Corrective Action Plans

Finding 560504 (2022-010)

Material Weakness 2022

AK

Allowable Costs / Cost Principles Eligibility Material Weakness

Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments have been filled to ensure that the Council follows internal control policies over grant reporting. Proposed Completion Date: Complete as of June 30, 2024

View Audit 356419

Finding 560503 (2022-009)

Material Weakness 2022

Orutsararmiut Native Council

AK

Special Tests & Provisions Material Weakness Internal Control / Segregation of Duties

Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Due to miscommunication and turnover of accounting personnel, a misunderstanding arose regarding the collateralization of the Council’s general checking account to which federal awards are deposited. The financial institution...

Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Due to miscommunication and turnover of accounting personnel, a misunderstanding arose regarding the collateralization of the Council’s general checking account to which federal awards are deposited. The financial institution utilizes a repurchase agreement by which the daily remaining collected balance in the checking account is invested by the bank, acting as agent of the Council. Securities purchased are exclusively obligations of the U.S. government and/or its agencies, or municipal bonds rated A or better. Proposed Completion Date: Complete as of June 30, 2024

View Audit 356419

Finding 560500 (2022-006)

Material Weakness 2022

Orutsararmiut Native Council

AK

Material Weakness Reporting Internal Control / Segregation of Duties

Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments will be filled to ensure that the Council follows internal control policies relating to timely and accurate reporting. Proposed Completion Date: Complete as of J...

Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments will be filled to ensure that the Council follows internal control policies relating to timely and accurate reporting. Proposed Completion Date: Complete as of June 30, 2024

View Audit 356419

Finding 560264 (2022-002)

Material Weakness 2022

Florida Grand Opera Inc.

FL

Internal Control / Segregation of Duties Reporting

The Organization has established policies and procedures to ensure appropriate segregation of duties as it relates to recording journal entries and account reconciliations. The Organization has brought in an outsourced accounting firm to assist with the preparation of journal entries and preparation...

The Organization has established policies and procedures to ensure appropriate segregation of duties as it relates to recording journal entries and account reconciliations. The Organization has brought in an outsourced accounting firm to assist with the preparation of journal entries and preparation of account reconciliations.

View Audit 356193

Finding 560263 (2022-001)

Material Weakness 2022

Florida Grand Opera Inc.

FL

Reporting Internal Control / Segregation of Duties

The Organization has established policies and procedures to close its financial statements in a timely manner. Additionally, the Organization has brought in an outsourced accounting firm to assist with the accounting and financial reporting.

View Audit 356193

Finding 560138 (2022-013)

Material Weakness 2022

Oregon Coast Community Action

AL

Allowable Costs / Cost Principles Eligibility Period of Performance § 200.303

ORCCA's current process at the program level has improved to ensure proper documentation of eligibility. The Housing director and staff have implemented this internal control at the program level. The finance department's internal control (as noted earlier) is in place to ensure the payment requests...

ORCCA's current process at the program level has improved to ensure proper documentation of eligibility. The Housing director and staff have implemented this internal control at the program level. The finance department's internal control (as noted earlier) is in place to ensure the payment requests have sufficient supporting documentation. As for record retention, ORCCA hired additional temp workers to ensure completed transactions are filed timely with the goal of going paperless in the near future. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 2025

View Audit 356132

Finding 560125 (2022-010)

Significant Deficiency 2022

Oregon Coast Community Action

AL

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.303

ORCCA is aware of the lack of documentation and internal control during the audit period due to various reasons, mainly short staffing and staff turnover, and has been working hard to prevent such occurrences. The Finance staff (Finance Director, Accounting Manager, Program Fiscal Compliance Coordin...

ORCCA is aware of the lack of documentation and internal control during the audit period due to various reasons, mainly short staffing and staff turnover, and has been working hard to prevent such occurrences. The Finance staff (Finance Director, Accounting Manager, Program Fiscal Compliance Coordinator) have already started communicating with program directors if any such issues are observed. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 2025

View Audit 356132

Finding 560096 (2022-002)

Significant Deficiency 2022

Central Area Rural Transit System, Inc.

AK

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

Finding 2022-002 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Corrective Action Plan To prevent recurrence of the late filing of financial reports, staff will work to prepare year end reconciliations for major programs, state and federal schedules of expendit...

Finding 2022-002 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Corrective Action Plan To prevent recurrence of the late filing of financial reports, staff will work to prepare year end reconciliations for major programs, state and federal schedules of expenditures to determine single audit status, and file corresponding reports in a timely manner. Expected Completion Date June 30, 2025

View Audit 356073

Finding 560043 (2022-001)

Significant Deficiency 2022

Wisconsin Cheese Makers Association

WI

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

Comments on findings and recommendations Management should implement a process to evaluate and allocate expenses on a regular basis. Actions taken or planned Management implemented a process to evaluate and allocate expenses based on employee estimates of time spent by function and proportion of th...

Comments on findings and recommendations Management should implement a process to evaluate and allocate expenses on a regular basis. Actions taken or planned Management implemented a process to evaluate and allocate expenses based on employee estimates of time spent by function and proportion of the association’s floor space utilized by each employee during the year. Anticipated completion date July 1, 2023

View Audit 355971

Finding 559801 (2022-007)

Material Weakness 2022

Redevelopment Authority of the County of Berks

PA

Questioned Costs Material Weakness Reporting § 200.307

PROGRAM INCOME - MATERIAL WEAKNESS Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks HOME Investment Partnership Program ALN 14.239; passed through the County of Berks Condition/Cause The Authority did not properly report program inc...

PROGRAM INCOME - MATERIAL WEAKNESS Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks HOME Investment Partnership Program ALN 14.239; passed through the County of Berks Condition/Cause The Authority did not properly report program income in IDIS during the year, and therefore could not support that program income was applied prior to drawing down entitlement funding. In some instances, program income received was not reported in IDIS, and one receipt was entered into IDIS twice. When received, program income is reported in a separate general ledger account in the financial reporting software. The Fiscal Officer then enters the program income into IDIS on a regular basis. No control exists to ensure completeness or accuracy of information entered into IDIS related to program income. Recommendation We recommend the Authority develop a procedure/internal control to ensure program income is entered accurately and completely within IDIS. This will allow for documentation to support that program income is being utilized prior to drawing down entitlement funding. This will also ensure compliance with reporting requirements for reports generated within IDIS on an annual basis. Management Response The Authority implemented a new policy to track and document program income: a. Upon receipt of program income, it shall be entered individually into IDIS and assigned to an activity or activities within fifteen (15) calendar days of receipt. b. At the next request for funds for an activity which includes funding from program income, program income shall be used prior to requesting federal funds for the activity. c. The request for federal funds shall be prepared by the Fiscal Officer and reviewed by one of the Assistant Fiscal Officers to determine if program income is being used prior to the request of federal funds. d. If it has been determined and documented that program income is being used prior to the request for federal funds, the request shall be forwarded to the Executive Director for approval.

View Audit 355767 Questioned Costs: $1

Finding 559798 (2022-006)

Significant Deficiency 2022

Redevelopment Authority of the County of Berks

PA

HUD Housing Programs Reporting Significant Deficiency

REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The Authority did not maintain documentation of internal ...

REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The Authority did not maintain documentation of internal controls over reporting for the programs. For required Community Development Block Grant Reporting under Section 3 of the Housing and Urban Development Act of 1968, total Labor Hours reported for 2022 did not agree to support maintained. Additionally, for the Emergency Rental Assistance program, while reporting spreadsheets were provided, supporting documentation for the amounts reported were not maintained. Recommendation We recommend that all grant reports are reviewed by a person independent of the preparer who has knowledge of the grant requirements. This review should include comparing the amounts reported to detailed support for accuracy. We also recommend the Authority review their recordkeeping procedures for documentation related to grant reporting. There should be a process in place to ensure all required documentation is maintained and filed in an orderly system that allows the Authority to locate and provide documentation when required. Management Response The Authority contracted with Neighborly Software for a program to use with ERAP. At the beginning of ERAP, the Authority relied upon the data from the Neighborly program to generate its reports. By the 4th quarter of 2021, the Authority realized it could only utilize a portion of the Neighborly program for the data required for the reports and needed to supplement or add its own internal data. This method of utilizing Neighborly and internal data is now being used for reports.

View Audit 355767

Finding 559666 (2022-002)

Significant Deficiency 2022

Greater Lawrence Technical School

MA

Allowable Costs / Cost Principles Reporting Significant Deficiency

Audit Finding Reference: 2022-002 Planned Corrective Action: The district created a Federal and State Grants Procedures Manual that includes specific procedures for Time and Effort. The Grant Procedure Manual was approved by the District Committee on December 12, 2023. Name of Contact Person: Melis...

Audit Finding Reference: 2022-002 Planned Corrective Action: The district created a Federal and State Grants Procedures Manual that includes specific procedures for Time and Effort. The Grant Procedure Manual was approved by the District Committee on December 12, 2023. Name of Contact Person: Melissa Martel, Director of Finance Completion Date: December 12, 2023

View Audit 355524

Finding 559159 (2022-013)

Significant Deficiency 2022

Caswell County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Proposed Completion Date: Finding: 2022-013 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor A refresher training will be held to review errors. Files will be reviewed internally to ensure proper documentation...

Proposed Completion Date: Finding: 2022-013 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor A refresher training will be held to review errors. Files will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. All files include accurate household members, online verifications, documented sources and verifications of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. An updated template has been put in place for applications and recertification to address household members, tax filing status, electronic checks/verifications and documentation that is needed to accurately approve/deny/continue or terminate benefits. Caseworkers will need to review Determinations to ensure all eligibility is calculated accurately. All active cases regardless of program in NCFAST are to be reviewed to ensure we have the correct information. Weekly Communications and Changes will be reviewed weekly at Unit Meeting to address any changes and NCFAST issues that may require a Help Desk Ticket. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. April 11, 2024 Section III - Federal Award Findings and Question Costs (continued) N/A - Caseworkers will adhere to the policy in Administrative Letter 13-23.

View Audit 355386

Finding 559022 (2022-004)

Significant Deficiency 2022

Alston Wilkes Society

SC

Internal Control / Segregation of Duties

Response of responsible Society official: Management will continue to review internal controls to identify and correct accounting errors during an employee's performance of their normal duties

View Audit 355287

Finding 558988 (2022-003)

Significant Deficiency 2022

Foothill House of Hospitality

CA

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

Management has worked with a few outside accounting firms over the last year and believes they have found a competent accounting person to assist with the financial statements and processes. Management is working with the new accounting firm to document the procedures and maintaining records.

View Audit 355237

Finding 558987 (2022-002)

Material Weakness 2022

Foothill House of Hospitality

CA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Management has worked with a few outside accounting firms over the last year and believes they have found a competent accounting person to assist with the financial statements and processes. Management is working with the new accounting firm to document the procedures and maintaining records.

View Audit 355237

Finding 556195 (2022-003)

Material Weakness 2022

Benton County

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Thank you for bringing this to our attention. There were several factors that contributed to the difficulties we encountered submitting the required quarterly reports and have since remedied those issues. The Human Services Department has worked with Treasury on the challenges we encountered uploa...

Thank you for bringing this to our attention. There were several factors that contributed to the difficulties we encountered submitting the required quarterly reports and have since remedied those issues. The Human Services Department has worked with Treasury on the challenges we encountered uploading the required reporting templates and we now has multiple people with access to the reporting portal and in the event of staff turnover we can continue to submit required reports. The Human Services Manager and the Budget and Finance Analyst have created reminders on their calendars to ensure reporting is completed on time and with accurate data.

View Audit 354873

Finding 556017 (2022-011)

None 2022

Cobre Consolidated School District

NM

Reporting Internal Control / Segregation of Duties § 200.512

Recommendation We recommend that Management enhance its internal control structure, including financial close and reporting, to ensure timely filing of future federal Uniform Grant Guidance reporting packages. Management Response Corrective Action: Change in Key Personnel: The District has had a ch...

Recommendation We recommend that Management enhance its internal control structure, including financial close and reporting, to ensure timely filing of future federal Uniform Grant Guidance reporting packages. Management Response Corrective Action: Change in Key Personnel: The District has had a change in key personnel after the close of FY22. The Chief Financial Officer has been replaced with a new Director of Finance. Change in Business Office Personnel: The District has had a major change in Business Office staff. Of the six roles in business operations, five staff members are new to the District after FY22. Ongoing Training and Procedure Development: The District has ongoing training for new staff and is constantly improving upon its accounting procedures. Due Date of Completion: FY24-25 Responsible Party(ies): Director of Finance and Business Office Staff

View Audit 354748

Finding 555757 (2022-002)

Significant Deficiency 2022

Arcare

AR

Reporting Internal Control / Segregation of Duties

Responsible Party: Talmage J. Whitehead, President/CFO Email: Talmage.Whitehead@arcare.net Phone Number: (870) 347-3313 Audit Period Ending: December 31, 2022 Audit Firm: Forvis Mazars, LLP Re: Finding No 2022-002 Federal Program: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural...

Responsible Party: Talmage J. Whitehead, President/CFO Email: Talmage.Whitehead@arcare.net Phone Number: (870) 347-3313 Audit Period Ending: December 31, 2022 Audit Firm: Forvis Mazars, LLP Re: Finding No 2022-002 Federal Program: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Program Assistance Listing Numbers: 93.498 Federal Agency: U.S. Department of Human Services The Organization applied provider relief payments to unreimbursed expenses attributable to COVID-19, instead of lost revenue, in the period four report submitted in the HHS Provider Relief Fund (PRF) portal. Recommendation We recommend implementing controls to ensure amounts reported are accurate, complete, and reviewed. Comments on the Finding and Recommendation Management agrees with this finding and the related recommendation. Action(s) Taken or Planned on the Finding Management will adjust internal control procedures in order to ensure the PRF portal reporting is complete and accurate. The completion date for the above-mentioned corrective action was September 29, 2023.

View Audit 354413

Finding 555744 (2022-003)

Significant Deficiency 2022

Behavioral Health Services, Inc.

CA

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.430

Audit Finding Description: Documentation for exempt employees' hours was unavailable or incomplete. Corrective Action Plan: 1. Problem Statement: • During testing over payroll, the auditors noted exempt employee salary expense that was not supported with accurate time records. • Root cause: Manageme...

Audit Finding Description: Documentation for exempt employees' hours was unavailable or incomplete. Corrective Action Plan: 1. Problem Statement: • During testing over payroll, the auditors noted exempt employee salary expense that was not supported with accurate time records. • Root cause: Management lacks policy over tracking time on the timesheet for the exempt employees. Since exempt employees are compensated monthly, it is not required for the exempt employees to record time in their timesheet. 2. Corrective Actions: • Review and Assessment: We have conducted a thorough review of the finding to understand its root cause and identify areas for improvement. • Policy and Procedure Enhancements: We will update relevant policies or procedures to strengthen systems and prevent recurrence. • Training and Education: Employees involved in the process will undergo additional training to ensure they fully understand compliance requirements and best practices. • Monitoring and Oversight: Management will implement regular monitoring and periodic internal audits to ensure continued compliance and effectiveness of the corrective actions. Name of responsible person: Andrea L. Jones, Chief Financial Officer Anticipated completion date: June 30, 2026

View Audit 354388 Questioned Costs: $1

Finding 555743 (2022-002)

Significant Deficiency 2022

Behavioral Health Services, Inc.

CA

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.430

Audit Finding Description: Documentation for exempt employees' hours was unavailable or incomplete. Corrective Action Plan: 1. Problem Statement: • During testing over payroll, the auditors noted exempt employee salary expense that was not supported with accurate time records. • Root cause: Manageme...

Audit Finding Description: Documentation for exempt employees' hours was unavailable or incomplete. Corrective Action Plan: 1. Problem Statement: • During testing over payroll, the auditors noted exempt employee salary expense that was not supported with accurate time records. • Root cause: Management lacks policy over tracking time on the timesheet for the exempt employees. Since exempt employees are compensated monthly, it is not required for the exempt employees to record time in their timesheet. 2. Corrective Actions: • Review and Assessment: We have conducted a thorough review of the finding to understand its root cause and identify areas for improvement. • Policy and Procedure Enhancements: We will update relevant policies or procedures to strengthen systems and prevent recurrence. • Training and Education: Employees involved in the process will undergo additional training to ensure they fully understand compliance requirements and best practices. • Monitoring and Oversight: Management will implement regular monitoring and periodic internal audits to ensure continued compliance and effectiveness of the corrective actions. Name of responsible person: Andrea L. Jones, Chief Financial Officer Anticipated completion date: June 30, 2026

View Audit 354388 Questioned Costs: $1

Finding 555242 (2022-005)

Significant Deficiency 2022

Community Health Service, Inc.

MN

Special Tests & Provisions Allowable Costs / Cost Principles Significant Deficiency

1. Improvement of Data Entry and Documentation Management: *The process for submitting, processing, and storing sliding fee applications will be reviewed and streamlined to ensure that all supporting income level documents are properly collected, verified, and stored at the time of application submi...

1. Improvement of Data Entry and Documentation Management: *The process for submitting, processing, and storing sliding fee applications will be reviewed and streamlined to ensure that all supporting income level documents are properly collected, verified, and stored at the time of application submission. *Employees involved in handling sliding fee applications and supporting documents will be provided with training on the importance of accurate documentation and the procedures for proper filing, both physically and electronically. 2. Implement Regular Monitoring and Auditing: *A regular internal review and audit process will be revisited to ensure that backup, storage, and retention practices are being followed. These audits will focus on verifying that all sliding fee applications and related documents are stored correctly and are retrievable as needed. *Any discrepancies or issues identified during audits will be addressed promptly, and corrective actions will be taken to ensure compliance with the established procedures. 3. Staff Training and Awareness: *Training sessions will be conducted for all relevant staff on the updated backup, storage, and retention procedures for sliding fee applications and income documentation. This training will emphasize the importance of maintaining accurate and accessible records to comply with regulatory and organizational standards. *Refresher training will be provided quarterly to ensure ongoing compliance and awareness.

View Audit 353875

Finding 555090 (2022-005)

Significant Deficiency 2022

Saint Anthony Health Ministries and Subsidiaries

IL

Reporting Internal Control / Segregation of Duties

2022-005 Segregation of Duties Finding: In order to provide assurance that unauthorized or fraudulent journal entries are not posted within the Corporation’s financial system, journal entries should be subjected to review and approval by an individual independent of the preparer of the journal entr...

2022-005 Segregation of Duties Finding: In order to provide assurance that unauthorized or fraudulent journal entries are not posted within the Corporation’s financial system, journal entries should be subjected to review and approval by an individual independent of the preparer of the journal entry prior to posting. The Corporation’s system allowed the same individual to approve and post the same entry, and entries were posted with only one level of review. Corrective Actions Taken or Planned: A process has been established effective July 2022 where journal entries are reviewed by an individual with appropriate authority, different than the preparer of the journal entry. Jamie Mack, Vice President of Finance, will approve the journal entries of Caralton Brown, Assistant Controller, and Caralton Brown will review and approve the entries prepared by Jamie Mack and Michael Caddick, outside contractor. Name of contact person responsible for corrective action: Jamie Mack, Vice President of Finance

View Audit 353678

Finding 554999 (2022-006)

Material Weakness 2022

White Shield School

ND

Material Weakness Internal Control / Segregation of Duties § 200.313

RECOMMENDATION: Create a property management system and adopted written policies and procedures. These procedures should be reviewed and updated to, at a minimum, adhere to the newest federal guidelines under OMB Uniform Guidance. Physical inventories should be performed periodically and reconciled ...

RECOMMENDATION: Create a property management system and adopted written policies and procedures. These procedures should be reviewed and updated to, at a minimum, adhere to the newest federal guidelines under OMB Uniform Guidance. Physical inventories should be performed periodically and reconciled to the property management records. Property management records should also include copies of the original asset purchase documentation. Action Taken: The School agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 353603

Finding 554998 (2022-005)

Material Weakness 2022

White Shield School

ND

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness

RECOMMENDATION: Develop and adopt a new policy over bank reconciliations.Action Taken: The School agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 353603

Corrective Action Plans

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