Corrective Action Plans

Finding 403820 (2022-005)

Material Weakness 2022

Jft Recovery and Veterans Support Services

PA

Allowable Costs / Cost Principles Cash Management Material Weakness

As of 2023 we will be adding the following policy to the fiscal manual and to the operations manual to read as follows: All monthly program reports shall be completed by the coordinator and sent to the Deputy Director for approval, once approved they will be sent to the Fiscal Coordinator. The Fis...

As of 2023 we will be adding the following policy to the fiscal manual and to the operations manual to read as follows: All monthly program reports shall be completed by the coordinator and sent to the Deputy Director for approval, once approved they will be sent to the Fiscal Coordinator. The Fiscal Coordinator will then complete the billing amount and fiscal narrative then the report will be reviewed by the Deputy Director. Once approved the report will be presented to the Executive Director for final review, approval and signature and date placed on each report before it is sent to the funder. All program coordinators will complete a JFT outcomes report that is placed in an electronic reporting system and these reports will be reviewed quarterly by the Deputy Director. The Deputy Director does data analysis and these reports are placed in narrative form by the Deputy Director quarterly and the year-end report. These are shared with the funders according to the reporting requirements in the grant. All reports must be to funders by the 15th of the following month, unless otherwise stated in funder contract. The following policy will also be added to the fiscal manual: All budget modifications will be written up on the budget modification form and sent to the funder electronically once approved the form will be notated and include the funders signature, written on the form verbal communication from the funder, or a copy of the email with funder approval.

View Audit 310733

Finding 403696 (2022-003)

None 2022

Nacogdoches Memorial Hospital District

TX

Allowable Costs / Cost Principles Special Tests & Provisions Cash Management

We are in receipt of the findings required to be reported by the single audit for COVID19 Claims Reimbursement for the Uninsured Program and the COVID19 Coverage Assistance Fund specifically, regarding discrepancies in funding received under a different employer identifier number. Management does no...

We are in receipt of the findings required to be reported by the single audit for COVID19 Claims Reimbursement for the Uninsured Program and the COVID19 Coverage Assistance Fund specifically, regarding discrepancies in funding received under a different employer identifier number. Management does not dispute the finding. The District is in it’s second year after going through an asset purchase transaction, whereby the physical assets were retained by the District, but the operations of the hospital were sold. As the District moves forward, we will work to develop policies and procedures over financial reporting to ensure they only request reimbursement for federal grants for programs with the correct employer identification number. Lynn Lindsey, Chief Financial Officer, will be responsible to ensure that this is accomplished and will begin to implement new procedures. The corrective action plan will be implemented by September 30, 2024.

View Audit 310696

Finding 403502 (2022-002)

None 2022

Firstmed Health and Wellness Center

NV

Cash Management Reporting

The Center has established clear reporting calendars with due dates. With significant turnover within accounting and finance departments, this responsibility has been reassigned and monitored by the CFO.

View Audit 310590

Finding 403119 (2022-010)

Material Weakness 2022

State of California

CA

Eligibility Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303

Public Health’s Office of Aids (OA) agrees with the finding and recommendation. OA developed and implemented additional internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the exist...

Public Health’s Office of Aids (OA) agrees with the finding and recommendation. OA developed and implemented additional internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guidelines, including acceptable supporting documentation and accurate eligibility requirements. Prior to this audit period, and through December 2021, ADAP had issued multiple policy memos to respond to the COVID-19 pandemic, which enabled staff and enrollment workers to defer documentation collection, when necessary, to remain flexible and ensure clients impacted by the pandemic, and associated site closures, did not lose eligibility and access to life-saving medications and comprehensive healthcare. These flexibilities in our guidelines were implemented based on guidance received from our federal funder, the Health Resources and Services Administration, which encouraged ADAP to reassess its organization's eligibility and recertification policies and procedures, and remove any barriers that may impede social distancing, or other public health strategies, necessary to minimize COVID-19 transmission. This documentation deferral was terminated on December 31, 2021, and since January 1, 2022, full documentation and eligibility requirements have been enforced. This, combined with ongoing QA efforts, will help mitigate future findings in ADAP applications. Estimated Implementation Date: Implemented as of April 2022 Contact: Joseph Lagrama, Branch Chief AIDS Drug Assistance Program Branch California Department of Public Health

View Audit 310237

Finding 403116 (2022-008)

Material Weakness 2022

State of California

CA

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

The Local Governmental Financing Division, in collaboration with the Audits and Investigations Division, agrees that policies and procedures will be developed to take additional action for significantly late-cost reports and non-compliant counties. As of July 1, 2023, the California Department of He...

The Local Governmental Financing Division, in collaboration with the Audits and Investigations Division, agrees that policies and procedures will be developed to take additional action for significantly late-cost reports and non-compliant counties. As of July 1, 2023, the California Department of Health Care Services transitioned counties away from cost reconciliation financing, and for any state fiscal year after July 1, 2023, counties will no longer be required to submit cost reports. Estimated Implementation Date: July 2023 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services

View Audit 310237

Finding 401926 (2022-003)

Significant Deficiency 2022

The Wayside House, Inc. and Subsidiary

MN

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

The Organization will implement control procedures that maintain proper segregation of duties. Expenditure amounts that are to be applied to federal awards shall be prepared the Staff Accountant and will require the formal approval from an individual in leadership (COO, Controller) prior to being re...

The Organization will implement control procedures that maintain proper segregation of duties. Expenditure amounts that are to be applied to federal awards shall be prepared the Staff Accountant and will require the formal approval from an individual in leadership (COO, Controller) prior to being recorded. The prepared file and documentation of the review and approval will be retained in a share drive for future access.

View Audit 309846

Finding 401733 (2022-001)

Significant Deficiency 2022

City of Hopkins

MN

Procurement, Suspension & Debarment Cash Management

CORRECTIVE ACTION PLAN The following is our response to findings in the audit as of June 30, 2022 FINDING 2022-001 - Uniform Guidance written policies and procedures During our audit, we discovered the City did not develop written procedures as required by the Uniform Guidance. Corrective Action Pla...

CORRECTIVE ACTION PLAN The following is our response to findings in the audit as of June 30, 2022 FINDING 2022-001 - Uniform Guidance written policies and procedures During our audit, we discovered the City did not develop written procedures as required by the Uniform Guidance. Corrective Action Plan (CAP): 1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: The City Council will adopt written federal grant policies and procedures. 3.Official Responsible for Ensuring CAP: Nick Bishop, Business Manager, is the official responsible for ensuring corrective action. 3. Planned Completion Date for CAP: Fiscal year end 2024. 4. Plan to Monitor Completion of CAP: The City Council will be monitoring this corrective action plan. Sincerely, Nick Bishop City Finance Director

View Audit 309670

Finding 401416 (2022-003)

None 2022

County of Columbia, Pennsylvania

PA

Subrecipient Monitoring Cash Management

Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Ag...

Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Agency, Pass-Through Entity Identifying Numbers: C000071546, C000073444, C000075689, C000075284, C000080637, and PEMA-2022-007 Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Assistance Listing #21.023, COVID-19 Emergency Rental Assistance Program, U.S. Department of Treasury, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available Assistance Listing #93.658, Foster Care - Title IV-E, U.S. Department of Treasury, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available Condition/Context: While the County has informal policies and procedures surrounding the administration of its federal programs, these policies and procedures have not been formally documented to ensure compliance with the areas of allowability of costs, cash management or subrecipient monitoring as required under the Uniform Guidance. Recommendation: We recommend that County management prepare the required written policies/procedures related to allowability of costs, cash management and subrecipient monitoring outlined with the Uniform Guidance. Corrective Action Planned: The County is working to write and adopt procedures that are needed to meet compliance. Name(s) of Contact Person(s) Responsible for Corrective Action: David Witchey, Chief Clerk Anticipated Completion Date: For the 2023 audit

View Audit 309542

Finding 401388 (2022-012)

Significant Deficiency 2022

Libson Regional School District

NH

School Nutrition Programs Cash Management Reporting

Audit Finding Reference: 2022-12 Management’s View and Planned Corrective Action A procedure is currently in place and being followed. In 2021-2022 there were new forms sent from the State to do our meal counts, this was the second COVID year and free lunch for all students. In our one room plus ...

Audit Finding Reference: 2022-12 Management’s View and Planned Corrective Action A procedure is currently in place and being followed. In 2021-2022 there were new forms sent from the State to do our meal counts, this was the second COVID year and free lunch for all students. In our one room plus a modular school housethat receives vended meals from Lisbon, Landaff, they used both the State form and MealTimes and then sometimes called and made changes at the last minute to the number of servable meals. We believe the glitch was at Landaff in terms of procedure so part of our plan will be to review with the Landaff staff how to correctly enter the information into MealTimes. I spot checked 22-23 and found that our claims are accurate to Meal Times. Name of Contact Person and Completion Date: Name 1 Toni Butterfield Name 2 Anticipated Completion Date – 6/30/2025

View Audit 309473

Finding 401387 (2022-011)

Material Weakness 2022

Libson Regional School District

NH

Questioned Costs School Nutrition Programs Internal Control / Segregation of Duties § 200.303

Audit Finding Reference: 2022-011 Management’s View and Planned Corrective Action: Management learned about 7 CFR, 210.14(b) when asked to create an Excess Food Service Fund Spend Down Plan this school year. We are now monitoring this and will make sure to spend down funds appropriately each year...

Audit Finding Reference: 2022-011 Management’s View and Planned Corrective Action: Management learned about 7 CFR, 210.14(b) when asked to create an Excess Food Service Fund Spend Down Plan this school year. We are now monitoring this and will make sure to spend down funds appropriately each year when operating the food service program. In addition, management is taking on a bigger role in overseeing the entire Food Service operation in regards to the Federal Regulations associated with the National School Lunch Program. Name of Contact Person and Completion Date: Name 1 Toni Butterfield Name 2 Anticipated Completion Date – 6/30/25

View Audit 309473 Questioned Costs: $1

Finding 401321 (2022-001)

Material Weakness 2022

Community Healthcare System Inc.

KS

Allowable Costs / Cost Principles Cash Management Material Weakness

Allowable costs related to the program are expenses or losses that were not reimbursed from other sources or that other sources were not obligated to reimburse. The System did not reduce COVID-19 related costs claimed under the PRF program for cost-based reimbursements received from the Medicare pro...

Allowable costs related to the program are expenses or losses that were not reimbursed from other sources or that other sources were not obligated to reimburse. The System did not reduce COVID-19 related costs claimed under the PRF program for cost-based reimbursements received from the Medicare program for the COVID-19 related expense. The System will ensure the costs included in all subsequent Provider Relief Fund reporting is reduced for amounts reimbursed by other sources. Status: Completed Name of Responsible Official: Monica Holthaus Chief Financial Officer Community Healthcare Systems NE Kansas 785-889-5036

View Audit 309423

Finding 401269 (2022-003)

Significant Deficiency 2022

Alternatives, Inc.

IL

Cash Management Subrecipient Monitoring Reporting

Finding 2022-003 Adherence and Application of Financial Policies and Procedures for Vouchering Federal Agency: U.S. Department of Health and Human Services Pass-Through Entity: Illinois Department of Human Services Program Name: ...

Finding 2022-003 Adherence and Application of Financial Policies and Procedures for Vouchering Federal Agency: U.S. Department of Health and Human Services Pass-Through Entity: Illinois Department of Human Services Program Name: Social Services Block Grant Assistance Listing #: 93.667 Questioned Costs: None Corrective Action: We agree with the auditor’s comments and actions stated in the recommendation. The Organization is rewriting its accounting policies and procedures to ensure adherence to the proper procedures for vouchering, which will be completed in fiscal year 2024. In August 2022, the building at 4730 N. Sheridan was sold. During the move some documents were misfiled or otherwise missed place. This made it difficult to find vouchers for the audit. The new accounting system allows Alternatives to save a copy of the vouchers and necessary support within the software. The electronic filing of the backup documentation will prevent misplacement of vouchers in the future. Contact Person: Sonya Cook, Finance Director Anticipated Completion Date: December 15, 2023

View Audit 309281

Finding 401243 (2022-003)

Material Weakness 2022

Hale County Hospital

AL

Reporting Cash Management Material Weakness

Finding 2022-003 – COVID-19 Provider Relief Fund – Assistance Listing Number 93.498 – Reporting (Material Weakness) We are implementing policies to address the audit finding 2022-003 as follows: We have implemented a policy to ensure that all future Provider Relief Fund reporting is reviewed prior ...

Finding 2022-003 – COVID-19 Provider Relief Fund – Assistance Listing Number 93.498 – Reporting (Material Weakness) We are implementing policies to address the audit finding 2022-003 as follows: We have implemented a policy to ensure that all future Provider Relief Fund reporting is reviewed prior to filing. Anticipated completion date: September 30, 2024

View Audit 309234

Finding 401242 (2022-002)

Material Weakness 2022

Hale County Hospital

AL

Allowable Costs / Cost Principles Cash Management Material Weakness

Finding 2022-002 – COVID-19 Provider Relief Fund – Assistance Listing Number 93.498 – Lack of Documentation of Review (Material Weakness) We are implementing policies to address the audit finding 2022-002 as follows: We have implemented a policy to ensure that all expenses are reviewed prior to dis...

Finding 2022-002 – COVID-19 Provider Relief Fund – Assistance Listing Number 93.498 – Lack of Documentation of Review (Material Weakness) We are implementing policies to address the audit finding 2022-002 as follows: We have implemented a policy to ensure that all expenses are reviewed prior to disbursement and that such evidence of approval is documented and retained. Anticipated completion date: September 30, 2024

View Audit 309234

Finding 401010 (2022-003)

Significant Deficiency 2022

Urban Indian Center of Salt Lake

UT

Cash Management Reporting § 200.305

Criteria: Recipients of federal awards must minimize the time elapsing between the receipt of funds from the U.S. Treasury and disbursement by the Organization set out at 2 CFR section 200.305(b). Audit Recommendation: We recommend that the Organization 1) maintains timely and accurate recording of ...

Criteria: Recipients of federal awards must minimize the time elapsing between the receipt of funds from the U.S. Treasury and disbursement by the Organization set out at 2 CFR section 200.305(b). Audit Recommendation: We recommend that the Organization 1) maintains timely and accurate recording of disbursements in its job‐costing system and 2) regularly request grant funds based on amounts expended as report in the Organization’s job‐costing system. Auditee Response: The Organization is implementing a grant tracking system in addition to its job costing system to better comply with these requirements. Together, these systems will be used to request only the amount attributable to the program for reimbursement. Corrective Action Plan: (1) Records will be kept in a newly developed spend down report for each grant/contract and reviewed with Division Directors and DFO monthly. All transactions are now being logged in QuickBooks with respective grant codes and departments, will not be processed without. (2) Monthly and quarterly invoicing according to each grant / contract agreement will be enforced by the GDCM and DFO in compliance with 2 CFR section 200.305(b). (3) The Organization has enrolled with the Treasury’s Invoice Processing Platform (IPP) to ensure all future Invoicing and payments can be easily tracked to the program/grant. Person Responsible: Matt Poss, Director of Finance Operations Timeline: All expenses and disbursements being coded to proper Grant/Type in QuickBooks Online – January 2023 Treasury Invoice Processing Platform (IPP) Onboarded – April 18th, 2023 Invoicing Timeline Created per collaboration with GDCM and DFO – May 18th, 2023 Revenue Reconciliation and clearing out of uncollectible or overbooked revenue – June 30th, 2023

View Audit 309064

Finding 400602 (2022-004)

Material Weakness 2022

Tca Health, Inc.

IL

Cash Management Material Weakness Matching / Level of Effort / Earmarking § 200.303

The COO at TCA Health will address Cash Management first, reviewing the policy and procedure to ensure it’s up to date with today’s best practices and modern standards. In doing so, TCA will review the organization chart to assess if the policy and procedure to match the personnel structure that’s c...

The COO at TCA Health will address Cash Management first, reviewing the policy and procedure to ensure it’s up to date with today’s best practices and modern standards. In doing so, TCA will review the organization chart to assess if the policy and procedure to match the personnel structure that’s currently in place. Changes will be made if necessary. Additionally, TCA has hired a third-party consulting firm that can assist with grant best practices.

View Audit 308641

Finding 400566 (2022-006)

Material Weakness 2022

Pembroke Hill School

NH

Questioned Costs School Nutrition Programs Internal Control / Segregation of Duties § 200.303

Audit Finding Reference: 2021-006 Cross Training of Staff and Review of Responsibilities Management’s View and Planned Corrective Action: Management does not agree with this deficiency. We do agree that Management is actively working on some changes as improvements are made each year to improve effi...

Audit Finding Reference: 2021-006 Cross Training of Staff and Review of Responsibilities Management’s View and Planned Corrective Action: Management does not agree with this deficiency. We do agree that Management is actively working on some changes as improvements are made each year to improve efficiency. Each position in the Business Office other than HR has been crossed trained with one-to-two other team members. Cross training throughout the business office was implemented in 2016 and has continued to exist. Each position has the ability to have someone step in case of emergency, elongated vacations and when/if someone resigns or is terminated. The positions are not covered in entirety, but the important items that must be dealt with can be and are accomplished. Examples are as such: Accounts Payable is covered by our Special Ed Bookkeeper, and other staff have the ability to review manifest once generated. Payroll has been covered by the Assistant Business Administrator when vacations or vacancies have existed, Grants can be covered by the Business Administrator when vacations or vacancies have existed. The Assistant Business Administrator is covered by the Business Administrator during vacations and vacancies. Each position continues to do their own assigned job duties and takes on the other tasks as necessary. The work may not get completed in the same timely fashion as if the actual staff member holding the position was there because they are also completing their own tasks, but the work does get accomplished. When there are multiple turnovers and/illness occurring at the sometime it makes it challenging even when cross training exists. Every year the Business Administrator reviews workloads and reassesses if changes should occur to help create efficiencies and create equivalent workload between all staff members. While some positions have more deadlines than others it can appear that their plates are larger than others, but frequently tasks are divided out throughout the team to help alleviate this. These discussions are brought forth to COLT, the Senior Leadership team at the SAU, and restructuring is finalized at that time. Name of Contact Person and Completion Date: Name 1 Amber Wheeler Name 2 Danielle Rossetti Anticipated Completion Date – Already occurs

View Audit 308621 Questioned Costs: $1

Finding 400453 (2022-007)

Significant Deficiency 2022

Reach Community Development, Inc.

OR

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

Finding No. 2022-007 - Community Development Block Grants/Entitlement Grants Federal Assistance Listing Number #14.218 Statement of Condition: Owner paid one vendor invoice, of eight tested, that was not listed on the CDBG Address List as reported to Portland Housing Bureau (“PHB”) and charged ...

Finding No. 2022-007 - Community Development Block Grants/Entitlement Grants Federal Assistance Listing Number #14.218 Statement of Condition: Owner paid one vendor invoice, of eight tested, that was not listed on the CDBG Address List as reported to Portland Housing Bureau (“PHB”) and charged through to and was reimbursed by PHB under their CDBG Grant. Corrective Action: Since the time of this we have made some changes to have the appropriate funding code on each client’s folder/information so that it is easy to see where to charge when making a purchase and the CBP manager is reaching out to PHB on resolution to this instance.

View Audit 308469 Questioned Costs: $1

Finding 400391 (2022-003)

Significant Deficiency 2022

Appalachian Headwaters INC

WV

Procurement, Suspension & Debarment Cash Management Reporting

Corrective action has already been taken. Appalachian Headwaters requests and receives detailed invoices for all employee reimbursements which include amounts, descriptions of items purchased, and delivery locations, when possible. Appalachian Headwaters pays vendors directly whenever possible.

View Audit 308440

Finding 400379 (2022-003)

Material Weakness 2022

Bradley Cleveland Community Services Agency

TN

Cash Management

Management disagrees with the finding. Their position is that funds are disbursed when checks are cut, regardless of when they are mailed. (As of 2023, this is no longer an issue due to changes to the program and compliance supplement)

View Audit 308423

Finding 400261 (2022-003)

Material Weakness 2022

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 308375

Finding 400153 (2022-008)

Significant Deficiency 2022

Puerto Rico Ports Authority

PR

Cash Management

None. This matter, as stated above, was properly addressed.

View Audit 308290

Finding 399999 (2022-009)

Material Weakness 2022

Lincoln-King Adams-Young Academy

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

The Academy signed a Promissory Note with Washington Parks Academy on February 8, 2024, to return all the ESSER dollars transferred to the Academy plus interest back to Washington Parks Academy over the next 60 months.

View Audit 308166

Finding 399996 (2022-006)

Material Weakness 2022

Lincoln-King Adams-Young Academy

MI

Cash Management

The Academy will monitor the budget to actual numbers on a monthly basis and review with the Board. We will also put in place tighter budgetary controls. The building leaders' and all other administrators' budgets will be monitored monthly, and budget overages will be resolved immediately. The Acade...

The Academy will monitor the budget to actual numbers on a monthly basis and review with the Board. We will also put in place tighter budgetary controls. The building leaders' and all other administrators' budgets will be monitored monthly, and budget overages will be resolved immediately. The Academy will follow the currently approved deficit reduction plan and submit revisions if needed.

View Audit 308166

Finding 399994 (2022-004)

Material Weakness 2022

Lincoln-King Adams-Young Academy

MI

Cash Management

Management will ensure experienced staff is recruited, retained, and trained to support grant revenues, which are accurately drawn and reported to an appropriate accountant for recording.

View Audit 308166

Corrective Action Plans

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