Corrective Action Plans

Finding 385041 (2023-001)

Material Weakness 2023

WI

Internal Control / Segregation of Duties

Finding #2023-001 – Limited Segregation of Duties (Prior Year Finding #2022-001) Condition: The available office staff precludes a proper segregation of duties in the control areas reviewed. Effect: Because of the lack of segregation of duties, errors or irregularities could occur and not be detec...

Finding #2023-001 – Limited Segregation of Duties (Prior Year Finding #2022-001) Condition: The available office staff precludes a proper segregation of duties in the control areas reviewed. Effect: Because of the lack of segregation of duties, errors or irregularities could occur and not be detected on a timely basis. Cause: Controls Over Accounts Payable/Disbursements 1. Person processing accounts payable is not always separate from those who print the checks. Controls Over Payroll 1. Person preparing the payroll is not independent of other personnel duties such as custody of the checks. Criteria: Internal controls should be in place that provide adequate segregation of duties. Generally, a system of internal control contemplates separation of duties such that no individual has responsibility to execute a transaction, have physical access to the related assets, and have responsibility or authority to record the transaction. Recommendation: Procedures should be implemented segregating duties among different employees. Management should continue to maintain a working knowledge of matters relating to the district’s operations. Response: We agree with this finding and continue to work to achieve segregation of duties whenever cost effective. The cash disbursements process includes approval of purchase orders and matching of approved purchase orders with invoices. Review of account coding is performed by the district accounting staff. The payroll disbursement process includes approval of timesheets and review of coding on an ongoing basis. The Board of Education reviews budget to actual information along with disbursement information monthly. Contact Person: Loras Winders Anticipated Completion: Not Applicable

View Audit 298149

Finding 385033 (2023-101)

Material Weakness 2023

City of Winslow, Arizona

AZ

HUD Housing Programs Internal Control / Segregation of Duties Special Tests & Provisions

2023-101 Special Tests and Provisions - Waiting List Recommendation: The Authority should develop procedures to help ensure that the waiting list is properly maintained and updated upon its policy Action Taken: City concurs and has implemented the recommendation. Completion date: During fiscal year ...

2023-101 Special Tests and Provisions - Waiting List Recommendation: The Authority should develop procedures to help ensure that the waiting list is properly maintained and updated upon its policy Action Taken: City concurs and has implemented the recommendation. Completion date: During fiscal year 2024 Contact Person: Margaret Dyer, Finance Director

View Audit 298130

Finding 385031 (2023-001)

Significant Deficiency 2023

Autonomous Municipality of Caguas

PR

HUD Housing Programs Subrecipient Monitoring Eligibility

The Municipality of Caguas PHA will implement internal controls which ensure that the families files conform to the program requirements for the annual recertifications. Each month the Program Manager or the persona assigned by the Director, will select a sample of files of each zone and verify the ...

The Municipality of Caguas PHA will implement internal controls which ensure that the families files conform to the program requirements for the annual recertifications. Each month the Program Manager or the persona assigned by the Director, will select a sample of files of each zone and verify the following: Voucher Size, Family Composition, income., Inspection Documents, Payment Standards, Utilities, and the rent calculation in the Form HUD-50058, Family Report and other required documents. Files without all the required documentation will be assigned to the respective Housing Office (HO). The HO must contact the family and request the necessary documentation in order to complete the tenant file. The HO will be required to complete all corrective actions within 15 days upon assignment. If additional time is needed, the Director or the person assigned will evaluate the case and may provide an additional 15 days for a maximum of 30 days.

View Audit 298127

Finding 385028 (2023-004)

Material Weakness 2023

Newell School District

SD

Reporting Internal Control / Segregation of Duties

FINDING: Audit Adjustments Responsible Individuals: Don Kirkegaard, Interim Superintendent Corrective Action Plan: The District agrees with the above finding and will make the audit adjustments per the auditor’s recommendations. Anticipated Completion Date: Ongoing

View Audit 298115

Finding 385022 (2023-001)

Material Weakness 2023

Jefferson County Iowa

IA

Internal Control / Segregation of Duties

Segregation of Duties Name of contact person - Scott Reneker, County Auditor Corrective Action - The duties will be separated as much as possible and alternative controls wil...

Segregation of Duties Name of contact person - Scott Reneker, County Auditor Corrective Action - The duties will be separated as much as possible and alternative controls will be considered to compensate for lack of separation. Proposed Completion Date - Ongoing.

View Audit 298108

Finding 385011 (2023-001)

None 2023

Universidad Central De Bayamon INC

PR

Student Financial Aid Eligibility Matching / Level of Effort / Earmarking

Finding No. 2023–001 – Disbursement to or on behalf students Title IV, HEA credit balances Name of Contact Person: Dr. Ismael A. Velez de la Rosa Corrective Action Plan The University affirms its understanding of its obligation to submit disbursement according to the 34 CFR 668.164(h)(2)(i) A title ...

Finding No. 2023–001 – Disbursement to or on behalf students Title IV, HEA credit balances Name of Contact Person: Dr. Ismael A. Velez de la Rosa Corrective Action Plan The University affirms its understanding of its obligation to submit disbursement according to the 34 CFR 668.164(h)(2)(i) A title IV, a HEA credit balance must be paid directly to the student or parent as soon as possible, but no later than fourteen (14) days after the balance occurred, if the credit balance occurred after the first day of class of a payment period. Due to an error in the system, within institutional officials in charge of managing this process, one disbursement was not submitted on a timely basis. UCB will reinforce their policies and procedures to satisfy all applicable requirements specified in 668.164 (h) and due a doble verification of the process to make sure every student no later than fourteen (14) days after the balance occurred. As of the date of the auditors’ report, the University request all of the institution’s officials to work in the school premises and the communication between officials has been improve, making easier the tracking of the disbursements on a timely basis to students. Anticipated completion date: Immediately.

View Audit 298066

Finding 384995 (2023-002)

Material Weakness 2023

Lincoln Parish School Board

LA

School Nutrition Programs Subrecipient Monitoring Cash Management

Reference # and title: 2023-002 Internal Control and Compliance over Financial Reporting Federal program and specific federal award identification: AL Number Award Year FEDERAL GRANTER/ PASS THROUGH GRANTOR/PROGRAM NAME United States Department of Agriculture; passed through Louisiana Department of ...

Reference # and title: 2023-002 Internal Control and Compliance over Financial Reporting Federal program and specific federal award identification: AL Number Award Year FEDERAL GRANTER/ PASS THROUGH GRANTOR/PROGRAM NAME United States Department of Agriculture; passed through Louisiana Department of Education Child Nutrition Cluster: School Breakfast Program AL #10.553 2023 National School Lunch Program AL #10.555 2023 Condition: Louisiana Department of Education (LDOE) requires the School Board to complete monthly claims for reimbursement for meals and snacks served to eligible students within 60 days of the following the last day of the month covered by the claim. Required internal controls over these claims for reimbursement required that all data for the claim be maintained and complete and accurate. Additionally, internal controls require that reports be reviewed by someone other than the person completing the claim. In testing a sample of two months, it was noted that the School Board did not have a review process of the claim by a second person before the claim was submitted. It was also noted that the School Board did not include all students that received meals in requesting for reimbursement as well as the School Board used the wrong CEP percentage in the request for reimbursement. In reviewing the full year’s claims to determine the amount over/under requested, it was noted that these errors caused the School Board to under request for reimbursement in the amount of $20,044. Corrective action planned: The Lincoln Parish School Board hired a new CNP Supervisor in November, 2023 and a new CNP secretary/bookkeeper in December, 2023. CEP reimbursement claim training was conducted on-site with CNP department staff on December 13, 2023, by: - Stephanie Loup – Executive Director of Nutrition – Louisiana Department of Education - Misty Woods – Director of School Food Service– Louisiana Department of Education During this training, the CEP free claim percentage for 2023-2024 was validated as 83.78% and a mock claim worksheet was completed with new administrative staff. This percentage will be validated annually. Regarding the review process of the CEP claim, we have implemented a two-check verification method for this process. Step One is related to the bookkeeper’s responsibilities. The bookkeeper collects and fills out the CNP Reimbursement Claim form in the CNP Claim portal, prints the completed form, and then signs and dates the form before it is submitted to the CNP Supervisor. Step Two is related to the CNP Supervisor’s responsibility. The Supervisor will conduct final review of the report data. If the report is accurate, the Supervisor signs and dates the printed form and returns the form to the Bookkeeper for filing with claim records. Then, the official claim is submitted electronically by the Bookkeeper via the State CNP Claim portal. Person responsible for corrective action: Mr. Cody Carrico, Supervisor of Food Service Phone: (318) 255-1474 Lincoln Parish School Board Fax: (318) 254-1220 1428 Arlington Street Ruston, LA 71270 Anticipated completion date: December 31, 2023 – Actively in place

View Audit 298062

Finding 384989 (2023-001)

Significant Deficiency 2023

Newberry County Memorial Hospital

NC

Questioned Costs Reporting Significant Deficiency

Department of Health and Human Services Newberry County Memorial Hospital respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 through June 30, 2023 The finding from the schedule of findings and questioned costs is discussed below....

Department of Health and Human Services Newberry County Memorial Hospital respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 through 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. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2023-001 Provider Relief Funding – Assistance Listing No. 93.498 Recommendation: We recommend the Organization perform a detailed review of the supporting documentation to ensure accurate expenses are inputted in the internal tracking spreadsheets that is ultimately used by the Management to input into the HRSA reporting portal. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The hospital attempted to track COVID supplies to each nursing unit cost center. This required the Materials Management department to track detailed items in a spreadsheet format. Human error resulted in two of the items being charged with an incorrect amount. The hospital is implementing a new procedure that will improve tracking each expense from the storeroom. An additional step will be for the ACFO to check each month's COVID expense allocation to the spreadsheet to identify potential errors and improve accuracy of the reporting the claimed expenses. Name(s) of the contact person(s) responsible for corrective action: John L. Doyle, Chief Financial Officer Planned completion date for corrective action plan: September 30, 2024 If the Department of Health and Human Services has questions regarding this plan, please call John L. Doyle, CFO, at 803-405-7137

View Audit 298040 Questioned Costs: $1

Finding 384985 (2023-001)

Significant Deficiency 2023

Madison Area Technical College District

WI

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Student Financial Aid Cluster – Assistance Listing No. 84.063 & 84.268 Recommendation: We recommend that the College design and implement controls to ensure reporting to NSLDS are designed to capture all enrolled students and programs offered by the District. Explanation of disagreement with audit...

Student Financial Aid Cluster – Assistance Listing No. 84.063 & 84.268 Recommendation: We recommend that the College design and implement controls to ensure reporting to NSLDS are designed to capture all enrolled students and programs offered by the District. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District worked with NSC to resolve the errors surrounding mismatched CIP codes, resulting in the enrollment report being finalized in late 2022. The College will work with their Records Department to explore accommodations surrounding future term requirements. Name(s) of the contact person(s) responsible for corrective action: Laurie Grigg, Chief Financial Officer Planned completion date for corrective action plan: June 30, 2024

View Audit 298033

Finding 384974 (2023-001)

Significant Deficiency 2023

Community Service Society of New York

NY

Subrecipient Monitoring Reporting Significant Deficiency

Community Service Society (the Society) requires its subrecipients to submit their financial and progress program reports five days after the end of the reporting period. This is done so that the Society can review the underlying documentation in those reports to ensure that proper payments are made...

Community Service Society (the Society) requires its subrecipients to submit their financial and progress program reports five days after the end of the reporting period. This is done so that the Society can review the underlying documentation in those reports to ensure that proper payments are made to the subrecipients and, in turn, proper and timely reports are filed by the Society with the State of New York. There are instances when, because of delays in receipt of information from the subrecipients, or information from the subrecipients needs to be revised, reports are submitted late to the State of New York. The Society notifies the State of New York when reports will be submitted late. In addition, the Society is working with its subrecipients to improve their reporting procedures, as well as the timeliness and accuracy of their reports. This will result in the Society improving the timeliness of its reporting to the State of New York.

View Audit 298015

Finding 384973 (2023-002)

None 2023

The Queens Borough Public Library

NY

Questioned Costs Eligibility Internal Control / Segregation of Duties

Finding Number: 2023-002 – Eligibility Planned Corrective Action: We agree with the finding. It should be noted that this individual received only 30 minutes of services. Nonetheless, to prevent future occurrences, we have established a peer-review process where student records are rev...

Finding Number: 2023-002 – Eligibility Planned Corrective Action: We agree with the finding. It should be noted that this individual received only 30 minutes of services. Nonetheless, to prevent future occurrences, we have established a peer-review process where student records are reviewed by a program coordinator or manager to ascertain compliance with the grant requirements. We have also scheduled a series of trainings for staff in addition to the ones offered by the state to keep staff up-to-date on guidelines and changes to the grants. Person Responsible: Stephen Mack, Chief Financial Officer Expected Completion Date: Immediately

View Audit 298014 Questioned Costs: $1

Finding 384971 (2023-001)

Material Weakness 2023

Oakland Unified School District

CA

HUD Housing Programs Material Weakness Reporting

December 15, 2023 SUBJECT: Corrective Action Plan For Oakland Unified School District for fiscal year ended June 30, 2023- Single Audit Under the provisions of Uniform Administrative Requirement, Cost Principles, and Audit Requirements for Federal Awards at 2 CFR 200 (Uniform Guidance), the auditee ...

December 15, 2023 SUBJECT: Corrective Action Plan For Oakland Unified School District for fiscal year ended June 30, 2023- Single Audit Under the provisions of Uniform Administrative Requirement, Cost Principles, and Audit Requirements for Federal Awards at 2 CFR 200 (Uniform Guidance), the auditee is responsible for follow-up and corrective action plans on all single audit findings. As part of this responsibility, Oakland Unified School District has prepared a corrective action plan for current year audit finding. OUSD’s Expanded Learning Office (ExLO) Conducted a Mandatory Attendance Meeting for all Site Coordinators and Agency Directors. ExLO staff worked alongside 83 different sites to ensure sites were aware of how to accurately track and enter attendance into escape. In addition, ExLO created an attendance dashboard that provides real-time attendance data. This new tool has allowed site coordinators to view attendance data and track missing/incorrect information. Expanded Learning Office has continued to hold regular meetings with Site Coordinators and Agency Directors to review attendance data to ensure high-quality programming occurs at all sites. This includes 4 Agency Directors meeting and 4 All leaders meeting. The Expanded Learning also hired Program Assistants to help support with monthly attendance audits to ensure accurate attendance tracking. This new role also provided on-site support to site coordinators. OUSD has implemented a new Expanded Learning Attendance improved tracking system and provided training to service providers. This new database allows for accurate and prompt attendance taking. 1.OUSD transitioned to a new attendance tracking system. Due to the multiple errors and consistentchanges in attendance, OUSD began using Aeries Supplemental Attendance tracking instead of CitySpanin fall 2021. This transition has allowed the Expanded Learning Office to support struggling sites withreal-time accurate attendance data. 2.On July 29, OUSD held a mandatory Aeries training for all after-school staff and reviewed all CDE (ASES,21st CCLC, and ASSETS) attendance requirements. Over 100 after-school staff attended. 3.All Attendance documents were revised to include Aeries attendance protocols. 4.OUSD Designed dashboards with real-time student and attendance data for all after-school providers. The CDE has accepted the District's CAP as of 8/29/2022.

View Audit 298008

Finding 384966 (2023-001)

Material Weakness 2023

10-15 Regional Transit Agency

IA

Internal Control / Segregation of Duties

Segregation of Duties - Name of Contact Person - Jay Allison Corrective Action - The duties will be separated as much as possible and alternative controls will be considered to compensate for lack of separation - Proposed Completion Date - Ongoing

View Audit 298002

Finding 384958 (2023-006)

None 2023

Vienna Public School District #55

IL

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.512

Name of Contact Person: Greg Frehner, Superintendent. Recommendation: We recommend that all required filings be submitted timely according to the Single Audit Act of 1984 and Title 2 U.S. Code of Federal Regulations Guidelines. Corrective Action: The auditors discussed the issue with the Distri...

Name of Contact Person: Greg Frehner, Superintendent. Recommendation: We recommend that all required filings be submitted timely according to the Single Audit Act of 1984 and Title 2 U.S. Code of Federal Regulations Guidelines. Corrective Action: The auditors discussed the issue with the District. A new checklist will be used with audit completion to ensure timely submission for the 2023 fiscal year. Proposed Completion Date: Immediately.

View Audit 297986

Finding 384941 (2023-001)

Significant Deficiency 2023

Fayette County

IA

Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN March 14, 2024 To: U.S. Department of Treasury Fayette County respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Hacker, Nelson & Co., CPAs 123 W. Water Street Decorah, IA ...

CORRECTIVE ACTION PLAN March 14, 2024 To: U.S. Department of Treasury Fayette County respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Hacker, Nelson & Co., CPAs 123 W. Water Street Decorah, IA 52101 Audit period: Year ended June 30, 2023. The finding from the June 30, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING - FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Treasury • Federal Assistance Listing Number 21.027 Coronavirus State and Local Fiscal Recovery Funds Internal control deficiencies: See Finding 2023-001 Recommendation: The County should review the operating procedures of the County offices to obtain the maximum internal control possible under the circumstances utilizing currently available staff, including elected officials. While we do recognize that the County is not large enough to permit a segregation of duties for effective internal controls, we believe it is important the Board be aware that this condition does exist. Action Taken: Management is cognizant of this limitation and will implement additional procedures where possible. Anticipated Date of Completion: June 30, 2024 Page 2 If the U.S. Department of Treasury has questions regarding this plan, please call Lori Moellers, County Auditor, at 563-422-3497. Sincerely yours, Lori Moellers, County Auditor Fayette County cc: Christi L. Meyer, CPA

View Audit 297981

Finding 384937 (2023-003)

Significant Deficiency 2023

Palmdale Aerospace Academy

CA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Fiscal year ended June 30, 2023, represents a transition year for the Academy as it is the first fiscal year in which Academy staff has been in charge of processing all accounting and business transactions in‐house. Previously the Academy utilized a back‐office provider. In making the transition to ...

Fiscal year ended June 30, 2023, represents a transition year for the Academy as it is the first fiscal year in which Academy staff has been in charge of processing all accounting and business transactions in‐house. Previously the Academy utilized a back‐office provider. In making the transition to in‐house processing, the Academy has sought to build up the capabilities of its business department, including the full implementation of a new financial software system as well as augmenting the capabilities of staff both in number and in capabilities. In addition, the Academy has made extensive use of expert outside consultants to strengthen its system of internal controls and accounting procedures to ensure that a robust system for processing accounting and business transactions is in place. The Academy will continue to both procure the services of outside experts and augment the capabilities of the business department as deemed necessary. In addition, the departments in charge of maintaining files and records pertinent to financial transactions will strengthen their procedures to ensure that all such files and records are properly maintained, and the business department will audit such on a quarterly basis. The business department will continue to ensure that all accounts receivable, accounts payable, and refundable advances will be reconciled quarterly. As well, at the end of each fiscal year, all areas will be reconciled and adjusted as needed. At the beginning of each fiscal year, all areas will be verified for accuracy and any necessary corrections will be made accordingly.

View Audit 297979

Finding 384934 (2023-002)

Significant Deficiency 2023

Palmdale Aerospace Academy

CA

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

Fiscal year ended June 30, 2023, represents a transition year for the Academy as it is the first fiscal year in which Academy staff has been in charge of processing all accounting and business transactions in‐house. Previously the Academy utilized a back‐office provider. In making the transition to ...

Fiscal year ended June 30, 2023, represents a transition year for the Academy as it is the first fiscal year in which Academy staff has been in charge of processing all accounting and business transactions in‐house. Previously the Academy utilized a back‐office provider. In making the transition to in‐house processing, the Academy has sought to build up the capabilities of its business department, including the full implementation of a new financial software system as well as augmenting the capabilities of staff both in number and in capabilities. In addition, the Academy has made extensive use of expert outside consultants to strengthen its system of internal controls and accounting procedures to ensure that a robust system for processing accounting and business transactions is in place. The Academy will continue to both procure the services of outside experts and augment the capabilities of the business department as deemed necessary. In addition, the departments in charge of maintaining files and records pertinent to financial transactions will strengthen their procedures to ensure that all such files and records are properly maintained, and the business department will audit such on a quarterly basis. The business department will continue to ensure that all accounts receivable, accounts payable, and refundable advances will be reconciled quarterly. As well, at the end of each fiscal year, all areas will be reconciled and adjusted as needed. At the beginning of each fiscal year, all areas will be verified for accuracy and any necessary corrections will be made accordingly.

View Audit 297979

Finding 384932 (2023-002)

Material Weakness 2023

Community Health Project, INC Dba Michael Callen-Audre Lorde Chc

NY

Material Weakness Reporting Internal Control / Segregation of Duties

March 15, 2024 Health Resources and Services Administration Patrick McGovern, Community Health Project, Inc.’s (d/b/a Michael Callen-Audre Lorde Community Health Center’s) CEO respectfully submits the following corrective action plan for the year ended June 30, 2023: CohnReznick LLP 1301 Avenue of t...

March 15, 2024 Health Resources and Services Administration Patrick McGovern, Community Health Project, Inc.’s (d/b/a Michael Callen-Audre Lorde Community Health Center’s) CEO respectfully submits the following corrective action plan for the year ended June 30, 2023: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2023 The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS FEDERAL AWARD PROGRAM AUDITS Material Weakness 2023-002 - Accuracy of Reporting to the PRF Portal: U.S. Department of Health and Human Services, COVID-19: Provider Relief Fund and American Rescue Plan ("ARP") Rural Distribution: Assistance Listing Number 93.498 – Reporting Recommendation We recommend that the Organization strengthen its system of internal controls to ensure that all reporting that is done and submitted is consistent with requirements and instructions as provided by regulatory agencies. Action Taken The Organization has implemented policies and procedure to ensure controls are implemented to review against underlying documentation prior to submission to ensure compliance with regulatory agencies. Significant Deficiency 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions Chelsea 356 West 18th Street New York, NY 10011 212.271.7200 Thea Spyer Center 230 West 17th St New York, NY 10011 212.271.7200 Bronx 3144 3rd Ave Bronx, NY 10451 718.215.1800 Recommendation We recommend that management implement their policy that requires board review of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record (EMR) system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Action Taken The organization has implemented an annual approval process for the sliding fee scale to be added as an agenda item for our board approval within the first quarter of every calendar year. For the 2023 sliding fee scale, the board subsequently performed its review and did not find any errors with it thus they retroactively approved and authorized its application We have implemented a procedure whereby the billing department in charge shall seek to obtain this approval annually. Sincerely yours, Signature: Name: Patrick McGovern Title: Chief Executive Officer Organization’s Name: Callen-Lorde Community Health Center Date: 3/15/2024

View Audit 297971

Finding 384925 (2023-001)

Significant Deficiency 2023

Community Health Project, INC Dba Michael Callen-Audre Lorde Chc

NY

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

March 15, 2024 Health Resources and Services Administration Patrick McGovern, Community Health Project, Inc.’s (d/b/a Michael Callen-Audre Lorde Community Health Center’s) CEO respectfully submits the following corrective action plan for the year ended June 30, 2023: CohnReznick LLP 1301 Avenue of t...

March 15, 2024 Health Resources and Services Administration Patrick McGovern, Community Health Project, Inc.’s (d/b/a Michael Callen-Audre Lorde Community Health Center’s) CEO respectfully submits the following corrective action plan for the year ended June 30, 2023: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2023 The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS FEDERAL AWARD PROGRAM AUDITS Material Weakness 2023-002 - Accuracy of Reporting to the PRF Portal: U.S. Department of Health and Human Services, COVID-19: Provider Relief Fund and American Rescue Plan ("ARP") Rural Distribution: Assistance Listing Number 93.498 – Reporting Recommendation We recommend that the Organization strengthen its system of internal controls to ensure that all reporting that is done and submitted is consistent with requirements and instructions as provided by regulatory agencies. Action Taken The Organization has implemented policies and procedure to ensure controls are implemented to review against underlying documentation prior to submission to ensure compliance with regulatory agencies. Significant Deficiency 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions Chelsea 356 West 18th Street New York, NY 10011 212.271.7200 Thea Spyer Center 230 West 17th St New York, NY 10011 212.271.7200 Bronx 3144 3rd Ave Bronx, NY 10451 718.215.1800 Recommendation We recommend that management implement their policy that requires board review of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record (EMR) system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Action Taken The organization has implemented an annual approval process for the sliding fee scale to be added as an agenda item for our board approval within the first quarter of every calendar year. For the 2023 sliding fee scale, the board subsequently performed its review and did not find any errors with it thus they retroactively approved and authorized its application We have implemented a procedure whereby the billing department in charge shall seek to obtain this approval annually. Sincerely yours, Signature: Name: Patrick McGovern Title: Chief Executive Officer Organization’s Name: Callen-Lorde Community Health Center Date: 3/15/2024

View Audit 297971

Finding 384924 (2023-034)

Material Weakness 2023

State of Vermont

VT

Subrecipient Monitoring Material Weakness Reporting § 200.303

Public Assistance: Once a subaward has been executed and the cumulative obligated project worksheets have reached the $30,000 reporting threshold, then the Financial Administrator must enter the subaward in FSRS as outlined above. Subsequent project worksheet obligations shall be treated as award am...

Public Assistance: Once a subaward has been executed and the cumulative obligated project worksheets have reached the $30,000 reporting threshold, then the Financial Administrator must enter the subaward in FSRS as outlined above. Subsequent project worksheet obligations shall be treated as award amendments and must be entered into FSRS no later than the last day of the month following the month in which the project worksheet was obligated. Name: Richard Hallenbeck Position: Director of Administration/Finance Email: Richard.hallenbeck@vermont.gov Phone Number: 802 241-5339 Date of Implementation of Corrective Action: 03/31/2024

View Audit 297960

Finding 384922 (2023-033)

Significant Deficiency 2023

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

The Financial Administrator will ensure that subrecipient grants containing federal funding that meet the FFATA reporting threshold are marked as “required for entry into the FSRS system” upon grant execution. The Financial Administrator and Manager will then confirm that all executed agreements tha...

The Financial Administrator will ensure that subrecipient grants containing federal funding that meet the FFATA reporting threshold are marked as “required for entry into the FSRS system” upon grant execution. The Financial Administrator and Manager will then confirm that all executed agreements that meet the FFATA reporting requirement have been entered and submitted into the FSRS system by the last business day of each month. Please note that the scheduled completion date is 2/1/23 as the same FFATA reporting finding was identified for a different program during the SFY22 Single Audit, and the corrective action plan was applied across the Department as a whole. The FFATA issues identified in the SFY23 Single Audit pre-dated the implementation of our corrective action plan. Scheduled Completion Date of Corrective Action Plan: Completed Contacts for Corrective Action Plan: Lillian Smith, VDH Financial Administrator lillian.smith@vermont.gov Jessica Brown, VDH Financial Manager jessica.p.brown@vermont.gov Megan Hoke, VDH Financial Director megan.hoke@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384910 (2023-030)

Significant Deficiency 2023

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (ALN 93.775, 93.777, 93.778) that is shared between all AHS departments. To address omissions and timeliness of subawards and subaward modifications reporting to FSRS, IAG...

Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (ALN 93.775, 93.777, 93.778) that is shared between all AHS departments. To address omissions and timeliness of subawards and subaward modifications reporting to FSRS, IAG conducted additional training tailored to each AHS Department to examine the results of FFATA testing conducted internally and reemphasized the FFATA compliance regulations. This ensured the Internal Audit Group (IAG) is provided with complete, accurate and timely subaward information for reporting in FSRS going forward. The results of the 2023 finding show that the departments understood the training materials and complied with the requirements to report. Although not timely, regarding the reporting in FY2023, the FY2024 should yield timeliness because of the prior year corrective action completion that was closed on 04/11/2023. On at least an annual basis, IAG conducts a review of current federal rules and regulations pertaining to FFATA reporting for FSRS to assure the Agency’s procedures are up to-date. Coincidentally, IAG will also select a random sample of subawards and subawards modifications that meet the required threshold for FFATA reporting to ensure they are reported in FSRS system on a complete, accurate and timely basis. Scheduled Completion Date of Corrective Action Plan: December 31, 2023: Annual review of FFATA rules and regulations including subawards review. Contacts for Corrective Action Plan: Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384906 (2023-029)

Material Weakness 2023

State of Vermont

VT

Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking § 200.303

Vermont Agency of Digital Services (ADS) meets the biennial ADP system security review requirement on behalf of Vermont Agency of Human Services (AHS) via an IRS Security Audit (cadency of every three years) and by contracting with 3rd party security risk assessment firms like JANUS Associates. Bot...

Vermont Agency of Digital Services (ADS) meets the biennial ADP system security review requirement on behalf of Vermont Agency of Human Services (AHS) via an IRS Security Audit (cadency of every three years) and by contracting with 3rd party security risk assessment firms like JANUS Associates. Both audits use the same standard IRS Publication 1075 which is built on the NIST standard 800-53 revision 5. Over the last year the DCF IT Maintenance & Operations (M&O) Team has provided the IRS two CAP updates for the finding related to the last IRS audit. There is expected to be an overlap between the findings of the last IRS Audit and those identified by JANUS and ADS will complete a cross reference analysis between these two audits by the end of this calendar year. If there are any findings that are unique to JANUS (i.e., not identified in the IRS audit), a CAP will be documented for the finding by the end of this calendar year. An experienced IT Specialist on the DCF IT M&O Team has been assigned to lead this compliance project. Scheduled Completion Date of Corrective Action Plan: December 31, 2023: CAP to be documented. TBD: Documented CAP to be completed. Contacts for Corrective Action Plan: Michael Blanchard, ADS IT Manager michael.blanchard@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

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Finding 384904 (2023-027)

Significant Deficiency 2023

State of Vermont

VT

Procurement, Suspension & Debarment Eligibility Significant Deficiency § 200.303

The case was mistakenly closed on 6/30/23 based on non-response to an income verification request. A verification notice was sent 6/12/2023. The member did not respond to this notice. The member should then have received notice of termination effective 7/31/2023. The case was not processed for clos...

The case was mistakenly closed on 6/30/23 based on non-response to an income verification request. A verification notice was sent 6/12/2023. The member did not respond to this notice. The member should then have received notice of termination effective 7/31/2023. The case was not processed for closure and appropriate notice was not sent because a system error caused this member to be classified as a new applicant instead of enrollee. This was likely due to case-specific circumstances of timing and household eligibility (other members were no longer eligible for Medicaid). Further, because they were classified as a new applicant, they received an additional verification notice (even though coverage was already terminated) and were ultimately “denied” for non-response in late July. As corrective action, we reinstated CHIP back to 7/1/2023 through 10/31/2023 after sending proper closure notice for failure to respond. Based on our internal QA process, Medicaid Recon and HCQC unit’s internal case reviews, no other incidents of this condition were found as of 10/2/2023. Scheduled Completion Date of Corrective Action Plan: Completed Contacts for Corrective Action Plan: Nicole McAllister, DVHA-HAEEU HCAA II nicole.mcallister@vermont.gov Sarah York, DVHA-HAEEU HCAA I sarah.york@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384901 (2023-024)

Material Weakness 2023

State of Vermont

VT

Subrecipient Monitoring Material Weakness Reporting § 200.303

The Financial Administrator will ensure that subrecipient grants containing federal funding that meet the FFATA reporting threshold are marked as “required for entry into the FSRS system” upon grant execution. The Financial Administrator and Manager will then confirm that all executed agreements tha...

The Financial Administrator will ensure that subrecipient grants containing federal funding that meet the FFATA reporting threshold are marked as “required for entry into the FSRS system” upon grant execution. The Financial Administrator and Manager will then confirm that all executed agreements that meet the FFATA reporting requirement have been entered and submitted into the FSRS system by the last business day of each month. Please note that the scheduled completion date is 2/1/23 as the same FFATA reporting finding was identified for a different program during the SFY22 Single Audit, and the corrective action plan was applied across the Department as a whole. The FFATA issues identified in the SFY23 Single Audit pre-dated the implementation of our corrective action plan. Scheduled Completion Date of Corrective Action Plan: 2/1/2023 Contacts for Corrective Action Plan: Lillian Smith, VDH Financial Administrator lillian.smith@vermont.gov Jessica Brown, VDH Financial Manager jessica.p.brown@vermont.gov Megan Hoke, VDH Financial Director megan.hoke@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

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