Corrective Action Plans

Finding 314 (2022-003)

Significant Deficiency 2022

AK

Internal Control / Segregation of Duties Subrecipient Monitoring Cash Management

Federal Award Finding: 2022-003 Significant Deficiency in Compliance and Internal Controls over Compliance - Reporting -Monitoring of Grant Budget and Expenditures Name and Contact Person: Heather Grato, Controller Corrective Action: The Controller with the help with of a hired consultant will gener...

Federal Award Finding: 2022-003 Significant Deficiency in Compliance and Internal Controls over Compliance - Reporting -Monitoring of Grant Budget and Expenditures Name and Contact Person: Heather Grato, Controller Corrective Action: The Controller with the help with of a hired consultant will generate a new policies and procedure that will help ensure the accounting is reviewed monthly and quarterly, and any errors are corrected before submission of grant reports. Once grant activity is adequately reviewed the Controller will create budget vs. actual financial reports to present to management and program managers or the Board. The accounting staff will file quarterly grant reports and drawdown funding before the deadline after transactions are prepared and reviewed. Proposed Completion Date: 6/30/2024

View Audit 588

Finding 304 (2022-002)

Significant Deficiency 2022

Caminar Latino Inc.

GA

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

Condition Upon review of the indirect cost calculations throughout the fiscal year, it was noted that there was no documentation of review and approval of three of the seven calculations tested. The auditors were able to review the drawdown reconciliations performed by the Caminar Latino and determi...

Condition Upon review of the indirect cost calculations throughout the fiscal year, it was noted that there was no documentation of review and approval of three of the seven calculations tested. The auditors were able to review the drawdown reconciliations performed by the Caminar Latino and determine the reports were materially accurate; however, no evidence of a formal supervisory review and approval of the reconciliation was maintained on-file in these three instances. Correction action As of Q4 2022, the Atlanta-based Co-CEO and the Chief of Programs and Administration have instituted a process of review and approval of drawdown reconciliations prior to drawdown to review for accuracy of calculations and to ensure that previous drawdown amounts are accurately recorded. A Finance Manager was hired in April 2023, and the responsibility of ongoing drawdown reconciliation and calculation of invoice amounts has shifted to the Finance Manager position. Monthly invoices and drawdowns are being reviewed and approved by the Co-CEO and Chief of Programs and Administration prior to drawdown. Responsible Person Co-CEO and Chief of Programs and Administration Anticipated completion date Completed - This process is currently in place.

View Audit 574

Finding 302 (2022-003)

Material Weakness 2022

Central Piedmont Community Action, Inc.

NC

Cash Management Material Weakness Internal Control / Segregation of Duties

Central Piedmont Community Action, Inc. (CPCA) will continue to submit requests for reimbursements before the 10th day of the month to help ensure timely payments from funding agencies. CPCA management staff will have a negative impact. CPCA’s Board of Directors, in conjunction with the Executive Di...

Central Piedmont Community Action, Inc. (CPCA) will continue to submit requests for reimbursements before the 10th day of the month to help ensure timely payments from funding agencies. CPCA management staff will have a negative impact. CPCA’s Board of Directors, in conjunction with the Executive Director, will continue to stress the importance of timely payments to funding agencies and how those untimely payments have a negative impact. CPCA’s Board of Directors, in conjunction with the Executive Director, will continue to raise funding and apply for unrestricted funding to maintain a steady cash flow and assist with administrative costs.

View Audit 566

Finding 204 (2022-002)

Material Weakness 2022

County of Mifflin

PA

Cash Management Matching / Level of Effort / Earmarking

Finding 2022-002: Cash Management / Matching / Interest Earned Contact Person: Michael R. Baker, Director of Fiscal Affairs Recommendation: The County should establish a separate fund to account for the activity of the Children and Youth program. Response: The County agrees with the finding and...

Finding 2022-002: Cash Management / Matching / Interest Earned Contact Person: Michael R. Baker, Director of Fiscal Affairs Recommendation: The County should establish a separate fund to account for the activity of the Children and Youth program. Response: The County agrees with the finding and has created a new fund – Fund 07 – in the County’s accounting software and has begun creating corresponding revenue and expense accounts to match the existing structure within the new fund. The County also opened a separate checking account at The Juniata Valley Bank for the Children and Youth Fund for all revenue and expenses beginning January 1, 2024. The County continues to engage an external third-party contractor provider familiar with Children and Youth Agency financial matters to assist in the transition, as well as with recent turnover in the financial positions within the Children and Youth Department. The County also made the affirmative decision to capitalize that fund with the prior year’s County-match at the start of the calendar year and continue to fund, as needed, throughout the year to insure the necessary County match is attained. The Children and Youth Agency will continue to insure compatibility and proper recording in MUNIS, the County accounting system, of all financial transactions to match with the internal accounting system maintained by the Children and Youth Agency. Action Planned: Post-audit submission, the County Director of Fiscal Affairs will meet and discuss with the engaged external service provider and the Children and Youth Finance Director and overall Child and Youth Agency Director to formulate the proper procedure for establishment of a separate fund balance as of January 1, 2024, and monitor proper posting of financial transactions in the appropriate fund to match all transactions posted in the internal accounting system maintained by the Children and Youth Agency. Date for Completion: January 1, 2024

View Audit 384

Finding 164 (2022-102)

Material Weakness 2022

Santa Cruz County

AZ

Questioned Costs Cash Management Eligibility § 200.303

The County is in the final stages of implementing grant policies, which will cover reimbursement procedures for all departmental grants. The County will work with the pass-through grantor to repay the amounts the County received in excess. The County will work with the Health Department director a...

The County is in the final stages of implementing grant policies, which will cover reimbursement procedures for all departmental grants. The County will work with the pass-through grantor to repay the amounts the County received in excess. The County will work with the Health Department director and staff to review grant policies and procedures.

View Audit 240 Questioned Costs: $1

Finding 1224506 (2021-013)

Material Weakness 2021

Quality Community Health Care, Inc.

PA

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

Criteria Recipients of federal grants are required by federal regulations (Uniform Guidance, 2 CPR Part 200) to maintain documentation demonstrating that cash receipts correspond to drawdowns based on actual, allowable costs incurred. Drawdowns for Federal awards should be properly supported with re...

Criteria Recipients of federal grants are required by federal regulations (Uniform Guidance, 2 CPR Part 200) to maintain documentation demonstrating that cash receipts correspond to drawdowns based on actual, allowable costs incurred. Drawdowns for Federal awards should be properly supported with relevant forms and reports to substantiate the costs incurred and evidence management review and approval. Condition and Context For the year ended July 31, 2021, QCHC recorded cash receipts related to their federal awards totaling $3,535,567. However, QCHC was unable to provide evidence that these amounts represent drawdowns from the federal grants. The only available documentation substantiates the receipt of cash, without linking it to eligible grant expenditures. Recommendation We recommend that management establish procedures to ensure that documents supporting all drawdown requests are properly retained. Such requests should also be reviewed and approved prior to the request being made, with this approval documented and retained. Views of Responsible Officials and Planned Corrective Actions QCHC acknowledges the finding and has implemented the following corrective actions: l. QCHC has implemented the Draw Down Policy & Procedure (Policy #308 DRAWDOWN) which establishes that drawdown of Federal funds must be made in accordance with the immediate needs of the award terms, to minimize time between request and expenditures, and funds will not be drawn down 5 business days prior to disbursement. 2. QCHC has established procedures requiring the preparation of a justification table of all staff members allocated to the federal grant fund, division of annual salaries by 26 pay periods per year, and preparation of SF-270 (Request for Advance or Reimbursement). 3. QCHC has established that the Chief Financial Officer is responsible for monitoring program cash flow needs and submitting drawdown requests in a timely manner to assure adequate coverage of program needs. 4. QCHC has implemented a review and approval process requiring the Chief Financial Officer and Chief Executive Officer to review, approve and execute the applicable drawdown. 5. QCHC has established that HRSA expenses are tracked in the accounting system by revenue source fund codes by the HRSA budget name, with accounts receivable related to grants recorded when a copy of the HRSA request is received.

View Audit 407750

Finding 1217594 (2021-001)

Material Weakness 2021

The Arizona Partnership for Immunization

AZ

Cash Management Eligibility Matching / Level of Effort / Earmarking § 200.303

Recommendation: The Arizona Partnership for Immunization should formally document its eligibility determination and insurance verification processes to ensure consistent application and compliance with award requirements. In addition, the organization should implement documentation standards to evid...

Recommendation: The Arizona Partnership for Immunization should formally document its eligibility determination and insurance verification processes to ensure consistent application and compliance with award requirements. In addition, the organization should implement documentation standards to evidence eligibility determinations, particularly during periods of increased service volume, to support accurate and allowable program charges. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Corrective Action taken in response to finding: Effective 4/2022, management has taken deliberate steps to strengthen documentation and standardize eligibility determination and insurance verification processes. These efforts include the development and formalization of written policies and procedures to ensure consistent application, improved documentation standards, and sustained compliance with HRSA award requirements. Name(s) of the contact person(s) responsible for corrective action: James Washington, Executive Director and Bernie Soderberg, Program Manager. Planned completion date for corrective action plan: December 2023

View Audit 403738

Finding 1217317 (2021-007)

Material Weakness 2021

Country Doctor Community Health Centers

WA

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.403

2021-007 Cash Management Corrective action planned: Drawdown Support and Timing: Processes have been implemented to ensure all drawdowns are supported by adequately documented, individually identifiable expenditures and are made only after costs have been incurred. Documentation Standards: Standard ...

2021-007 Cash Management Corrective action planned: Drawdown Support and Timing: Processes have been implemented to ensure all drawdowns are supported by adequately documented, individually identifiable expenditures and are made only after costs have been incurred. Documentation Standards: Standard requirements are now in place to maintain complete supporting documentation for each draw, including linkage to underlying expenses. Review and Approval Controls: Formal review procedures have been established, requiring documented evidence of supervisory review and approval prior to submission of draw requests. Anticipated completion date: Completed in 2022 Contact person responsible for corrective action: Angela Treptow, Interim Finance Director

View Audit 403489

Finding 1179949 (2021-004)

Material Weakness 2021

ADAMS COUNTY PUBLIC HOSPITAL DISTRICT #3 D/B/A OTHELLO COMMUNITY HOSPITAL

WA

Allowable Costs / Cost Principles Cash Management Significant Deficiency

The District hired a new Chief Financial Officer in 2023 and was able to catch the District up on three years of financials statements and all missing audits. The new CFO made the following changes to ensure compliance: 1. Update internal controls and monitoring. The new CFO created a Federal Fundin...

The District hired a new Chief Financial Officer in 2023 and was able to catch the District up on three years of financials statements and all missing audits. The new CFO made the following changes to ensure compliance: 1. Update internal controls and monitoring. The new CFO created a Federal Funding Monitoring and Reporting Policy that specifies that responsibilities over compliance, expenditures, and reporting. 2. Implement Process Improvements. The new CFO and Accounts Payable were able to identify grant fund expenditures and work closely to make sure all future grant expenditures are identified and tracked. 3. Communicate with External Audit Team. The new CFO communicates regularly with the external audit team to ensure they are aware of the grant funds received and the type of audit that is required and coordinate audits with plenty of time to complete the audit before deadlines.

View Audit 392296

Finding 1177797 (2021-013)

Material Weakness 2021

St. Croix Chippewa Housing Authority

CA

Cash Management Material Weakness

2021-013 Support for Payroll Material Weakness Recommendation: Auditor’s recommend the governing board require proper documentation on all types of expenditures and that only members of the board have the authority to sign checks. Action Taken: The Housing Authority agrees with this finding and will...

2021-013 Support for Payroll Material Weakness Recommendation: Auditor’s recommend the governing board require proper documentation on all types of expenditures and that only members of the board have the authority to sign checks. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 391158

Finding 1177795 (2021-011)

Material Weakness 2021

St. Croix Chippewa Housing Authority

CA

Matching / Level of Effort / Earmarking Subrecipient Monitoring Cash Management § 200.305

2021-011 Timely Grant Draws Material Weakness Recommendation: The Housing Authority should adopt written grant draw policies into its financial policies and procedures manual. Financials should be reviewed monthly, and drawdowns made as needed. Action Taken: The Housing Authority agrees with this fi...

2021-011 Timely Grant Draws Material Weakness Recommendation: The Housing Authority should adopt written grant draw policies into its financial policies and procedures manual. Financials should be reviewed monthly, and drawdowns made as needed. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 391158

Finding 1177789 (2021-005)

Material Weakness 2021

St. Croix Chippewa Housing Authority

CA

Cash Management Material Weakness

2021-005 Timely Bank Reconciliations Material Weakness Recommendation: Implement currently adopted policies over bank reconciliations. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 391158

Finding 1177788 (2021-004)

Material Weakness 2021

St. Croix Chippewa Housing Authority

CA

Cash Management Material Weakness

2021-004 Cash Management Material Weakness Recommendation: Auditors recommend filing documentation for grant draws along with payment vouchers throughout the year. Action Taken: Documentation for grant draws and expenditures to support the request for funding is vouchered along with wire transaction...

2021-004 Cash Management Material Weakness Recommendation: Auditors recommend filing documentation for grant draws along with payment vouchers throughout the year. Action Taken: Documentation for grant draws and expenditures to support the request for funding is vouchered along with wire transaction documentation that requires the signature of 3 Tribal Council for processing.

View Audit 391158

Finding 1176708 (2021-005)

Material Weakness 2021

Beartooth Billings Clinic

MT

Allowable Costs / Cost Principles Cash Management Reporting

Following the Period 1 submission, the Organization identified that the patient revenue figures used in the lost revenue calculation did not reconcile to the audited financial statements. The lost revenue model was subsequently re performed using audited patient revenue data, and the corrected calcu...

Following the Period 1 submission, the Organization identified that the patient revenue figures used in the lost revenue calculation did not reconcile to the audited financial statements. The lost revenue model was subsequently re performed using audited patient revenue data, and the corrected calculation was incorporated into the Period 4 PRF submission. To prevent recurrence, the Organization has strengthened its internal review protocols for reporting, including mandatory reconciliation of all revenue inputs to audited financial statements and secondary review by the Regional Controller prior to submission. These enhanced controls ensure that future lost revenue calculations are accurate, supportable, and compliant with HRSA reporting requirements.

View Audit 390602

Finding 1176707 (2021-004)

Material Weakness 2021

Beartooth Billings Clinic

MT

Allowable Costs / Cost Principles Cash Management Period of Performance

Capital expenditures charged to the PRF program were allowable; however, at June 30, 2021, HHS had not yet issued clear technical guidance indicating that capital costs must be fully completed or received within the Period of Availability, therefore causing the expenditures to be out of period. Defi...

Capital expenditures charged to the PRF program were allowable; however, at June 30, 2021, HHS had not yet issued clear technical guidance indicating that capital costs must be fully completed or received within the Period of Availability, therefore causing the expenditures to be out of period. Definitive guidance clarifying this requirement was not released until August 2021, after the close of the reporting period. As a result, the Organization applied the best available interpretation at the time of close. To prevent similar issues, the Organization will incorporate ongoing monitoring of updated directives, strengthen pre submission technical reviews, and consult with external advisors to validate compliance with period of availability rules prior to future filings.

View Audit 390602

Finding 1176706 (2021-003)

Material Weakness 2021

Beartooth Billings Clinic

MT

Allowable Costs / Cost Principles Cash Management Reporting

The keying error in the original Period 1 submission was corrected in the Period 4 PRF report, and additional review controls have been implemented to prevent manual data-entry inaccuracies. G&A expenses, initially allocated based on limited guidance, are now supported by a standardized methodology ...

The keying error in the original Period 1 submission was corrected in the Period 4 PRF report, and additional review controls have been implemented to prevent manual data-entry inaccuracies. G&A expenses, initially allocated based on limited guidance, are now supported by a standardized methodology with full underlying documentation in line with PRF reporting requirements.

View Audit 390602

Finding 1172422 (2021-003)

Material Weakness 2021

Housing Authority of the City of Tulsa

OK

HUD Housing Programs Cash Management Significant Deficiency

Section 8 Project Based Cluster – ALN #14.195 & 14.856 Recommendation: We recommend that management review their procedures for ensuring that contract rent changes are implemented and evidenced timely and accurately, and establish a method that ensures compliance. Explanation of disagreement with au...

Section 8 Project Based Cluster – ALN #14.195 & 14.856 Recommendation: We recommend that management review their procedures for ensuring that contract rent changes are implemented and evidenced timely and accurately, and establish a method that ensures compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority reviewed and updated procedures for implementing contract rent increases and configured automated financial system flags to ensure that rent adjustments are applied on their effective dates. The Management Analyst now verifies contract rent changes during monthly internal reviews, and staff were retrained on rent adjustment documentation and approval workflows. Name(s) of the contact person(s) responsible for corrective action: Jason Epperson, Assistant Vice President Planned completion date for corrective action plan: December 31, 2025

View Audit 385538

Finding 1168772 (2021-005)

Material Weakness 2021

VALLEY CITY PUBLIC SCHOOL DISTRICT

ND

Cash Management School Nutrition Programs Significant Deficiency

Contact Person Jackie Cordie, Business Manager Corrective Action Plan The District plans to implement the auditor's recommendation. Planned Completion Date for CAP Fiscal year beginning July 1, 2024

View Audit 380881

Finding 1165035 (2021-007)

Material Weakness 2021

Pima Council on Aging

AZ

Allowable Costs / Cost Principles Cash Management Significant Deficiency

Finding Number 2021-007: No Review of Reimbursement Requests Before Submission (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not review reimbursement requests before submission PCOA personnel responsible for enacting corrective action plan: Ja...

Finding Number 2021-007: No Review of Reimbursement Requests Before Submission (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not review reimbursement requests before submission PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org The corrective action plan:  Reimbursement requests now undergo formal internal review prior to submission.  A checklist-based review process was developed with assistance from the Director of Contracts, and compliance is enforced by the Finance Director.  Additional accounting staff are being hired to support the month-end closing process and ensure reimbursement requests are reconciled and supported appropriately. Completion Date: July 31, 2025

View Audit 375125

Finding 1165031 (2021-003)

Material Weakness 2021

Pima Council on Aging

AZ

Allowable Costs / Cost Principles Cash Management Reporting

Finding Number 2021-003: Lack of Review of Meal Sign-In Sheets (Allowable Costs/Cost Principles) , July 1, 2020 through June 30,2021. Statement of Condition: The Meal Sign-in Sheets were not regularly and consistently attached to proper documentation. PCOA personnel responsible for enacting correcti...

Finding Number 2021-003: Lack of Review of Meal Sign-In Sheets (Allowable Costs/Cost Principles) , July 1, 2020 through June 30,2021. Statement of Condition: The Meal Sign-in Sheets were not regularly and consistently attached to proper documentation. PCOA personnel responsible for enacting corrective action plan: Francine McGetrick, Contracts Director, Fmcgetrick@pcoa.org The corrective action plan: 1. PCOA has implemented procedures requiring internal review of all client sign-in sheets related to meals billed for reimbursement. 2. While the required sign-in documentation was completed and retained, it was stored in the contracts area and not submitted with the DES files. A new process has been established to ensure that sign-in sheets are filed along with the corresponding summary information at the time of submission. 3. PCOA has designed the updated process and trained staff to ensure proper documentation is verified prior to billing. 4. Ongoing compliance is now overseen by the Director of Contracts, and operational staff have been re-trained to ensure consistent execution. Completion Date: June 30th, 2025

View Audit 375125

Finding 1162226 (2021-003)

Material Weakness 2021

Stonewall County Hospital District

TX

Questioned Costs Allowable Costs / Cost Principles Cash Management

Corrective Action Plan for Finding 2021-003 We are in receipt of the finding required to be reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting and Activities Allowed or Unallowed and Allowable Costs/Cost Principles Reporting. Management agrees with the ...

Corrective Action Plan for Finding 2021-003 We are in receipt of the finding required to be reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting and Activities Allowed or Unallowed and Allowable Costs/Cost Principles Reporting. Management agrees with the finding. Policies and procedures over federal grant reporting will be modified to ensure reports are prepared using complete and accurate information. We will increase compensating controls for introducing additional oversight and review for future federal funding reporting. Lewis Robbins, CFO, will be responsible to ensure this is accomplished. The District had enough lost revenues related to Period 1, as reported in the Period 4 reporting submission, that the error determined in Finding 2021-003 will not result in a conflict with funding received. The Corrective Action Plan will be implemented by September 30, 2025.

View Audit 372037 Questioned Costs: $1

Finding 1161609 (2021-003)

Material Weakness 2021

Defensewerx

FL

Cash Management

We agree with the recommendations offered and will establish updated policies and procedures to address the finding while considering appropriate measures for operating grants on a cost reimbursement basis. We have addressed this finding to our grantors. One grantor has requested the continuation of...

We agree with the recommendations offered and will establish updated policies and procedures to address the finding while considering appropriate measures for operating grants on a cost reimbursement basis. We have addressed this finding to our grantors. One grantor has requested the continuation of cash advances in the manner which we have been operating. We have worked with the other grantors and have come up with an incremental funding plan based on needs that are appropriate in maintaining the operational requirements set forth by the awards. Periodically we updated the grantor on the funds that have been used or those funds that are excess.

View Audit 371463

Finding 1161064 (2021-004)

Material Weakness 2021

Coal County Healthcare Authority

OK

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

Condition - Expenditures reported to HRSA were not in accordance with Pub. L. No. 116-136, 134 Stat. 563 Plan of Corrective Action Much research was performed by the Authority's leadership to identify guidance from HRSA including reviewing FAQs, Fact Sheets, consulting attorneys, auditors, consultan...

Condition - Expenditures reported to HRSA were not in accordance with Pub. L. No. 116-136, 134 Stat. 563 Plan of Corrective Action Much research was performed by the Authority's leadership to identify guidance from HRSA including reviewing FAQs, Fact Sheets, consulting attorneys, auditors, consultants and other parties. The complexity of the reporting requirements, including changing FAQ's and our inability to gain a definite approval of the use of our funds, resulted in the Authority filing the its submission based on the best available information at the time. The Authority's position is that the Provider Relief Funds were appropriately expensed using additional expenses and lost revenues not initially submitted to the portal. The Authority will continue to monitor the guidance for use of funds provided by HRSA and will strive to appropriately utilize all funds in the future. The Authority will review the most recently distributed Provider Relief Fund FAQ's which provide details on requirements related to the program Contact person: Chris Martin, CEO cmartin@ccghospital.com (580)927-2327 Expected implementation:2024 - 2025

View Audit 371035 Questioned Costs: $1

Finding 1159984 (2021-001)

Material Weakness 2021

Native Village of Tyonek

AK

Cash Management § 200.302

Management will ensure that all nongrant expenditures are kept to a minimum until the cash balance of NVT is in excess of the unearned grant revenue and restricted fund balance. A large part of this problem in the current year was the amount of money paid to the Village’s accountants/consultant in p...

Management will ensure that all nongrant expenditures are kept to a minimum until the cash balance of NVT is in excess of the unearned grant revenue and restricted fund balance. A large part of this problem in the current year was the amount of money paid to the Village’s accountants/consultant in prior years. This has been resolved and the new accountant’s fees are much more in line with reasonable amounts.

View Audit 370455

Finding 576064 (2021-002)

Material Weakness 2021

Salem Housing Development Corporation

NE

Questioned Costs Cash Management HUD Housing Programs

Management agrees with the recommendation and will fund the residual receipts account during 2025.

View Audit 365960 Questioned Costs: $1

Corrective Action Plans

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