corrective Action Plan Finding 2022-001 Federal Agency: United States Department of Health and Human Services Program Name: Provider Relief Fund (PRF) Assistance Listing Number: 93.498 Responsible Individual: Katherine Bacher, VP of System Services Accounting and Finance Co...

Management Response and Corrective Action Plan Finding 2022-001 Federal Agency: United States Department of Health and Human Services Program Name: Provider Relief Fund (PRF) Assistance Listing Number: 93.498 Responsible Individual: Katherine Bacher, VP of System Services Accounting and Finance Contact Information: Katherine.bacher@bilh.org; 617-278-7059 There was an error in PRF Reporting period 2 and 3 due to a misapplication of utilizing the same quarterly budget amount for both Quarter 3 and Quarter 4, resulting in an understatement of lost revenue. Management agrees with the recommendation and moving forward, there will be at least two reviews of the PRF filing prior to submission to better ensure complete and accurate information is submitted to HRSA. Corrective Action Plan: BILH will develop dual signoff of all submissions: • Director of Revenue and Reimbursement will compile and review the initial draft • VP of Revenue and Reimbursement will review the initial draft for completeness and accuracy • VP of System Services Accounting and Finance will final review for completeness and accuracy Expected Completion Date: September 30, 2024 Status of Completion: Not Started

View Audit 296974

Finding 383733 (2022-004)

Significant Deficiency 2022

Ford County, Kansas

KS

Subrecipient Monitoring Cash Management Significant Deficiency § 200.305

The County does not have a complete set of written cash management policies and procedures as required by the Uniform Guidance. The lack of written procedures did not result in any material noncompliance, fraud or abuse with respect to the major program. Recommendation: Management should determine...

The County does not have a complete set of written cash management policies and procedures as required by the Uniform Guidance. The lack of written procedures did not result in any material noncompliance, fraud or abuse with respect to the major program. Recommendation: Management should determine the scope of written policies needed for compliance with all federal programs and develop policies and procedures to comply with the Uniform Guidance. Grantee Response: Management agrees with the finding and recommendation. The County’s existing policies are currently under review by management and staff to determine what updates/changes are necessary in order to meet the Uniform Guidance requirements. Once any updates/changes are drafted, the policy will be presented to the Governing Body for review and approval.

View Audit 296750

Finding 382705 (2022-002)

Material Weakness 2022

University of Kansas Hospital Authority

KS

Questioned Costs Cash Management Eligibility

The Authority has performed a review of all patients who have had indications of additional health insurance on an account with a HRSA payment, and made appropriate refunds.

View Audit 296291 Questioned Costs: $1

Finding 382662 (2022-010)

Significant Deficiency 2022

County of Delta

MI

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Cash Management

2022-010: Significant Deficiency and Noncompliance – Improper Payments Requested for Reimbursement Statement of Condition/Criteria: Delta County prepared reimbursement requests by manually transferring data from the general ledger to summary spreadsheets. The transferred data contained errors that r...

2022-010: Significant Deficiency and Noncompliance – Improper Payments Requested for Reimbursement Statement of Condition/Criteria: Delta County prepared reimbursement requests by manually transferring data from the general ledger to summary spreadsheets. The transferred data contained errors that resulted in the request for reimbursement being overstated. However, there were other costs incurred that would have been eligible. Planned Corrective Action: County management will develop control to ensure a secondary review and approval process is put into place for all reimbursement request submissions so that only allowable costs are charged to the grant. Contact person responsible for corrective action: Ashleigh Young, County Controller/Administrator Anticipated Completion Date: March 2024

View Audit 296246

Finding 382656 (2022-007)

Material Weakness 2022

County of Delta

MI

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

2022-007: Material Weakness and Noncompliance – Written Policies Required by the Uniform Guidance Statement of Condition/Criteria: Delta County does not have written policies and procedures to implement the requirements of 2 CFR section 200 for the administration of federal awards specific to the Ai...

2022-007: Material Weakness and Noncompliance – Written Policies Required by the Uniform Guidance Statement of Condition/Criteria: Delta County does not have written policies and procedures to implement the requirements of 2 CFR section 200 for the administration of federal awards specific to the Airport or for federal awards in general. 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal controls over the federal awards that provide assurance that the entity is managing the federal awards in compliance with federal statutes, regulations, and the conditions of the federal award. Planned Corrective Action: County management will develop written policies and procedures for grants and will formalize responsibilities between Airport management, Michigan Department of Transportation and other consultants. Contact person responsible for corrective action: Ashleigh Young, County Controller/Administrator Anticipated Completion Date: March 2024

View Audit 296246

Finding 382613 (2022-001)

Material Weakness 2022

Delaware Academy of Medicine, Inc.

DE

Questioned Costs Allowable Costs / Cost Principles Cash Management

In the exploratory phase of applying for a new grant, the Executive Director will ascertain whether or not the source of funding is Federal. The Executive Director will be assisted in this responsibility by a professional accountant that has been retained from an accounting firm. Where any doubt e...

In the exploratory phase of applying for a new grant, the Executive Director will ascertain whether or not the source of funding is Federal. The Executive Director will be assisted in this responsibility by a professional accountant that has been retained from an accounting firm. Where any doubt exists, the funding partner will be contacted to confirm their perspective.

View Audit 296191 Questioned Costs: $1

Finding 381083 (2022-003)

Significant Deficiency 2022

Stillaguamish Pointe

WA

HUD Housing Programs Subrecipient Monitoring Cash Management

Execute the transfer of cash into the residual receipts reserve account.

View Audit 295833

Finding 380869 (2022-003)

Significant Deficiency 2022

Silver Lake Regional School District

MA

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties

Similar to 2022-001, the Silver Lake Regional School District will create and adhere to a Federal Grants Compliance Manual.

View Audit 295550

Finding 380810 (2022-005)

Significant Deficiency 2022

City of Lynn

MA

School Nutrition Programs Internal Control / Segregation of Duties Allowable Costs / Cost Principles

Audit Finding Reference: 2022-005 Limit Federal Cash on Hand (Significant Deficiency) Planned Corrective Action: The district is aware of this finding and will be taking steps to address this in the coming months. The City needs to decrease the cash balance in the school lunch fund so that it fall...

Audit Finding Reference: 2022-005 Limit Federal Cash on Hand (Significant Deficiency) Planned Corrective Action: The district is aware of this finding and will be taking steps to address this in the coming months. The City needs to decrease the cash balance in the school lunch fund so that it falls within acceptable Federal guidelines. Name of Contact Person and Completion Date Kevin McHugh, City of Lynn School Business Manager December 31, 2024

View Audit 295538

Corrective Action Plans

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