Corrective Action Plans

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

Finding 480940 (2023-002)

Material Weakness 2023

Usd #272, Cawker City, Kansas

KS

Material Weakness Reporting Internal Control / Segregation of Duties

2023-002 Reporting to the Federal Audit Clearinghouse (Material Weakness) Federal Agency: U.S. Environmental Protection Agency Program Name: Clean School Bus Program Assistance Listing Number: 66.045 Award Period: June 30, 2023 Recommendation: The Board of Education and management should implem...

2023-002 Reporting to the Federal Audit Clearinghouse (Material Weakness) Federal Agency: U.S. Environmental Protection Agency Program Name: Clean School Bus Program Assistance Listing Number: 66.045 Award Period: June 30, 2023 Recommendation: The Board of Education and management should implement internal control procedures that will ensure timely submission of the audit package and data collection form to the Federal Audit Clearinghouse within the required timeline. Action Taken (Unaudited): Management plans to develop proper written policies and procedures that will ensure timely submission of the audit package and data collection form to the Federal Audit Clearinghouse within the required timeline during years in which the District incurs federal expenditures above the threshold required by Uniform Guidance. Contact Name – Jesse Janssen Expected Completion Date – 12/31/2024

View Audit 317046

Finding 480928 (2023-002)

Material Weakness 2023

The Simple Foundation

NE

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.318 § 200.326

FINDING 2023-002: Procurement Please provide an explanation of how your organization plans to resolve procurement error moving forward The Simple Foundation has implemented a newly developed procurement policy that aligns with the Uniform Guidance procurement standards. Moving forward, this policy w...

FINDING 2023-002: Procurement Please provide an explanation of how your organization plans to resolve procurement error moving forward The Simple Foundation has implemented a newly developed procurement policy that aligns with the Uniform Guidance procurement standards. Moving forward, this policy will be strictly followed for all agreements and transactions under the Federal procurement requirements within Uniform Guidance. Attached below in the procurement policy and the Purchase Justification Form. Reasonable completion date: 08/04/2024 Responsible Party: D&K Financial, Compliance

View Audit 317033

Finding 480921 (2023-009)

None 2023

City of Derby, Connecticut

CT

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Recommendation: We recommend that the Finance Department and/or the Board of Education annually prepare the Schedule of Expenditures of Federal Awards and State Financial Assistance to be presented to the auditor for audit. The auditor can then render an opinion with respect to compliance with and ...

Recommendation: We recommend that the Finance Department and/or the Board of Education annually prepare the Schedule of Expenditures of Federal Awards and State Financial Assistance to be presented to the auditor for audit. The auditor can then render an opinion with respect to compliance with and internal control over compliance with laws, regulations, contracts and grants. This will provide the proper segregation of responsibilities over the preparation of the schedules and the rendering of an opinion of these schedules. Management’s Response: The City and BOE will prepare the Schedules of Expenditures of Federal and State Financial Assistance going forward.

View Audit 317016

Finding 480919 (2023-004)

Material Weakness 2023

Pembroke Hill School

NH

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

Audit Finding Reference: 2023-004 Excess Food Service Fund Balance Management's View and Planned Corrective Action: Management agrees that the Food Service Fund Balance needs to be reduced The Department of Education in FY2023 they did not require a spend down plan for the application. With that s...

Audit Finding Reference: 2023-004 Excess Food Service Fund Balance Management's View and Planned Corrective Action: Management agrees that the Food Service Fund Balance needs to be reduced The Department of Education in FY2023 they did not require a spend down plan for the application. With that said we currently have a spend down plan in place to reduce the fund balance to a more appropriate fund balance and to meet the regulation. The spend down plan was submitted in March 2024. Name of Contact Person and Completion Date: Name 1 Amber Wheeler Name 2 Danielle Rossetti Anticipated Completion Date - December 31, 2024

View Audit 317015 Questioned Costs: $1

Finding 480885 (2023-004)

Significant Deficiency 2023

Anoka County

MN

Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2023-004 Finding Title: Special Tests and Provisions – Review of Prevailing Wage Reports Program: 20.205 Highway Planning and Construction Name of Contact Person Responsible for Corrective Action: Joe MacPherson – Chief Officer, Transportation & County Engineer, Highway Corrective Ac...

Finding Number: 2023-004 Finding Title: Special Tests and Provisions – Review of Prevailing Wage Reports Program: 20.205 Highway Planning and Construction Name of Contact Person Responsible for Corrective Action: Joe MacPherson – Chief Officer, Transportation & County Engineer, Highway Corrective Action Planned: On projects, such as the Ramsey Gateway Improvement Project (Project # SP 002-596-026) where the County contracts with the State related to the provision of construction project management services, the County Engineer and their team will request a prevailing wage report from the construction administration/engineering team at the Minnesota Department of Transportation (MnDOT) prior to certifying all contract payments. The report will include a summary of the prevailing wage reports that have been submitted/reviewed and describe any issues or concerns that were found and addressed. Anticipated Completion Date: This procedure will be implemented immediately (as of July 3, 2024).

View Audit 316995

Finding 480840 (2023-002)

Significant Deficiency 2023

Springfield Housing Authority

IL

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

FINDING 2023-002 "Housing Choice Voucher Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance & Significant Deficiency " SHA RESPONSE The Springfield Housing Authority acknowledges the seven (7) errors as delineated in the full 2023 FYE audit report. In 2023, the Spri...

FINDING 2023-002 "Housing Choice Voucher Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance & Significant Deficiency " SHA RESPONSE The Springfield Housing Authority acknowledges the seven (7) errors as delineated in the full 2023 FYE audit report. In 2023, the Springfield Housing Authority Housing Choice Voucher program delineated the following positions to undertake Income and rent calculations: one {l) Special Programs Coordinator, four (4) HCV Specialists and one {1) Program Integrity Specialist. Of those six (6) employees, only onehas a tenure longer than 12 months. Due to continuing post COVID-19 turnover and lack of qualified workers in the local workforce, the SHA expertenced a higher than usual turnover rate in the HCV positions that conduct rent calculations during the majority of FY2023. The Springfield Housing Authority hired third party consultants to assist with annualrecertificationsin the 3rd Quarter of 2023. The primary function of the Program Integrity Specialist position ls to audit and quality control tenant files and rent calculations conducted by HCV Specialists. The HCV Director and/or HCV Manager is responsible for reviewing 3% of recertiflcations audited by the Program Integrity Specialist position as an additional quality control measure. This error rate was directly attributable to the unprecedented turnover rate of HCV Specialists duringthe 2023 fiscal year. The SHA will take the following corrective actions to correct the errors and/or prevent the errors moving forward: • The Program Integrity Speclalist will conduct reviews of 100% of annual and interim recertificatlons for HCV program participants by December 31, 2024. • The Program Integrity Specialist will ensure 100% audited file corrections are completed by the HCV Specialists, monthly. • The HCV Director and/or Manager will review 10% of the recertifications audited by the Program Integrity Speclallst as an additional quality controlmeasure by December 31, 2024. • The HCV Director, HCV Manager, HCV Specialists and Program Integrity Specialist will be provided with additional internal and external training opportunities in Housing Choice Voucher program income andrent calculations andprogram Integrity by December 31, 2024. • The HCV Manager will re-review the flies Identified with errors during the independent audit and resolve the errors in accordance with the SHA Administrative Plan and HUD rules and regulations by September 30, 2024. Person Responsible: Melissa Huffstedtler, Deputy Director Anticipated Completion Date: December 31, 2024

View Audit 316970

Finding 480839 (2023-001)

Significant Deficiency 2023

Springfield Housing Authority

IL

HUD Housing Programs Subrecipient Monitoring Significant Deficiency

FINDING 2023-001 "Public Hous;ng Tenant Fffes - fllgibility- tnrerno/ Control Over Tenant Files Non-Compliance and Significant Deficiency" SHA RESPONSE The Springfield Housing Authority acknowledges the five (5) errors as delineated in the full 2023 FYE audit report. The identified errors constitut...

FINDING 2023-001 "Public Hous;ng Tenant Fffes - fllgibility- tnrerno/ Control Over Tenant Files Non-Compliance and Significant Deficiency" SHA RESPONSE The Springfield Housing Authority acknowledges the five (5) errors as delineated in the full 2023 FYE audit report. The identified errors constitute a 54% reduction in file errors from fY 2022. In 2023, the Springfield Housing Authority Public Housing program employed three (3} Asset Managers, three (3) Occupancy Specialists and one (1) Program Integrity Specialist. Due to continuing post COVID-19 turnover and lack of qualified workers in the local workforce, the SHA continued to experience a higher than usual turnover rate Ir, the positions that conduct rent calculattons duringthe majority of FY2023. Thepositions began to stabilize by the 4th quarter of 2023. The primary function of the Program Integrity Specialist position is to audit and quality control tenant files and rent calculations conducted by Occupancy Specialists. The Asset Managers are responsible for reviewing 3% of recertifications audited by the Program Integrity Specjalist position as an additional quality controlmeasure. Further, during the auditor's closeout meetingwith the SHA Management team, the auditors indicated that the SHA team conducted necessary file audits and identified deficiencies, however the corrections were not timely. This error rate was directly attributable to the continued high turnover rate of Occupancy Specialists during the 2023 fiscalyear. The SHA will take the following corrective actions to correct the errors and/or prevent the errors moving forward: • The Program Integrity Specialist will conduct reviews of 100% of annual and interim recertiflcations for publlc housing tenants by December 31, 2024. • The Program Integrity Specialist will ensure 100% audited file corrections are completed by the Occupancy Specialists, monthly. • The Asset Manager(s) will review 10% of the recertifications audited by the Program Integrity Specialist as an additional quality control measure by December 31, 2024. • The Asset Managers, Occupancy Specialists and Program Integrity Specialist will be provided with additional internal andexternal trainingopportunities In low rent public housingrentcalculations and program integrity by December 31, 2024. • The Asset Managers will re-review the files identified with erro)J.during the independent audit and resolve the errors in accordance with the SHA Admissions and Cbntl nued Occupancy Plan and HUD rules and regulations by September 30, 2024. Person Responsible: Melissa Huffstedtler, Deputy Director Anticipated Completion Date: December 31, 2024

View Audit 316970

Finding 480832 (2023-005)

Significant Deficiency 2023

Lewisburg Borough

PA

Internal Control / Segregation of Duties

Finding 2023-005 Grant Program/CFDA#: Community Development Block Grant Program, 14.228 Federal Agency/Pass-Through Entity: United States Department of Housing and Urban Development/Pennsylvania Department of Community and Economic Development Finding - Segregation of Duties: A limited number...

Finding 2023-005 Grant Program/CFDA#: Community Development Block Grant Program, 14.228 Federal Agency/Pass-Through Entity: United States Department of Housing and Urban Development/Pennsylvania Department of Community and Economic Development Finding - Segregation of Duties: A limited number of personnel are involved in accounting functions in which they are responsible for all related transactions (i.e. the same person recording transactions, preparing checks, recording cash disbursements, mailing checks and reconciling bank accounts, etc.). This lack of segregation of duties results in a weakness within the Borough’s internal control system. It was recommended by the auditors that a greater segregation of duties can be achieved by the implementation of additional procedures that utilize current and new personnel. However, in evaluating this need, the Borough must weigh the cost of employing additional personnel against the benefits to be derived there from. Borough Response: The Borough understands that it only has a limited number of employees within the business office to assign certain duties. Additionally, it understands the various employees’ capabilities restrict its options to achieve an optimal segregation of duties. Consequently, the Borough has determined that with its current checks and balances in place, it feels it has achieved its optimal segregation of duties. It does not expect to generate any future benefit by expending additional funding to achieve a greater segregation of duties.

View Audit 316967

Finding 480831 (2023-004)

Material Weakness 2023

Lewisburg Borough

PA

Reporting Internal Control / Segregation of Duties

Finding 2023-004 Grant Program/CFDA#: Community Development Block Grant Program, 14.228 Federal Agency/Pass-Through Entity: United States Department of Housing and Urban Development/Pennsylvania Department of Community and Economic Development Finding - General - Financial Statement Preparat...

Finding 2023-004 Grant Program/CFDA#: Community Development Block Grant Program, 14.228 Federal Agency/Pass-Through Entity: United States Department of Housing and Urban Development/Pennsylvania Department of Community and Economic Development Finding - General - Financial Statement Preparation: In connection with the audit of the Borough of Lewisburg’s financial statements, like most smaller local governmental entities, management has requested that its external auditors assist in the drafting of the schedule of expenditures of federal awards. Borough management has determined that it is more cost-beneficial to utilize the services of its auditors to assist in drafting the schedule of expenditures of federal awards, as opposed to hiring a professional accountant trained in such matters. While the Borough’s internal accounting personnel have the ability to interpret and understand its schedule of expenditures of federal awards, they do not have sufficient experience in preparing that schedule in accordance with generally accepted accounting principles. It was recommended by the auditors that management should prepare its schedule of expenditures of federal awards. However, in evaluating this need, the Borough must weigh the cost of employing additional personnel against the benefits to be derived therefrom. Borough Response: The Borough will consider training staff to achieve these duties, but it does not expect to hire additional personnel to perform these duties.

View Audit 316967

Finding 480779 (2023-001)

Significant Deficiency 2023

Puerto Rico Office Management and Budget

PR

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

GOBIERNO DE PUERTO RICO OFICINA DE GERENCIA Y PRESUPUESTO July 23, 2024 OFFICE OF MANAGEMENT AND BUDGET CORRECTIVE ACTION PLAN FOR PROGRAM SPECIFIC AUDIT FINDING FISCAL YEAR 2022-2023 Finding No. 2023-001: Program 21.027 Condition: Single Audit report for fiscal year 2022-2023 was ...

GOBIERNO DE PUERTO RICO OFICINA DE GERENCIA Y PRESUPUESTO July 23, 2024 OFFICE OF MANAGEMENT AND BUDGET CORRECTIVE ACTION PLAN FOR PROGRAM SPECIFIC AUDIT FINDING FISCAL YEAR 2022-2023 Finding No. 2023-001: Program 21.027 Condition: Single Audit report for fiscal year 2022-2023 was not submitted by March 31, 2024, as required by regulations. Recommendation: Keep track and communication of federal programs compliances with regulatory parties and among agency's responsible departments involve and establish a program deadline calendar. Views of Responsible Officials/Corrective Action Plan: 1. Engagement of CPA Firm: o Action: The Puerto Rico Office of Management and Budget has contracted a CPA firm, contract number 2024-00003 7 for the Single Audit 2023 that was signed on August 2, 2023. o Responsible Officer: Mrs. Nivis Gonzalez Rodriguez o Timeline: Immediate and ongoing 2. Early Initiation of the Audit Process: o Action: Initiate the audit process well in advance of the deadline to ensure sufficient time for completion and review. o Responsible Officer: Mrs. Nivis Gonzalez Rodriguez o Timeline: Audit process to begin six months prior to the submission deadline. 3. Improvement of Internal Controls: o Action: Develop and implement stronger internal controls over financial reporting to ensure timely production of financial statements. o Responsible Officer: Mrs. Nivis Gonzalez Rodriguez o Timeline: Within three months 4. Training and Communication: o Action: Conduct training sessions for all relevant personnel on compliance requirements and the importance of timely financial reporting. Calle Cruz #254 Esq. Tetu~n, San Juan, PR/ PO Box 9023228, San Juan, PR 00902-3228 o Responsible Officer: Mrs. Nivis Gonzalez Rodriguez o Timeline: Bi annually training sessions 5. Establishment of Deadline Calendar: o Action: Create and maintain a detailed program deadline calendar to ensure all involved departments are aware of key dates and responsibilities. o Responsible Officer: Mrs. Nivis Gonzalez Rodriguez o Timeline: Calendar to be established and communicated within one month Responsible Officials: ( Mrs. Nivis Gonzalez Rodrigu Estimated Completion Date: July 2024 for Single audit implementation, if apply.

View Audit 316956

Finding 480778 (2023-001)

Significant Deficiency 2023

National Foundation for Credit Counseling, Inc.

DC

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

Reporting Recommendation: We recommend that the Foundation update its policies and procedures to ensure formal documented review and approval over financial and performance reports. Procedures must include documentation and proper sign offs from preparer and reviewer of the reports. Explanation of...

Reporting Recommendation: We recommend that the Foundation update its policies and procedures to ensure formal documented review and approval over financial and performance reports. Procedures must include documentation and proper sign offs from preparer and reviewer of the reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procedures updated to reflect a formal sign off for all electronically submitted reports to prove proper reviews were completed. A sign off email will be included in the files going forward. Name of the contact person responsible for corrective action: Ellen Goury Planned completion date for corrective action plan: 6/30/2024

View Audit 316953

Finding 480745 (2023-001)

Significant Deficiency 2023

Dunn Housing Authority

NC

Eligibility HUD Housing Programs Reporting

Dunn Housing Authority Corrective Action Plan For the Year Ended December 31, 2023 Finding 2023-001 Name of Contact Person: Felicia Chester Executive Director Corrective Action: We will implement proper internal control procedures for the Public and Indian Housing program eligibility requirements. ...

Dunn Housing Authority Corrective Action Plan For the Year Ended December 31, 2023 Finding 2023-001 Name of Contact Person: Felicia Chester Executive Director Corrective Action: We will implement proper internal control procedures for the Public and Indian Housing program eligibility requirements. Management has established a checklist for applications and will establish checklists for move-ins and move-outs. Proposed Completion Date: Immediately

View Audit 316948

Finding 480735 (2023-002)

Significant Deficiency 2023

Childhelp Inc.

AZ

Allowable Costs / Cost Principles Reporting Significant Deficiency

Corrective Action Plan: Childhelp will implement the following actions by December 31, 2024. 1. Develop Comprehensive Review Procedures: Create detailed review checklists and procedures to be used by management for assessing the accuracy and completeness of grant reports. Ensure checklists address a...

Corrective Action Plan: Childhelp will implement the following actions by December 31, 2024. 1. Develop Comprehensive Review Procedures: Create detailed review checklists and procedures to be used by management for assessing the accuracy and completeness of grant reports. Ensure checklists address all key elements of Uniform Guidance compliance, including allowable costs, matching principles, and required disclosures. 2.Enhance Management Oversight: Implement regular management reviews of grant reports prior to submission 3. Strengthen Communication and Collaboration: Establish formal communication channels between finance and the program managers. Develop a collaborative approach to report preparation and review. Implement regular meetings to discuss reporting requirements and challenges. 4. Implement a Robust Monitoring System: Develop key performance indicators (KPIs) to measure the accuracy and timeliness of grant reporting. Establish a monitoring system to track and trend KPIs. 5. Provide Training and Development: Develop and implement training programs on Uniform Guidance requirements for all relevant personnel. Provide ongoing training to address changes in regulations or reporting requirements.

View Audit 316944

Finding 480718 (2023-004)

Significant Deficiency 2023

Three Links Apartments

MN

Special Tests & Provisions Procurement, Suspension & Debarment HUD Housing Programs

Special Tests and Provisions Noncompliance and Significant Deficiency in Internal Control over Compliance US Department of Housing and Urban Development CFA #14.155 Section 223(f) Mortgage Insurance for the Purchase or Refinance of Existing Multifamily Housing Projects Finding Summary: No documentat...

Special Tests and Provisions Noncompliance and Significant Deficiency in Internal Control over Compliance US Department of Housing and Urban Development CFA #14.155 Section 223(f) Mortgage Insurance for the Purchase or Refinance of Existing Multifamily Housing Projects Finding Summary: No documentation was maintained for two cash disbursements. Responsible Individuals: Mari Chambers, CFO Corrective Action Plan: All invoices are now maintained electronically which will eliminate the possibility of misplacing paper invoices. Anticipated Completion Date: Resolved

View Audit 316935

Finding 480717 (2023-003)

Significant Deficiency 2023

Three Links Apartments

MN

Special Tests & Provisions Procurement, Suspension & Debarment Cash Management

Special Tests and Provisions Significant Deficiency in Internal Control over Compliance US Department of Housing and Urban Development CFA #14.155 Section 223(f) Mortgage Insurance for the Purchase or Refinance of Existing Multifamily Housing Projects Finding Summary: The Project did not have proper...

Special Tests and Provisions Significant Deficiency in Internal Control over Compliance US Department of Housing and Urban Development CFA #14.155 Section 223(f) Mortgage Insurance for the Purchase or Refinance of Existing Multifamily Housing Projects Finding Summary: The Project did not have proper documentation of reviews over cash disbursements and bank reconciliations. Responsible Individuals: Mari Chambers, CFO Corrective Action Plan: Management agrees with the finding and has implemented procedures to properly document the approvals of cash disbursements and bank reconciliations. Anticipated Completion Date: Resolved

View Audit 316935

Finding 480695 (2023-001)

Significant Deficiency 2023

Southwest Mississippi Regional Medical Center

MS

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303 § 200.430

Finding 2023-001 – Allowable Activities and Costs of Provider Relief Fund Significant Deficiency in Internal Control over Compliance Program: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Federal Assistance Listing Number: 93.498 Federal Grantor: U.S. D...

Finding 2023-001 – Allowable Activities and Costs of Provider Relief Fund Significant Deficiency in Internal Control over Compliance Program: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Federal Assistance Listing Number: 93.498 Federal Grantor: U.S. Department of Health and Human Services Pass-Through Entity: None Criteria: Per 2 CFR 200.430(i), personnel costs charged to federal grants are required to be supported by documentation including time records. Per 2 CFR 200.303, a non-federal entity must establish and maintain effective internal control over Federal awards that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and terms and conditions of the Federal award. Condition: Our audit procedures over the calculation of COVID patient days used to allocate the payroll cost to the PRF/ARP federal program disclosed the amounts were not properly calculated. Cause: The Medical Center has controls in place to review the calculation; however, the control did not operate to identify an error in the calculation of COVID patient days. Effect: The error in the calculation resulted in underreporting payroll costs allowed to be charged to PRF/ARP in the amount of $566,272. Questioned Costs: None Perspective: The error in the calculation resulted in underreporting payroll costs allowed to be charged to PRF/ARP in the amount of $566,272. Repeat Finding: This is not a repeat finding. Recommendation: We recommend the Medical Center implement additional internal controls over compliance in order to properly identify any errors in calculation. Management’s Action Plan: The Medical Center will implement additional internal controls over compliance. Such controls will include verification of all calculations used by two parties, the Director of Finance and CFO as well as signoff on calculations. Name of Person Responsible for the Plan: Mallory Ginn, CFO Anticipated Completion Date of the Plan: 7/31/2024

View Audit 316922

Finding 480668 (2023-003)

Significant Deficiency 2023

Yankton Transit, Inc.

SD

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Significant Deficiency § 200.313

Response to "2023 - 003 Finding: Activities Allowed/Unallowed and Cost Principles (Compliance; Internal Controls Over Compliance)" Yankton Transit will become familiar with the requirements of 2 CFR, §200.313(a) and will establish internal control policies and procedures and will train staff on tho...

Response to "2023 - 003 Finding: Activities Allowed/Unallowed and Cost Principles (Compliance; Internal Controls Over Compliance)" Yankton Transit will become familiar with the requirements of 2 CFR, §200.313(a) and will establish internal control policies and procedures and will train staff on those policies and procedures.

View Audit 316848

Finding 480663 (2023-008)

Material Weakness 2023

Integrated Community Solutions, Inc.

WI

HUD Housing Programs Allowable Costs / Cost Principles Material Weakness

Action taken in response to finding: A paperless / electronic invoice approval system has begun in 2024. All invoices are received via email or scanned in and saved as a PDF and stored by month paid. Invoices are emailed to a responsible manager for approval and the approval response email is save...

Action taken in response to finding: A paperless / electronic invoice approval system has begun in 2024. All invoices are received via email or scanned in and saved as a PDF and stored by month paid. Invoices are emailed to a responsible manager for approval and the approval response email is saved with the invoice. The invoice and approval is also uploaded into Financial Edge with the invoice. Electronic records are available in an Accounts Payable network folder and in Financial Edge for additional review or reference. Names of the contact persons responsible for corrective action: Matt Roberts, Joe Kahler, Chimeng Vang Planned completion date for corrective action plan: Began January 2024

View Audit 316843

Finding 480658 (2023-007)

Significant Deficiency 2023

Integrated Community Solutions, Inc.

WI

HUD Housing Programs Subrecipient Monitoring Significant Deficiency

Action taken in response to finding: ICS will train current and new staff regarding the importance of ensuring all documentation is in the file prior to scanning and that when the file is scanned all documentation is legible. Housing Specialists will continue to be trained on calculating HAP and th...

Action taken in response to finding: ICS will train current and new staff regarding the importance of ensuring all documentation is in the file prior to scanning and that when the file is scanned all documentation is legible. Housing Specialists will continue to be trained on calculating HAP and the importance of reviewing all documentation in the file prior to releasing payments to assure all rent amounts and dates are accurate and match what is being put into the system. RTAs and Leases should always be compared to assure the rent amount provided on the RTA matches the rent amount provided on the executed lease. Names of the contact persons responsible for corrective action: Matt Roberts and Megan Walker Planned completion date for corrective action plan: Immediately

View Audit 316843

Corrective Action Plans

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