Corrective Action Plans

Finding 479460 (2023-001)

Material Weakness 2023

Feeding Illinois

IL

Cash Management Internal Control / Segregation of Duties

All future federal grant programs that require substantial lines of information and calculations to be submitted for reimbursement of allowable costs will be reviewed by at least two qualified persons before submission to the administering agency (e.g. IDHS)..

View Audit 315994

Finding 479458 (2023-004)

Material Weakness 2023

Frazer School District

MT

Internal Control / Segregation of Duties § 200.303

FINDING 2023-004: Impact Aid Application Controls Response: The District will review its internal control systems over its Impact Aid application and ensure that the document management systems are adequate to ensure appropriate filing of supporting documentation to the applications maintained.

View Audit 315988

Finding 479455 (2023-001)

Significant Deficiency 2023

Juneau County Housing Authority

WI

Internal Control / Segregation of Duties Reporting

Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongo...

Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongoing

View Audit 315985

Finding 479448 (2023-001)

Significant Deficiency 2023

Prairie View, Inc.

KS

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

Criteria or Specific Requirement – Reporting (Reference number 2023-001) Recommendation – The Organization should continue to improve understanding of the guidance related to this type of reporting and work to identify areas for improvement prior to submission to the Provider Relief Fund reporting ...

Criteria or Specific Requirement – Reporting (Reference number 2023-001) Recommendation – The Organization should continue to improve understanding of the guidance related to this type of reporting and work to identify areas for improvement prior to submission to the Provider Relief Fund reporting portal. Management should ensure proper internal controls are put into place to ensure that allowable expenses reported are not reimbursed by other sources or in previous submission period. Views of Responsible Officials and Corrective Action Plan – Management agrees with the finding. The reporting discrepancy was due to a misunderstanding of how the cost portion of the report should have been presented. The presentation was submitted with the same methodology as the lost revenue presentation, which was on a cumulative basis vs. the incremental period required for costs. In addition, staff turnover, including the responsible official (CFO), during this period of time impacted the execution of the last repoting requirement and improper reporting to HHS. The Organization believes that it had sufficient lost revenues to justify retention of all PRF Period 4 funds. There is no expected future reporting for the Provider Relief Funds. Personnel Responsible – John Hydock, Interim CFO Timeline – There is no expected future PRF submissions, but in the event one is required, the Organization will have a quality control process in place to review reporting of expenses to ensure no duplication or carry-over of expenses occurs.

View Audit 315978

Finding 479440 (2023-001)

Material Weakness 2023

County of Accomack, Virginia

VA

Subrecipient Monitoring Material Weakness Reporting

Corrective Action Plan for Finding FA-2023-001: Lack of Timely Reporting, Reporting, Education Stabilization Funds (ESF) #84.425C, 84.425D, and 84.425U (Material Weakness and Nonmaterial Compliance) A master calendar is now being kept of required reports and their due date to ensure timely reportin...

Corrective Action Plan for Finding FA-2023-001: Lack of Timely Reporting, Reporting, Education Stabilization Funds (ESF) #84.425C, 84.425D, and 84.425U (Material Weakness and Nonmaterial Compliance) A master calendar is now being kept of required reports and their due date to ensure timely reporting. Responsible Official: Dr. Rhonda Hall, Accomack County Public Schools Superintendent, rhonda.hall@ accomack.k12.va.us (757-787-5759); Estimated completion date is not later than the June 30, 2024.

View Audit 315971

Finding 479422 (2023-001)

Significant Deficiency 2023

Metropolitan Council of the Twin Cities Area

MN

HUD Housing Programs Eligibility Significant Deficiency § 200.303

Finding Number: 2023-001 Finding Title: Eligibility – Source Documentation Program: 14.871 Section 8 Housing Choice Vouchers 14.879 Mainstream Vouchers Name of Contact Person Responsible for Corrective Action: Terri Smith, Director Metro HRA Corrective Action Planned: HRA staff has developed a check...

Finding Number: 2023-001 Finding Title: Eligibility – Source Documentation Program: 14.871 Section 8 Housing Choice Vouchers 14.879 Mainstream Vouchers Name of Contact Person Responsible for Corrective Action: Terri Smith, Director Metro HRA Corrective Action Planned: HRA staff has developed a checklist form and update procedures for all staff to ensure signatures and forms are not missing in case files, this includes but is not limited to criminal background checks performed, citizenship forms, members of the household forms, and debts owed forms. The checklist will be completed for each case and stored in each participant file as part of the quality control process. The quality control process that was implemented in June 2023 had not been in place for a full year when the 2023 audit was completed. All files are being checked at Annual Recertification. Once this has been in place for a full year, all files will have been checked for the appropriate forms and signatures. Anticipated Completion Date: This process will be in place effective July 2024.

View Audit 315951

Finding 479416 (2023-001)

Material Weakness 2023

Empire Justice Center

NY

Internal Control / Segregation of Duties

Name of Auditee: Empire Justice Center Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2023 CAP Prepared by: Kristin Brown Phone: 518-852-5766 (A) Current Finding on the Schedule of Findings and Responses (1) Audit Finding 2023-001 (a) Comments on the ...

Name of Auditee: Empire Justice Center Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2023 CAP Prepared by: Kristin Brown Phone: 518-852-5766 (A) Current Finding on the Schedule of Findings and Responses (1) Audit Finding 2023-001 (a) Comments on the finding and recommendation: Management agrees with the finding. (b) Actions Taken: Management has taken steps to ensure timely filing for the year ended December 31, 2023. (c) Anticipated Completion Date: Management anticipates this finding will be resolved for the year ending December 31, 2023.

View Audit 315919

Finding 479415 (2023-002)

Significant Deficiency 2023

Family Counseling Service of the Finger Lakes, Inc.

NY

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Internal Control / Segregation of Duties

The Finance team experienced significant turnover and transition in 2023, leading to documentation being filed/stored inconsistently and instances where approvals were verbal instead of written. A review of internal controls has been completed and changes made to documentation storage, as well as ...

The Finance team experienced significant turnover and transition in 2023, leading to documentation being filed/stored inconsistently and instances where approvals were verbal instead of written. A review of internal controls has been completed and changes made to documentation storage, as well as approvals of expenses. Documentation will be electronically attached to the relative expense if it is a credit card/debit card purchase. Documentation will be electronically attached to the invoice/check request in Bill.com if it is not a credit/debit card purchase. Approvals for debit/credit card purchases will be made by the Supervisor or the Director of the appropriate program. In cases where the Supervisor or Director are not available, approvals for debit/credit card purchases will be approved by either the VP of Operations or the President/CEO. For purchases made by check or electronic payment, authorized approvers will be assigned in Bill.com and payments will not be made unless the authorized approver(s) via the Bill.com approval process have indicated the expense is valid and funding is appropriate.

View Audit 315916

Finding 479414 (2023-001)

Significant Deficiency 2023

Family Counseling Service of the Finger Lakes, Inc.

NY

Internal Control / Segregation of Duties

We feel this situation was an anomaly, as the employee’s original Supervisor had taken a new position and the hiring of a replacement Supervisor had not yet taken place. Normally, the Director of Therapeutic Services would have stepped in; however, they were out on medical leave. These special cir...

We feel this situation was an anomaly, as the employee’s original Supervisor had taken a new position and the hiring of a replacement Supervisor had not yet taken place. Normally, the Director of Therapeutic Services would have stepped in; however, they were out on medical leave. These special circumstances, while rare, do not negate the need for contingency plans. We will continue to require employees to complete OVS Functional Timecards each month and have their Supervisor review and approve. If the Supervisor is unavailable, the Director of the appropriate program will review and approve. If the Director of the appropriate program is unavailable, VP of Operations will review and approve the functional timecard. Specifically, employees will complete and sign their monthly functional timecards and submit for Supervisor review no later than the 15th of the month following their support of OVS. Supervisors (or if needed, Program Directors or VP of Operations) will review and approve via signature no later than end of the month following timecard timeframe. All completed and approved functional timecards will be sent by the supervisor to VP of Operations for review of completeness and filed for documentation purposes.

View Audit 315916

Finding 479413 (2023-003)

Material Weakness 2023

Southeast Iowa Regional Medical Center

IA

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

U.S. Department of Health and Human Services Great River Health System, Inc. and Subsidiaries respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 – June 30, 2023 The finding from the schedule of findings and questioned costs is discu...

U.S. Department of Health and Human Services Great River Health System, Inc. and Subsidiaries respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 – June 30, 2023 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING—FEDERAL AWARD PROGRAMS AUDITS MATERIAL WEAKNESS U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-003 Provider Relief Fund – Assistance Listing No. 93.498 Recommendation: We recommend the Organization put in place controls over compliance that mitigate the risk of errors in reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We added an additional management review for future submissions prior to filing and submission. Name(s) of the contact person(s) responsible for corrective action: Jeremy Alexander, CFO Planned completion date for corrective action plan: 7/01/2024 If the Department of Health and Human Services has questions regarding this plan, please call Jeremy Alexander at 319-768-3280.

View Audit 315911 Questioned Costs: $1

Finding 479406 (2022-004)

Significant Deficiency 2023

Meadows Mental Health Policy Institute for Texas

TX

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties

Develop a comprehensive policy outlining the procedures for reviewing the monthly payroll grant summary. Provide training and guidance to the designated reviewer on the policies and procedures outlined in the new policy. Maintain thorough documentation of the review activities conducted, including a...

Develop a comprehensive policy outlining the procedures for reviewing the monthly payroll grant summary. Provide training and guidance to the designated reviewer on the policies and procedures outlined in the new policy. Maintain thorough documentation of the review activities conducted, including any corrective actions taken in response to identified issues.

View Audit 315903

Finding 479405 (2022-003)

Significant Deficiency 2023

Meadows Mental Health Policy Institute for Texas

TX

Allowable Costs / Cost Principles Cash Management Period of Performance

Maintain detailed documentation of the review process, including any findings or discrepancies identified during the review of drawdowns. Establish clear review procedures for the drawdowns prepared by the Assistant Controller. Continuously monitor the effectiveness of the review process and identif...

Maintain detailed documentation of the review process, including any findings or discrepancies identified during the review of drawdowns. Establish clear review procedures for the drawdowns prepared by the Assistant Controller. Continuously monitor the effectiveness of the review process and identify areas for improvement. Implement any necessary changes or enhancements to the review procedures to ensure thorough compliance with grant requirements.

View Audit 315903

Finding 479400 (2023-001)

None 2023

Midland County

MI

Reporting Internal Control / Segregation of Duties

The County's system of internal control detected this error prior to commencement of audit procedures for 2023 and was corrected during the grant reporting process for the quarter ended March 31, 2024.

View Audit 315895

Finding 479373 (2023-001)

Material Weakness 2023

Spyglass Ridge

OR

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

Views of Responsible Officials and Planned Corrective Actions We agree with this finding. NWCH was successful in adding needed staff in 2023, but was unable to hire a degreed accountant or controller, or to contract with an accounting firm for oversight of the accounting function. Bookkeeper trainin...

Views of Responsible Officials and Planned Corrective Actions We agree with this finding. NWCH was successful in adding needed staff in 2023, but was unable to hire a degreed accountant or controller, or to contract with an accounting firm for oversight of the accounting function. Bookkeeper training was provided from Shelter Resources Financial Manager in February 2023. NWCH is researching CPA firms in order to contract a qualified controller with expertise in real estate holdings relevant to NWCH. NWCH has been actively searching for a qualified CPA to hire or contract with since 2021, however, due to capacity constraints and overwhelmed CPA firms, NWCH has been unsuccessful. Efforts to hire experienced accounting personnel continues.

View Audit 315878

Finding 479339 (2023-002)

Material Weakness 2023

1260 Housing Development Corporation

PA

HUD Housing Programs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding 2023-002: Special Tests and Provisions The Corporation has three properties secured by CDBG loans. The properties are known as Mid-City, AppleTree Housing, Inc. (“ATH”), and Center West. The Corporation was unable to support that at least fifty-one percent (51%) of the tenants at the ATH pro...

Finding 2023-002: Special Tests and Provisions The Corporation has three properties secured by CDBG loans. The properties are known as Mid-City, AppleTree Housing, Inc. (“ATH”), and Center West. The Corporation was unable to support that at least fifty-one percent (51%) of the tenants at the ATH property were leased to and occupied by low or very low-income persons as determined by the Federal “Section 8” Income Standards with completed tenant certifications and recertifications. At ATH, 6 of 6 occupied unit’s certifications were not completed during the year ended June 30, 2023. This was an initial finding during the year ended June 30, 2020. Planned Corrective Action: It is the goal of the Corporation to maintain compliance with regulatory requirements. Where hardships are encountered the Corporation remains in ongoing communication with respective regulatory agencies to promote transparency and mitigate risk of loss in fundings or default. Mark Deitcher, CFO, is responsible for the corrective action plan. If the U.S Department of Housing and Urban Development has questions regarding this plan, please call Mark Deitcher at 1-215-557-8414.

View Audit 315836

Finding 479334 (2023-001)

Significant Deficiency 2023

Gravette School District

AR

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

The District has instituted an internal control that requires the preparation, review and retention of documentation as evidence that coding changes have not only been made but also made in a timely manner. The District will ensure that a contract is executed for every full-time employee included in...

The District has instituted an internal control that requires the preparation, review and retention of documentation as evidence that coding changes have not only been made but also made in a timely manner. The District will ensure that a contract is executed for every full-time employee included in the human resources module in eFinance by reconciling employee and contract counts.

View Audit 315830 Questioned Costs: $1

Finding 479333 (2023-002)

Significant Deficiency 2023

Gravette School District

AR

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

In our test of disbursements, we identified unallowable costs totaling $4,458 for football kicking lessons ($2,250) and student t-shirts to be worn at sporting events ($2,208) were paid from Education Stabilization Funds.

View Audit 315830 Questioned Costs: $1

Finding 479328 (2023-010)

Significant Deficiency 2023

Colorado Legal Services, INC

CO

Cash Management Reporting Significant Deficiency § 200.303

COIVD-19: Coronavirus State and Local Fiscal Recovery – Assistance Listing No. 21.027 Recommendation: We recommend that the Organization consider implementing a process that documents review and approval of submitted indirect cost claims by someone other than the preparer of such claims. Documentat...

COIVD-19: Coronavirus State and Local Fiscal Recovery – Assistance Listing No. 21.027 Recommendation: We recommend that the Organization consider implementing a process that documents review and approval of submitted indirect cost claims by someone other than the preparer of such claims. Documentation of contemporaneous review should also be maintained. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The organization will review this finding and current methodology and propose corrections as part of a broader review of its technologies. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025

View Audit 315826

Finding 479298 (2023-007)

Material Weakness 2023

Colorado Legal Services, INC

CO

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

Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization update its derivative income allocation method, policy and procedures to reflect the method described in the federal regulations. Explanation of disagreement with audit finding: ...

Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization update its derivative income allocation method, policy and procedures to reflect the method described in the federal regulations. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization will reach out to LSC to understand if our current method is acceptable. If not, the Organization will implement corrections to comply with applicable standards. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025

View Audit 315826

Finding 479296 (2023-005)

Significant Deficiency 2023

Colorado Legal Services, INC

CO

Significant Deficiency Internal Control / Segregation of Duties Special Tests & Provisions

Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization review its case file review internal controls to ensure that they are designed in a manner to detect and prevent noncompliance with this requirement. Explanation of disagreement ...

Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization review its case file review internal controls to ensure that they are designed in a manner to detect and prevent noncompliance with this requirement. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization has robust training for case handlers around when a retainer is required. The Organization will keep these measures in place and also plan to provide additional training for all case handlers on our case handler standards, which we will make sure also covers retainer agreements and managers’ review of case files. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025

View Audit 315826

Finding 479279 (2023-005)

Material Weakness 2023

Puerto Rico Safe Drinking Water Treatment Revolving Loan Fund

PR

Internal Control / Segregation of Duties

Finding 2023-005 Medical Assistance Program Special Test and Provisions- ADP Risk Analysis and System Security Review Material Weakness and Noncompliance The DOH disagrees with this finding as they believe the MCO should have received a SOC 1 Type 1 and Type 2 Report. The DOH has requested this ...

Finding 2023-005 Medical Assistance Program Special Test and Provisions- ADP Risk Analysis and System Security Review Material Weakness and Noncompliance The DOH disagrees with this finding as they believe the MCO should have received a SOC 1 Type 1 and Type 2 Report. The DOH has requested this information from the MCO however it has not been provided yet due to the short time frame for gathering the requested information. Responsible Officials Dinorah Collazo Ortiz Executive Director 787-765-2929 ext. 3402 Felmarie Cruz Morales Fiscal Director 787-765-2929 ext. 6721 Marcia Berrios De La Torre Financial Advisor 787-765-2929 ext. 6746 Estimated Completion Date Implementation is expected to be completed on or before the end of the year 2025.

View Audit 315825

Finding 479252 (2023-001)

Material Weakness 2023

Puerto Rico Safe Drinking Water Treatment Revolving Loan Fund

PR

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Finding 2023-001 Financial Administration- Standards for Financial Management System Financial Internal Control Weakness and Noncompliance The PRDOH agrees with the finding. However, PRDOH has implemented various corrective actions. Regarding Project Costing Module, the PRDOH already has implemente...

Finding 2023-001 Financial Administration- Standards for Financial Management System Financial Internal Control Weakness and Noncompliance The PRDOH agrees with the finding. However, PRDOH has implemented various corrective actions. Regarding Project Costing Module, the PRDOH already has implemented the Travel and Expenses Module, Payment Management System, which integrates with the Account Receivable to streamline revenue records and Payroll Solutions. The effectiveness of these will be observed during the fiscal year 2024-2025. Also, the PRDOH and Central Government are currently working on ERP implementation in all Government Agencies. This new ERP will be in place in the fiscal year 2024-2025. Furthermore, the PRDOH has established control in order for all program to ensure the timely performed reconciliations between the finance office, the federal affair office, this procedure has started since august 2022. In the other hand the State Department of Treasury has begun a series of training with regard the new ERP that will, be in place by October 2024. This new system in order to close the monthly period all programs will need to reconcile first before closing of the period. Responsible Official Mrs. Velmary Martinez Yace Finance Director Tel. 787-765-2929 ext. 3291 Mrs. Mayra Reyes Accounting Office Supervisor Tel. 787-765-2929 ext. 3294 Estimated Completion Date Implementation is expected to be completed on or before the end of October 2024.

View Audit 315825

Finding 479248 (2023-002)

Significant Deficiency 2023

Minnesota Prairie County Alliance

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2023-002 Finding Title: Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The agency will take the following ...

Finding Number: 2023-002 Finding Title: Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The agency will take the following steps to come into compliance: 1 Correct the cases that were found to be in error. 2 Establish an internal case review process. 3 Provide training and review the policy areas where deficiencies were identified with the family team. 4 Require family team to take new DHS training on assets. 5 Use DHS TANF case reviews as learning tools and share results with the family team. Anticipated Completion Date: Cases will be corrected, and the review process will be in place by 7/31/2024

View Audit 315808

Finding 479247 (2023-001)

Significant Deficiency 2023

Minnesota Prairie County Alliance

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2023-001 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The agency will take the following steps to come into...

Finding Number: 2023-001 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The agency will take the following steps to come into compliance: 1. Correct the cases that were found to be in error. 2. Establish an internal case review process. 3. Provide training and review the policy areas where deficiencies were identified with the family team. 4. Require family team to take new DHS training on assets. 5. Use DHS TANF case reviews as learning tools and share results with the family team. Anticipated Completion Date: Cases will be corrected, and the review process will be in place by 7/31/2024.

View Audit 315808

Finding 479219 (2023-002)

Significant Deficiency 2023

City of St. James

MN

Internal Control / Segregation of Duties

The City has determined the benefit of adequately segregating duties is less than the cost. Based on this assessment, the City is accepting the risk posed by the deficiency while also evaluating mitigating controls that will help reduce the risk of material misstatement of the financial statements. ...

The City has determined the benefit of adequately segregating duties is less than the cost. Based on this assessment, the City is accepting the risk posed by the deficiency while also evaluating mitigating controls that will help reduce the risk of material misstatement of the financial statements. Management is attempting to mitigate the associated risks by doing the following: Identifying areas lacking segregation of duties and where there are higher risks of fraud occurring. Implementing limited segregation to the extent possible to reduce risks without impairing efficiency. Using the knowledge of management and the City Council to review accounting records and reports.

View Audit 315783

Corrective Action Plans

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