Corrective Action Plans

Finding 404103 (2023-001)

None 2023

Tufts Medical Center Inc. and Affiliates

MA

Reporting Internal Control / Segregation of Duties

Re: Finding 2023-001 – Lost Revenue Reporting, Corrective Action Plan To whom it may concern: We agree with the auditor’s finding that the Home Health Visiting Nurse Association (VNA) erroneously filed Reporting Period 5 separately from the Tufts Medicine filing, with data inconsistent with the pre...

Re: Finding 2023-001 – Lost Revenue Reporting, Corrective Action Plan To whom it may concern: We agree with the auditor’s finding that the Home Health Visiting Nurse Association (VNA) erroneously filed Reporting Period 5 separately from the Tufts Medicine filing, with data inconsistent with the previous filings and methodologies. Management has implemented controls to ensure access is limited and that the reporting will be communicated and submitted by the Tufts Medicine Corporate Finance team. Management has communicated the matter with HHS and is currently in communications to resolve. Tufts Medicine Finance

View Audit 310888

Finding 404102 (2023-001)

Material Weakness 2023

City of Groveland, Florida

FL

HUD Housing Programs Reporting Matching / Level of Effort / Earmarking § 200.303

The City agrees with the recommendation to strengthen internal controls over grant reporting processes. To enhance accountability and accuracy, grant reports authored by the designated grant recipient, who is the City employee tasked with managing the grant activity, will now undergo a review by som...

The City agrees with the recommendation to strengthen internal controls over grant reporting processes. To enhance accountability and accuracy, grant reports authored by the designated grant recipient, who is the City employee tasked with managing the grant activity, will now undergo a review by someone else in the City independent of the report preparation. This review will focus on ensuring the reports are complete, accurate, and fully compliant with all stipulated grant requirements.

View Audit 310883

Finding 404100 (2023-001)

Significant Deficiency 2023

Boys and Girls Clubs of Toledo and the Toledo Newsboys Association

OH

Cash Management Internal Control / Segregation of Duties

Auditor Description of Condition and Effect. We selected a sample of disbursements that were charged to the grant. Of this sample, 5 out of 40 disbursements had questioned costs. Two disbursements had amounts submitted for reimbursement but no actual costs were incurred by the Organization. Another ...

Auditor Description of Condition and Effect. We selected a sample of disbursements that were charged to the grant. Of this sample, 5 out of 40 disbursements had questioned costs. Two disbursements had amounts submitted for reimbursement but no actual costs were incurred by the Organization. Another two disbursements included expenses for other clubs outside the grant agreement that was charged to the grant. The last disbursement was missing supporting documentation for the costs charged to the grant. As a result of this condition, the Organization did not fully comply with the requirements of the Uniform Guidance. Auditor Recommendation. We recommend that the Organization verify that costs submitted for reimbursement are valid and allowable expenses. Additionally, the Organization needs to properly allocate costs in accordance with the grant agreements. Corrective Action. Management concurs with the finding. The Organization will ensure valid and allowable expenses, including proper allocation of costs, are remitted through enhancement of the current review processes. Responsible Person. Stacy Holman, Chief Financial Officer. Anticipated Completion Date. December 31, 2024.

View Audit 310880

Finding 404058 (2023-002)

Significant Deficiency 2023

Wisconsin Coalition Against Sexual Assault Inc.

WI

Internal Control / Segregation of Duties

Grantee Response: We acknowledge the finding of the audit regarding the overclaimed amounts and the need for improved reconciliation and claim adjustments. We will implement a review procedure to enhance accountability and transparency in managing federal and state grant funds. Contact Person: Kel...

Grantee Response: We acknowledge the finding of the audit regarding the overclaimed amounts and the need for improved reconciliation and claim adjustments. We will implement a review procedure to enhance accountability and transparency in managing federal and state grant funds. Contact Person: Kelly Moe Litke, Interim Executive Director Anticipated Completion Date: Complete

View Audit 310863

Finding 404040 (2023-001)

Significant Deficiency 2023

Governmental Dept of the Fond Du Lac Band of Lake Superior Chippewa

MN

Internal Control / Segregation of Duties

Finding 2023-001 – Special Tests - Character Investigations by Indian Tribes and Tribal Organizations Assistance Listing Number – 93.210 Condition: One employee out of a selection of 25 for testing was found guilty of a felonious offense or any of two or more misdemeanor offenses under Federal, Stat...

Finding 2023-001 – Special Tests - Character Investigations by Indian Tribes and Tribal Organizations Assistance Listing Number – 93.210 Condition: One employee out of a selection of 25 for testing was found guilty of a felonious offense or any of two or more misdemeanor offenses under Federal, State, or Tribal law involving crimes of violence; sexual assault, molestation, exploitation, contact, or prostitution; crimes against persons; or offenses committed against children. Explanation of Disagreement: The Governmental Department of the Fond du Lac Band of Lake Superior Chippewa does not disagree with the finding. Corrective Action Plan: The Band will review its background investigation files for current employees to identify noncompliant adjudications that occurred prior to 2017. The employees identified as subject to a statutory bar under 42 C.F.R. § 136.405 will be unable to remain in their current positions. Name of Contact Person Responsible for Corrective Action Plan: Karen Walter, HR Director Anticipated Completion Date: August 30, 2024

View Audit 310860

Finding 404007 (2023-003)

Significant Deficiency 2023

Great Lakes Inter-Tribal Council Inc.

WI

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

Corrective Actions Taken or Planned: Create procedures by type of required reporting by grantor, as necessary. The procedure will include what and how the required report will be completed, who will and/or should review the required report, including signature for proof, and when the required report...

Corrective Actions Taken or Planned: Create procedures by type of required reporting by grantor, as necessary. The procedure will include what and how the required report will be completed, who will and/or should review the required report, including signature for proof, and when the required report should be completed. Procedures will be added to the accounting department procedures and shared with staff as necessary. Contact person(s) responsible for corrective action: Gina Brown, CFO Anticipated Completion Date: September 2024

View Audit 310846

Finding 403969 (2023-002)

Material Weakness 2023

Southeast Georgia Consolidated Housing Authority

GA

Questioned Costs Eligibility HUD Housing Programs

Finding 2023-002 Internal Controls over Documentation in Tenant Files The auditors chose 40 files to review but have NOT and did NOT provide the listing of issues and missing documentation by tenant so the Authority could verify the auditors' issues. Until this information is provided to the Aut...

Finding 2023-002 Internal Controls over Documentation in Tenant Files The auditors chose 40 files to review but have NOT and did NOT provide the listing of issues and missing documentation by tenant so the Authority could verify the auditors' issues. Until this information is provided to the Authority a corrective action plan cannot be formulated. The Authority has already reviewed all 163 tenant files as a result of the HUD Review conducted by the Atlanta Field Office. The Field Office report was received by the Authority in late December 2023. Date of Completion: Awaiting information from auditors so any revision to the procedures currently in place can be updated.

View Audit 310841 Questioned Costs: $1

Finding 403910 (2023-001)

Significant Deficiency 2023

Maverick County, Texas

TX

Reporting Significant Deficiency Internal Control / Segregation of Duties

Date: June 21, 2024 Finding 2023-001: Performance Reporting Federal Program: CLFR American Rescue Plan ALN 21.027 Federal Agency: U.S. Department of Treasury Federal Award Year: 2021 Type of Finding: Significant Deficiency in Internal Control over Compliance and Noncompliance Raul Trevino: The Count...

Date: June 21, 2024 Finding 2023-001: Performance Reporting Federal Program: CLFR American Rescue Plan ALN 21.027 Federal Agency: U.S. Department of Treasury Federal Award Year: 2021 Type of Finding: Significant Deficiency in Internal Control over Compliance and Noncompliance Raul Trevino: The County has experienced a rotation of County Auditor position for the past 6 years, within 2-year term each. Unfortunately, the American Rescue Plan Act (ARPA) was 100% handled by former County Auditor Sonia Junfin. The reporting submission was affected due to her resignation, but only for the quarter ending 12/31/2022. Corrective Actions: • Designate Access: During the 2nd Quarter of Fiscal Year 2023, the County ensured that not only the Auditor has access, at least one Assistant County auditor has access to the required information and system for report submission. • Cross-Training Program: During the 2nd Quarter of Fiscal Year 2023, the County implemented a comprehensive cross-training program to ensure all designated employees had a thorough understanding of reporting guidelines and procedures. • Designated Responsibility: During the 2nd Quarter of Fiscal Year 2023, the County designated specific individuals to be responsible of overseeing report submission deadlines to ensure compliance. Additionally, the County established clear communication channels for reporting deadlines and responsibilities to designated staff members. By following this plan, the County has addressed the issue of delayed report submissions and ensured smoother operations despite turnover in staff. Date corrective action plan was implemented: February 02, 2023.

View Audit 310796

Finding 403862 (2023-002)

Significant Deficiency 2023

Palm Beach County Board of County Commissioners

FL

Reporting Internal Control / Segregation of Duties

The department has an internal process in place requiring the review and signature by Finance Director prior to the submission of quarterly report. This policy has been reviewed with staff and Management has counseled staff regarding the submission time frames and will take necessary measures to ens...

The department has an internal process in place requiring the review and signature by Finance Director prior to the submission of quarterly report. This policy has been reviewed with staff and Management has counseled staff regarding the submission time frames and will take necessary measures to ensure review, signoff and timely submission of quarterly Cash on Hand Reporting.

View Audit 310753

Finding 403860 (2023-007)

Significant Deficiency 2023

Palm Beach County Housing Authority

FL

HUD Housing Programs Subrecipient Monitoring Significant Deficiency

Public Housing – Assistance Listing No. 14.850 Recommendation: We recommend management review policies and procedures in place and develop work processes to ensure it is in compliance with the ACOP and HUD. Explanation of disagreement with audit finding: There is no disagreement with the audit fin...

Public Housing – Assistance Listing No. 14.850 Recommendation: We recommend management review policies and procedures in place and develop work processes to ensure it is in compliance with the ACOP and HUD. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Beginning in March 2023, the PBCHA implemented the completion of all waiting lists generation/selection and intakes for eligibility within its Yardi resident portal. Intakes within Yardi automates applications, provides consistency, increases efficiency and ensures compliance with program requirements. Additionally, the PBCHA has been working with its software vendor to correct deficiencies that occurred during conversion. In taking steps to automate the RFTA process for the participants and landlords and make any necessary conversion corrections and/or improvements the PBCHA expects to address this deficiency. The PBCHA will utilize available dashboards and reports to improve monitoring and oversight to ensure compliance. Name(s) of the contact person(s) responsible for corrective action: Cheryl Lewis Planned completion date for corrective action plan: 12/31/2024

View Audit 310743

Finding 403859 (2023-006)

Significant Deficiency 2023

Palm Beach County Housing Authority

FL

HUD Housing Programs Subrecipient Monitoring Eligibility

Public Housing – Assistance Listing No. 14.850 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month and to determine if the tenant files were prepared in accordance with internal policies and until the compliance d...

Public Housing – Assistance Listing No. 14.850 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month and to determine if the tenant files were prepared in accordance with internal policies and until the compliance deficiencies have been corrected. We recommend the Authority hire outside consultants to assist with eligibility requirements or increase staffing in this area. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Beginning in March 2023, the PBCHA implemented the completion of all reexaminations within its Yardi resident portal. Reexaminations within Yardi provide online workflows that maximize efficiency, provide consistency, streamline compliance, reduce errors and increase reporting accuracy. The PBCHA will utilize available dashboards and reports to improve monitoring and oversight to ensure compliance. Name(s) of the contact person(s) responsible for corrective action: Cheryl Lewis Planned completion date for corrective action plan: 12/31/2024

View Audit 310743

Finding 403856 (2023-005)

Significant Deficiency 2023

Palm Beach County Housing Authority

FL

HUD Housing Programs Reporting Significant Deficiency

Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority implement processes to ensure HUD-50058 submissions are completed in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Acti...

Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority implement processes to ensure HUD-50058 submissions are completed in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Beginning in March 2023, the PBCHA implemented the completion of all reexaminations within its Yardi resident portal. Reexaminations within Yardi provide online workflows that maximize efficiency, streamline compliance, reduce errors and increase reporting accuracy. The PBCHA will implement processes to ensure that HUD 50058 submissions are uploaded in accordance with HUD regulations. The PBCHA will utilize available dashboards and reports to improve monitoring and oversight to ensure compliance. Name(s) of the contact person(s) responsible for corrective action: Cheryl Lewis Planned completion date for corrective action plan: 12/31/2024

View Audit 310743

Finding 403853 (2023-004)

Material Weakness 2023

Palm Beach County Housing Authority

FL

HUD Housing Programs Subrecipient Monitoring Eligibility

Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority designate an individual to maintain the waiting list and track all correspondence with potential tenants. We recommend that the Authority’s waitlist tracking software be monitored to e...

Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority designate an individual to maintain the waiting list and track all correspondence with potential tenants. We recommend that the Authority’s waitlist tracking software be monitored to ensure tenants are notified appropriately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Beginning in March 2023, the PBCHA implemented the completion of all waiting lists generation/selection and intakes for eligibility within its Yardi resident portal. Intakes within Yardi automates applications, provides consistency, increases efficiency and ensures compliance with program requirements. Additionally, the PBCHA has been working with its software vendor to correct deficiencies that occurred during conversion. In taking steps to automate the RFTA process for the participants and landlords and make any necessary conversion corrections and/or improvements the PBCHA expects to address this deficiency. The PBCHA will utilize available dashboards and reports to improve monitoring and oversight to ensure compliance. Name(s) of the contact person(s) responsible for corrective action: Cheryl Lewis Planned completion date for corrective action plan: 12/31/2024

View Audit 310743

Finding 403850 (2023-003)

Material Weakness 2023

Palm Beach County Housing Authority

FL

HUD Housing Programs Material Weakness Internal Control / Segregation of Duties

Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority designate an individual to review tenant files to determine if a rent reasonableness has been performed and was completed in a timely manner. We recommend the Authority hire outside co...

Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority designate an individual to review tenant files to determine if a rent reasonableness has been performed and was completed in a timely manner. We recommend the Authority hire outside consultants to assist with reasonable rent determinations or increase staffing in this area. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Beginning in July 2024, the PBCHA will utilize the RFTA portal within its Yardi software for all HCV participant move-ins. Completing the RFTA process within Yardi provides online workflows that maximize efficiency, provide consistency, streamline compliance, reduce errors and increase reporting accuracy. The PBCHA will utilize available dashboards and reports to improve monitoring and oversight to ensure compliance. Name(s) of the contact person(s) responsible for corrective action: Cheryl Lewis Planned completion date for corrective action plan: 12/31/2024

View Audit 310743

Finding 403847 (2023-002)

Material Weakness 2023

Palm Beach County Housing Authority

FL

HUD Housing Programs Material Weakness Internal Control / Segregation of Duties

Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend management should designate one person to oversee the inspection process to ensure that all inspections are performed in a timely manner. Furthermore, management should ensure no HAP payments are issued ...

Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend management should designate one person to oversee the inspection process to ensure that all inspections are performed in a timely manner. Furthermore, management should ensure no HAP payments are issued for units that have not passed HQS inspections. We recommend the Authority hire outside consultants to assist with inspections or increase staffing in this area. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The PBCHA will review and/or renegotiate its contract with a third-party inspection vendor and ensure adherence to provide inspection reports. HCV staff will ensure that reports are reviewed and that units with HQS deficiencies are not paid housing assistance payments. The PBCHA HCV Leadership is working to determine a strategy to consistently monitor inspection reports for passed and/or failed inspections to ensure proper abatement of HAP after the second failed inspection. The PBCHA has diligently worked to recruit, retain and train staff within its HCV department despite today’s challenging employment environment. Name(s) of the contact person(s) responsible for corrective action: Cheryl Lewis Planned completion date for corrective action plan: 12/31/2024

View Audit 310743

Finding 403844 (2023-001)

Material Weakness 2023

Palm Beach County Housing Authority

FL

HUD Housing Programs Subrecipient Monitoring Eligibility

Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month, to determine if the tenant files were prepared in accordance with internal policies and unit ...

Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month, to determine if the tenant files were prepared in accordance with internal policies and unit the compliance deficiencies have been corrected. We recommend the Authority to hire outside consultants to assist with eligibility determination and verification or increase staffing in this area. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Beginning in March 2023, the PBCHA implemented the completion of all reexaminations within its Yardi resident portal. Reexaminations within Yardi provide online workflows that maximize efficiency, streamline compliance, reduce errors and increase reporting accuracy. The PBCHA will utilize available dashboards and reports to improve monitoring and oversight to ensure compliance. Name(s) of the contact person(s) responsible for corrective action: Cheryl Lewis Planned completion date for corrective action plan: 12/31/2024

View Audit 310743

Finding 403813 (2023-004)

Significant Deficiency 2023

Institute for Sustainable Communities, Affiliate and Subsidiary

VT

Cash Management Period of Performance Significant Deficiency § 200.303

Management agrees with the recommendations. We are revising our Award Management policies to ensure the closeout procedures are clear and comply with this recommendation. We will ensure that all relevant teams are part of the closeout planning process to ensure expenses are planned for and allocated...

Management agrees with the recommendations. We are revising our Award Management policies to ensure the closeout procedures are clear and comply with this recommendation. We will ensure that all relevant teams are part of the closeout planning process to ensure expenses are planned for and allocated correctly within the period of performance. We also established a Grants Compliance Team that will be responsible for the compliance oversight of awards from inception to closeout.

View Audit 310730

Finding 403707 (2023-002)

Material Weakness 2023

Wayne Metropolitan Community Action Agency and Affiliates

MI

Questioned Costs Procurement, Suspension & Debarment Material Weakness

The submission of purchase requisitions within the ERP system is reviewed and monitored by accounts payable staff. Requisitions are now reviewed and approved by the Program supervisor and the Accounts Payable section manager. Proper documentation is required prior to the approval of all requisitions...

The submission of purchase requisitions within the ERP system is reviewed and monitored by accounts payable staff. Requisitions are now reviewed and approved by the Program supervisor and the Accounts Payable section manager. Proper documentation is required prior to the approval of all requisitions and such documentation must match the requisition in vendor name, address, amount, invoice number and appropriate program code. Staff have been trained on the use of the purchase requisition system and briefed on the necessary documentation standards.

View Audit 310726 Questioned Costs: $1

Finding 403704 (2023-003)

Significant Deficiency 2023

Wayne Metropolitan Community Action Agency and Affiliates

MI

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

Adjustments to payroll distributions, including changes in pay rates, must be requested and documented in writing by department supervisor and reviewed by the payroll manager as well as the grant accountant responsisble for the grant funding source. All requests will be included in the employee's fi...

Adjustments to payroll distributions, including changes in pay rates, must be requested and documented in writing by department supervisor and reviewed by the payroll manager as well as the grant accountant responsisble for the grant funding source. All requests will be included in the employee's file as part of the HRIS.

View Audit 310726 Questioned Costs: $1

Finding 403702 (2023-002)

Material Weakness 2023

City of Opp, Al

AL

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.305 § 200.319 § 200.320

Item 2023‐002 Written policies, procedures, and standards of conduct Recommendation: Grantees should have written policies, procedures, and standards of conduct as required by 2 CFR 200, Subparts D & E of the Uniform Guidance. 2 CFR 200, Subparts D & E requires the non‐Federal entity to establish an...

Item 2023‐002 Written policies, procedures, and standards of conduct Recommendation: Grantees should have written policies, procedures, and standards of conduct as required by 2 CFR 200, Subparts D & E of the Uniform Guidance. 2 CFR 200, Subparts D & E requires the non‐Federal entity to establish and maintain written policies, procedures, and standards of conduct including internal controls over the Federal awards that provides reasonable assurance that the non‐Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award. Specific requirements relate to the following: § 200.302 Financial management  § 200.305 Payment  § 200.319 Competition  § 200.320 Methods of procurement to be followed  § 200.430 Compensation—personal services  § 200.431 Compensation—fringe benefits We recommend that the City implement the required written policies and procedures. Action Taken: Management, namely Jan Boutwell, City Clerk, agrees with the finding and will implement the necessary written policies to comply with the UG. Management anticipates completion by September 30, 2024.

View Audit 310723

Finding 403693 (2023-001)

Significant Deficiency 2023

Town of Preston

CT

Cash Management Reporting School Nutrition Programs

FINDING 2023-001 – Significant Deficiency in Internal Control over Compliance – Reporting Description of Finding: Controls should be in place to ensure the accuracy of reporting submitted for federal awards programs with proper supporting documentation to agree to the reports being submitted to the ...

FINDING 2023-001 – Significant Deficiency in Internal Control over Compliance – Reporting Description of Finding: Controls should be in place to ensure the accuracy of reporting submitted for federal awards programs with proper supporting documentation to agree to the reports being submitted to the Department of Education. As part of the recordkeeping process, each month’s claim for reimbursement and all data used in the claims review process must be maintained on file. Of the eleven monthly claims reports reviewed during the audit, the supporting documentation for one of the claims (April 2023) could not be located. Statement of Concurrence or Nonconcurrence: The Town agrees with this finding. Corrective Action: The Town agrees with the finding and has implemented internal controls to ensure the supporting documentation for each monthly claim are filed and maintained. Each month the monthly claims reports and supporting documentation will be filed away in a designated secure location with a checklist by month to confirm processing. Name of Contact Person: Cynthia Varricchio, MBA, Director of Finance and School Business Operations. Projected Completion Date: June 30, 2024

View Audit 310692

Finding 403620 (2023-001)

Significant Deficiency 2023

Prosecuting Attorneys Association of Michigan

MI

Allowable Costs / Cost Principles Cash Management Reporting

Grantee Response: The Association took immediate action to notify the grant administrators when the condition was discovered, performed an investigation, and submitted a report to the grant administrators detailing their findings. As a result of these circumstances, the Association has made several ...

Grantee Response: The Association took immediate action to notify the grant administrators when the condition was discovered, performed an investigation, and submitted a report to the grant administrators detailing their findings. As a result of these circumstances, the Association has made several updates to their policies including 1) regularly reviewing cell phone records to detect out of state calls within one month of their occurrence; 2) developing an approval form for out of state travel that must include proof of the grant administrators approval and a detailed agenda of the trip; 3) requiring that expense reimbursement forms include travel dates and times as well as the event that the travel is related to; 4) crosschecking the shared office Outlook calendar each payroll period to personal leave requested in the payroll system; and 5) attending monthly grant administrator meetings to facilitate communication and ensure that the Association is made aware of travel requests.

View Audit 310671

Finding 403617 (2023-001)

Significant Deficiency 2023

Hospital Development Company D/b/a Roane General Hospital

WV

Special Tests & Provisions Reporting Matching / Level of Effort / Earmarking

Federal Program: Community Facilities Loans and Grants Cluster: Community Facilities Loans and Grants Assistance Listing Number: 10.766 Criteria: Section 4.6 of the USDA's Loan Guarantee Agreement stipulates that the borrower must maintain certain financial reporting covenants, such as debt servic...

Federal Program: Community Facilities Loans and Grants Cluster: Community Facilities Loans and Grants Assistance Listing Number: 10.766 Criteria: Section 4.6 of the USDA's Loan Guarantee Agreement stipulates that the borrower must maintain certain financial reporting covenants, such as debt service coverage ratio of at least 1.25, days cash on hand in excess of 65 days, and obtaining an audited fiscal year-end financial statement audited by independent certified public accountants withing one hundred ten days subsequent to year end. Additionally, section 4(d) of the Community Facilities Loan Resolution Agreement stipulates that the Hospital will establish and maintain a bookkeeping or separate bank account for the debt reserve funds. As of September 30, 2023 the Hospital had not maintained a separate account at the bank with sufficient funds, nor was a separate general ledger account established. Condition and Context: The Hospital did not maintain a days cash on hand in excess of 65 days, as of September 30, 2023. Additionally, the Hospital failed to maintain a separate account at the bank with sufficient funds, nor was a separate general ledger account established. The Hospital's audited financial statements as of September 30, 2023 were issued subsequent to one hundred ten days following September 30, 2023. Corrective Action Planned: Management has contacted the financial institutions and the United States Department of Agriculture, for waivers of debt covenants to prevent triggering an event of default. Additionally, management has reviewed and modified its internal controls to ensure monitoring of ongoing compliance. Name of Contact Person Responsible for Corrective Action: Amy Downey, Chief Financial Officer, 200 Hospital Drive, Spencer, WV 25276 Anticipated Completion Date: June 27, 2024

View Audit 310662

Finding 403506 (2023-001)

Significant Deficiency 2023

City of Hope

CA

Questioned Costs Internal Control / Segregation of Duties Period of Performance

Finding 2023-001: Internal control deficiency and noncompliance over Period of Performance. In response to this finding City of Hope (COH) will complete the following: 1. Research Accounting will present finding and revisit guidelines on period of performance requirements with Research and Post A...

Finding 2023-001: Internal control deficiency and noncompliance over Period of Performance. In response to this finding City of Hope (COH) will complete the following: 1. Research Accounting will present finding and revisit guidelines on period of performance requirements with Research and Post Award Accounting personnel. 2. COH will refund the identified questioned costs. Contact Person: Joe Norton, Vice President, Corporate Accounting and Operations Expected Completion Date: September 30, 2024

View Audit 310598 Questioned Costs: $1

Finding 403486 (2023-002)

Significant Deficiency 2023

Hunter Health Clinic, Inc.

KS

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Audit Finding: 2023-002 Eligibility Corrective Action Plan: Policy & Procedure modified to align more with IHS requirements and to make access for minors less burdensome. Persons Responsible: Tara Nolen, Director of Population Health Estimated Completion Date: August 31,2024

View Audit 310552

Corrective Action Plans

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