Corrective Action Plans

Finding 481192 (2023-004)

Significant Deficiency 2023

Regional Health Services of Howard County

IA

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

American Rescue Plan and Provider Relief Fund – Assistance Listing No. 93.498 Recommendation: We recommend that management implement more formal control process surrounding the use of federal awards where there is segregation between individuals identifying or proposing expenditures/uses of funds a...

American Rescue Plan and Provider Relief Fund – Assistance Listing No. 93.498 Recommendation: We recommend that management implement more formal control process surrounding the use of federal awards where there is segregation between individuals identifying or proposing expenditures/uses of funds and an individual reviewing and approving that expenditure/use. We also recommend for any formal reporting required under federal awards that there be a formal review process where an individual is reviewing and approving the report who did not prepare the report. Documentation of review and approval should be retained in both cases. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Regional Health Services of Howard County implemented a new policy for the tracking, review, and approval of grant fund use and reporting in January 2023. However, due to the timing of expenditures of American Rescue Plan and Provider Relief Fund monies, this process was not put in place until after the grant funds were utilized and reported on. Name(s) of the contact person(s) responsible for corrective action: Brandon Brevig, CFO Planned completion date for corrective action plan: January 2023

View Audit 317319

Finding 481189 (2023-001)

Significant Deficiency 2023

Nebraska Children & Families Foundation

NE

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

To ensure that reports are submitted on time to the reporting agency from Nebraska Children and Families Foundation (NCFF), we will implement the following corrective action plan: 1) All (sub)awards will be reviewed by the Program Lead responsible for the deliverables included in the (sub)award agre...

To ensure that reports are submitted on time to the reporting agency from Nebraska Children and Families Foundation (NCFF), we will implement the following corrective action plan: 1) All (sub)awards will be reviewed by the Program Lead responsible for the deliverables included in the (sub)award agreement. All requirements, including but not limited to reporting requirements, will also be sent to the Program Lead's supervisor for approval. 2) If necessary, reporting requirements are shared with the contracts and legal department. 3) The Program Lead will complete the required reports before they are due to the awarding agency and sent to their supervisor. 4) The supervisor will review and approve the reports. The supervisor will return with approval or indicate the revision needed. 5) Upon final approval, the Program Lead, or appropriate staff, will submit the report to the awarding agency before the deadline and copy the transmission to their supervisor. 6) The Program Lead will archive the report on NCFF's secure data storage site.

View Audit 317317

Finding 481171 (2023-001)

Significant Deficiency 2023

United Way of Middle Tennessee, INC

TN

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

U.S. Department of Health and Human Services; Centers for Disease Control and Prevention: ALN #93.939 HIV Prevention Activities Non-Governmental Organization Based Management’s Response: We concur. View of Responsible Officials and Corrective Action: United Way used the Notice of Award as guidanc...

U.S. Department of Health and Human Services; Centers for Disease Control and Prevention: ALN #93.939 HIV Prevention Activities Non-Governmental Organization Based Management’s Response: We concur. View of Responsible Officials and Corrective Action: United Way used the Notice of Award as guidance for reporting requirements under this grant. Additional compliance requirements were not indicated upon inquiry with the granting agency. As this reporting requirement was listed in a separate document under the Notice of Funding Opportunity (NOFO) it was an oversight. The Director of HIV/AIDS Initiative and the Director of Finance will review both the NOFO and Notice of Award for subsequent grant awards received directly from a federal agency to ensure compliance with grant requirements. Copies of reporting submissions will be maintained with the grant activity to ensure proper compliance documentation is kept. We are currently in the process of gathering information from subrecipients to submit the required reporting under the FFATA. Name(s) of the Contact Person(s) Responsible for Corrective Action: Niki Easley and Matt Lim Anticipated Completion Date: September 30, 2024

View Audit 317269

Finding 481111 (2023-002)

Significant Deficiency 2023

Adams County Housing Authority

WI

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding 2023-002 - Identity of lnterest Forms Not Current (Loan Programs #10.415 and #10.447) Condition: Identity of Interest forms were not current during the year under audit. ...

Finding 2023-002 - Identity of lnterest Forms Not Current (Loan Programs #10.415 and #10.447) Condition: Identity of Interest forms were not current during the year under audit. Effect: Adam's County Housing Authority's system of internal control may not prevent, detect, or correct noncompliance with applicable programs. Cause: The Identity of Interest forms were not updated and approved by Rural Development when expired. Criteria: Adams County Housing Authority must monitor compliance requirements and update forms as needed. Recommendation: Adams County Housing Authority track compliance requirements to ensure Identity of Interest forms are updated timely. Response: All Identity oflnterest forms have been updated in 2024. Contact Person: Jayne Anderson, Controller Anticipated Completion Date: 9/30/2024

View Audit 317249

Finding 481079 (2023-005)

Material Weakness 2023

City of Keene, Texas

TX

Reporting Internal Control / Segregation of Duties § 200.328

Corrective Action Plan for Finding 2023-005 City Management is in receipt of the Finding Required to be Reported by the Uniform Guidance, specifically finding 2023-005 regarding the COVID-19 – Coronavirus State and Local Fiscal Recovery Funds with respect to the Reporting Compliance Requirement. Co...

Corrective Action Plan for Finding 2023-005 City Management is in receipt of the Finding Required to be Reported by the Uniform Guidance, specifically finding 2023-005 regarding the COVID-19 – Coronavirus State and Local Fiscal Recovery Funds with respect to the Reporting Compliance Requirement. Corrective Actions Already Taken Place: City Management acknowledges this finding. City Management has thoroughly reviewed the existing procedures to determine where improvements could be made. As part of this process, City Management identified improvements to policies and procedures to ensure reports are prepared, reviewed and submitted prior to the deadline. View of Responsible Officials and Timeline for Implementation: Responsible Person’s: Charles Williams, Finance Director, and Brent Batla, City Manager. The planned corrective action will be in effect by May 30, 2024, through completion of the COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Program.

View Audit 317236

Finding 481070 (2023-003)

Significant Deficiency 2023

Cache County Corporation

UT

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.328

County staff have improved the internal control processes to include a secondary review of all submittals related to federal grants. The County Finance Director or delegate will review these submittals quarterly in advance of remitting them.

View Audit 317204

Finding 481068 (2023-005)

Material Weakness 2023

Western Iowa Housing Corporation

IA

Questioned Costs HUD Housing Programs Material Weakness

2023-005 Section 811 Capital Advance – Assistance Lising Number: 14.181 Recommendation: We recommend the Project set a separate account for residual receipts and deposit surplus cash into this account within 60 days of year-end. Explanation of disagreement with audit finding: There is no disagreemen...

2023-005 Section 811 Capital Advance – Assistance Lising Number: 14.181 Recommendation: We recommend the Project set a separate account for residual receipts and deposit surplus cash into this account within 60 days of year-end. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Residual receipts account was established and surplus cash will be deposited. Name(s) of the contact person(s) responsible for corrective action: Erik Marsh, CFO Planned completion date for corrective action plan: December 31, 2024.

View Audit 317201 Questioned Costs: $1

Finding 481067 (2023-004)

Material Weakness 2023

Western Iowa Housing Corporation

IA

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

2023-004 Section 811 Capital Advance – Assistance Lising Number: 14.181 Recommendation: We recommend the Project deposit the proper amount monthly and maintain the proper amount in the account. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action ta...

2023-004 Section 811 Capital Advance – Assistance Lising Number: 14.181 Recommendation: We recommend the Project deposit the proper amount monthly and maintain the proper amount in the account. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Regular monthly deposits into the repair and replacement escrow account. Name(s) of the contact person(s) responsible for corrective action: Erik Marsh, CFO Planned completion date for corrective action plan: December 31, 2024

View Audit 317201 Questioned Costs: $1

Finding 481061 (2023-003)

Significant Deficiency 2023

Beloved Community Charter School

NJ

Internal Control / Segregation of Duties

Accounting Dept will review all transactions for accuracy by a date set by the SBA to ensure the School Treasurer can reconcile all school funds before issuance of the Board Secretary Report

View Audit 317186

Finding 481045 (2023-001)

Material Weakness 2023

Winlock School District No. 232

WA

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

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Winlock School District No. 232 September 1, 2022 through August 31, 2023 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regu...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Winlock School District No. 232 September 1, 2022 through August 31, 2023 This schedule presents the corrective action planned by the District for findings reported 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: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Gloria Dupree, Business Manager, N.E. 1st Street, Winlock, WA 98596, (360) 785-3582 Corrective action the auditee plans to take in response to the finding: Corrective actions for ensuring compliance with federal wage requirements. 1) Maintain detailed documentation of all wage rate determinations, calculations, and payments made to employees by verifying contractors certified weekly payrolls. 2) Print and maintain all certified payrolls from the L&I website, contractors, sub-contractors and maintain copies onsite with awarded contract. 3) Provide training to employees involved in contracting on federal wage rate requirements to ensure they are aware of their responsibilities. 4) Monitor changes in federal wage rate requirements and update internal controls accordingly to stay compliant. Anticipated date to complete the corrective action: 9/01/2024

View Audit 317184

Finding 481043 (2023-003)

Significant Deficiency 2023

Capitan Municipal Schools

NM

Subrecipient Monitoring Reporting Significant Deficiency

Auditor’s Recommendations – We recommend that the District strengthen the controls in place to provide assurance that proper review and approvals occur and retain backup documentation for support. iews of Responsible Officials and Planned Corrective Action – The District will make sure to document t...

Auditor’s Recommendations – We recommend that the District strengthen the controls in place to provide assurance that proper review and approvals occur and retain backup documentation for support. iews of Responsible Officials and Planned Corrective Action – The District will make sure to document the review and approval process to include sign off and date by the preparer and reviewer. Responsible Officials – Jamie Shepperd, Chief Financial Officer; Becky Huey, Federal Programs Director; Vance Lee, Superintendent Timeline and Estimated Completion Date – July 31, 2024

View Audit 317182

Finding 481042 (2023-003)

Material Weakness 2023

Mower County

MN

Eligibility Material Weakness Internal Control / Segregation of Duties

Recommendation: We recommend that a supervisor or team lead perform regular internal reviews on MAXIS and METS casefiles to determine that proper policies and procedures are being followed in determining eligibility. Explanation of disagreement with audit finding: There is no disagreement with the ...

Recommendation: We recommend that a supervisor or team lead perform regular internal reviews on MAXIS and METS casefiles to determine that proper policies and procedures are being followed in determining eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement policies to complete casefile reviews over all Medical Assistance casefiles. Name of the contact person responsible for corrective action: Loni Swenson, Finance Manager Planned completion date for corrective action plan: December 31, 2024

View Audit 317177

Finding 481038 (2023-002)

Material Weakness 2023

Ripley County

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.1 § 200.303

FINDING 2023-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The County did not have procedures in place to prevent, or detect and correct, errors on Project and Expenditure (P&E) reports submitted to the U.S. Department of the Treasu...

FINDING 2023-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The County did not have procedures in place to prevent, or detect and correct, errors on Project and Expenditure (P&E) reports submitted to the U.S. Department of the Treasury. The report submitted during the audit period included projects with current period obligations and cumulative obligations totaling $3,319,955 that had not yet been obligated by the end of the reporting period. It was recommended that management of the County design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight of federal reports are taking place and to ensure the County provides the Treasury with complete and accurate information for the P&E report. Contact Person Responsible for Corrective Action: Amy Copeland Contact Phone Number and Email Address: acopeland@ripleycounty.com; 812-689-6311 INDIANA STATE BOARD OF ACCOUNTS 21 Ripley County Auditor Amy Copeland – Auditor 102 West 1st North Street, PO Box 235 Versailles, IN 47042 Ph: 812-689-6311 Fax: 812-689-3006 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: I, Amy Copeland, Auditor, plan to have the county attorney sit with me when I fill this report out from now on. I will also have one of my employees look over it before it is submitted. Anticipated Completion Date: April 30, 2025

View Audit 317157

Finding 481011 (2023-002)

Significant Deficiency 2023

City of Hanley Falls

MN

Internal Control / Segregation of Duties

Segregation of Duties

View Audit 317110

Finding 481011 (2023-002)

Significant Deficiency 2023

City of Hanley Falls

MN

Internal Control / Segregation of Duties

Name of Contact Person: Patricia Savoie, City Clerk

View Audit 317110

Finding 481011 (2023-002)

Significant Deficiency 2023

City of Hanley Falls

MN

Internal Control / Segregation of Duties

Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providing some of these controls.

View Audit 317110

Finding 481011 (2023-002)

Significant Deficiency 2023

City of Hanley Falls

MN

Internal Control / Segregation of Duties

Proposed Completion Date: The City Council will implement the above procedures immediately.

View Audit 317110

Finding 480999 (2023-002)

Significant Deficiency 2023

Town of Sutton

MA

School Nutrition Programs Eligibility Significant Deficiency

Audit Reference: 23-002 Non-Compliance Issue: lack of confirming signature on free/reduced applications. Applications must be confirmed by the confirming official listed on the Free & Reduced Price Meals Policy submitted to ESE. Root Cause Analysis: All applications were not printed and signed by co...

Audit Reference: 23-002 Non-Compliance Issue: lack of confirming signature on free/reduced applications. Applications must be confirmed by the confirming official listed on the Free & Reduced Price Meals Policy submitted to ESE. Root Cause Analysis: All applications were not printed and signed by confirming official. Corrective Action(s): Printing and signing all applications as they come in including online applications. 2. Action Item: o Description: Setting plans in place to make sure all applications are signed as printed or passed in and making sure that all signed applications are passed in to auditor not electronic copies. o Responsible Person/Department: Christina Poquette o Expected Completion Date: On going Name: Christina Poquette Title: Director of Food and Nutrition Signature: Date: 5/20/2024 Acknowledgement by Responsible Parties: Name: Title: Signature: Date: 5/20/2024

View Audit 317107

Finding 480998 (2023-001)

Material Weakness 2023

Town of Sutton

MA

School Nutrition Programs Eligibility Internal Control / Segregation of Duties

Organization Name: Sutton Public Schools Address: 16 Putnam Hill Rd Sutton MA 01590 Issue Date: 05/20/2024 Audit Reference: 23-001 Non-Compliance Issue: verification process not completed during school year 22-23 Root Cause Analysis: This was caused by lack of knowledge due to manager change over wi...

Organization Name: Sutton Public Schools Address: 16 Putnam Hill Rd Sutton MA 01590 Issue Date: 05/20/2024 Audit Reference: 23-001 Non-Compliance Issue: verification process not completed during school year 22-23 Root Cause Analysis: This was caused by lack of knowledge due to manager change over with no overlap and managers starting date after verification completion deadline. Corrective Action(s): In planning for next school year, it has been set as a calendar reminder for October 1st to start the verification process with weekly goals set as to what needs to be done each week. As well as a reminder set for November 15th to make sure verification paperwork is submitted prior to the due date of November 17th. 1. Action Item: o Description: Set plans and calendar reminders in place to ensure the verification process is start prior to the end of September and that all is completed to be completed accurately before due date o Responsible Person/Department: Christina Poquette o Expected Completion Date:10/17/2024 Name: Christina Poquette Title: Director of Food and Nutrition Signature: Date: 5/20/2024 Acknowledgement by Responsible Parties: Name: Title: Signature: Date:5/20/2024 Organization Name: Sutton Public Schools Address: 16 Putnam Hill Rd Sutton MA 01590 Issue Date: 05/20/2024

View Audit 317107

Finding 480997 (2023-002)

Significant Deficiency 2023

Indiana University Health, Inc. and Subsidiaries

IN

Allowable Costs / Cost Principles HUD Housing Programs Reporting § 200.303

Finding 2023-02 Reporting (ALN 14.241) Indiana University Health established a control of programmatic review of the Consolidated Annual Performance and Evaluation Report (CAPER). A discrepancy in the amount of expenditures reported on the CAPER related to the Indiana Housing and Community Departme...

Finding 2023-02 Reporting (ALN 14.241) Indiana University Health established a control of programmatic review of the Consolidated Annual Performance and Evaluation Report (CAPER). A discrepancy in the amount of expenditures reported on the CAPER related to the Indiana Housing and Community Department Authority (IHCDA) grants for the report period ended June 30, 2023 was not discovered in review. Indiana University Health submitted a corrected, amended CAPER for this award period on July 19, 2024. The control for the amended CAPER (and for future CAPERs) was strengthened to include documented reconciliation to expenditures claimed as well as both programmatic and financial services review. Contact Person(s) Responsible for Corrective Action: Christine Smith Completion Date: July 19, 2024

View Audit 317105

Finding 480996 (2023-001)

None 2023

Indiana University Health, Inc. and Subsidiaries

IN

Subrecipient Monitoring Eligibility Reporting

Finding 2023-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Chri...

Finding 2023-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Christine Smith Anticipated Completion Date: N/A

View Audit 317105

Finding 480991 (2023-002)

Material Weakness 2023

Chestnut Ridge Public Service District

WV

Material Weakness Reporting Internal Control / Segregation of Duties

Management's goal is to complete the annual audit on schedule and if required, submit the date collection form into the Federal Audit Clearinghouse.

View Audit 317100

Finding 480973 (2023-005)

Significant Deficiency 2023

Heartland Alliance for Human Needs & Human Rights

IL

Internal Control / Segregation of Duties Reporting § 200.303 § 200.512

Finding Number: 2023-005 Reporting - Compliance and Internal Control Summary of Finding: CFR Section 200.303, Internal Controls, Section (a) states the Organization must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Organization is ...

Finding Number: 2023-005 Reporting - Compliance and Internal Control Summary of Finding: CFR Section 200.303, Internal Controls, Section (a) states the Organization must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Organization is managing the federal awards in compliance with federal statutes, regulations, and terms and conditions of the federal award. Management is responsible for establishing and maintaining a system of internal control that should include controls over its reporting process. 2 CFR section 200.512(a) states that the data collection form and reporting package must be submitted the earlier of 30 calendar days after receipt of the auditor’s reports or nine months after the end of the audit period to the Federal Audit Clearinghouse (FAC). If the due date falls on a Saturday, Sunday, or federal holiday, the reporting package is due the next business day. The Uniform Guidance does not have a provision addressing whether the cognizant or oversight agencies may extend due dates. During the fiscal year, we noted that the Organization failed to submit the data collection form and reporting package to FAC on a timely basis. Response to finding: We agree with the finding. Corrective Action: The retaining of a new audit firm for the FY2023 audit, the departure of key staff and reorganizational issues, winding down of Heartland Alliance and spin-off of entities into their own companies all have prevented the timely filing this year. Each new spin-off company will now be responsible for their own Financial Audit and Heartland Alliance is winding down and will not require any further audits. Individual(s) Responsible for Corrective Action Plan: o Name: Robin Armour o Title: Interim Chairman of the Board o Email address: robin@amdcapital.com o Anticipated Completion Date: March 31, 2025

View Audit 317091

Finding 480968 (2023-002)

Significant Deficiency 2023

San Ysidro Health, Inc.

CA

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring

Finding 2023-002 Federal Agency: U.S. Department of Health and Human Services, ALN#93.224/93.527 Health Centers Cluster Response: Management acknowledges the finding of the auditors and recognizes the need for improving its Sliding Fee Discount Program systems, processes, and monitoring. In the ...

Finding 2023-002 Federal Agency: U.S. Department of Health and Human Services, ALN#93.224/93.527 Health Centers Cluster Response: Management acknowledges the finding of the auditors and recognizes the need for improving its Sliding Fee Discount Program systems, processes, and monitoring. In the latter half of 2024, the Billing Department leadership and front desk training team will renew its staff training and oversight efforts to improve compliance. Training on San Ysidro Health’s Sliding Fee Discount Program policies and procedures will be planned, scheduled, and provided for all front desk leaders and staff to ensure that the policies and procedures are followed to mitigate the risk of repetitive findings in following years. In addition, the Billing Department will expand the number of sliding fee encounters sampled and tested for compliance monthly. Noncompliance will serve as the basis for additional follow-up training of staff when noted. Monthly compliance reporting will be provided to senior finance and operational leaders to ensure ongoing monitoring of performance and timely resolution of noncompliance. Responsible Party: Charles Nubia, Director of Revenue Cycle; Brian Wallace, CFO Estimated Completion Date: July 22, 2024

View Audit 317089

Finding 480946 (2023-002)

Significant Deficiency 2023

Town of Wilbraham, Ma

MA

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.329

Audit Finding Reference: 2023-002 – Improve Oversight of Reporting of Federal Funds The March 2023 Annual Performance report showed an expense of $239,098 in FY2023 which was not actually expended until FY2024. The Town agrees with the finding. Planned Corrective Action: When the FY2023 report w...

Audit Finding Reference: 2023-002 – Improve Oversight of Reporting of Federal Funds The March 2023 Annual Performance report showed an expense of $239,098 in FY2023 which was not actually expended until FY2024. The Town agrees with the finding. Planned Corrective Action: When the FY2023 report was filed, the expense in the wrong period was discovered. Efforts were made to try and correct this error prior to filing the FY2023 Report, but the system would not allow any corrections. The Town makes every effort to include the source documents that support the reports submitted, which is the way this was discovered prior to submitting the FY2023 report. The Town will continue this procedure to include the source documents (Trial Balances) which support the projects and amounts filed within the report. This will ensure that the General Ledger and the reports filed are in balance. The only corrective measure for this error will occur when the FY2024 Single Audit is prepared which shows the expense expended in FY2024.

View Audit 317055

Corrective Action Plans

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