Corrective Action Plans

Finding 392629 (2022-001)

Significant Deficiency 2022

OH

Subrecipient Monitoring Eligibility Significant Deficiency

Contact Person: Shameikia Smith, VP of Housing Services We agree with the finding. Clear documentation of eligibility requirements for each grant should be communicated with program personnel and should be verified for each applicant. In May of 2023, we implemented an internal auditing system to en...

Contact Person: Shameikia Smith, VP of Housing Services We agree with the finding. Clear documentation of eligibility requirements for each grant should be communicated with program personnel and should be verified for each applicant. In May of 2023, we implemented an internal auditing system to ensure compliance with grant/funding requirements, ensuring eligibility and eligible costs. 50 files are reviewed each month. Any deficiencies are required to be updated within two-weeks of the receipt of the report. As of 2024, there is stability in the staffing pattern and leadership of the Emergency Rental Assistance Program. In February of 2024, the Emergency Rental Assistance team is now combined with our Housing Services department. This change will help mitigate risk and increase compliance to 100%. Completion Date: Completion Date February 29, 2024

View Audit 302930

Finding 392598 (2022-002)

Significant Deficiency 2022

Alaska Village Electric Cooperative, Inc. and Subsidiary

AK

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding 2022-002 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Program Research and Development Program Cluster: Renewable Energy Research and Development and Denali Commission Programs Planned Corrective Action Plan To improve the timeliness of the SF-SAC,...

Finding 2022-002 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Program Research and Development Program Cluster: Renewable Energy Research and Development and Denali Commission Programs Planned Corrective Action Plan To improve the timeliness of the SF-SAC, the President & CEO will require the Manager of Key Accounts and Special Projects to allocate adequate resources to ensure the timely preparation and submission of audit requirements for audit purposes. The President & CEO will proactively enforce the audit schedule and require departments to complete grant requirements by their due dates. Completion Date By April 1, 2024. Bill Stamm, President & CEO bstamm@avec.org 4831 Eagle Street, Anchorage, Alaska 99503 4831

View Audit 302894

Finding 392592 (2022-002)

Material Weakness 2022

Lenox Community School District

IA

Internal Control / Segregation of Duties

The District will continue to review the duties of office employees and segregate duties where possible.

View Audit 302884

Finding 392561 (2022-007)

Significant Deficiency 2022

Folsom Cordova Community Partnership

CA

Cash Management Period of Performance Reporting

Response: The organization agrees with the finding. There were gaps in information flow due to staff turnover. The organization already has a process in place for reviewing payroll expenditures. The organization will significantly increase the practice of capturing payroll expenses in the appropriat...

Response: The organization agrees with the finding. There were gaps in information flow due to staff turnover. The organization already has a process in place for reviewing payroll expenditures. The organization will significantly increase the practice of capturing payroll expenses in the appropriate period and within the appropriate grant period to report grant expenses for reimbursement. Completed before January 2024.

View Audit 302849

Finding 392492 (2022-001)

Significant Deficiency 2022

Rtog Foundation, Inc.

PA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Finding 2022-001 – Segregation of Duties Statement of Condition: The Foundation does not have adequate segregation of duties present for the approval of payments to subcontractors, which is reflected as federal subcontracts expense on the financial statements. The project manager, who was responsib...

Finding 2022-001 – Segregation of Duties Statement of Condition: The Foundation does not have adequate segregation of duties present for the approval of payments to subcontractors, which is reflected as federal subcontracts expense on the financial statements. The project manager, who was responsible for reviewing and approving the subcontractor’s invoices in preparation for payment authorization by members of the Foundation’s Board, was employed by the subcontractor. Management Response: In August of 2022, the RTOG Foundation Inc. executed a Financial Management Services Agreement with the NSABP Foundation Inc. to provide oversight and management of financial statement preparation. The independent resources provided under this contract include day to day financial support from a Director of Finance with a supporting staff of accountants, financial analysts, and top-level oversight by a Senior Director of Finance with extensive experience in the financial management of clinical trials. The prior project manager referenced above has relinquished all financial accounting responsibilities and appropriate segregation of duties has been achieved, including, but not limited to, internal controls surrounding the payment of invoices. Routine financial analysis, account reconciliations, treasury functions, audit support and budgeting are also included under this services agreement. Monthly financial results are reviewed with the Board of Directors at regularly scheduled meetings.

View Audit 302833

Finding 392451 (2022-007)

Material Weakness 2022

Puerto Rico Safe Drinking Water Treatment Revolving Loan Fund

PR

Internal Control / Segregation of Duties

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

Medical Assistance Program Special Test and Provisions- ADP Risk Analysis and System Security Review Material Weakness and Noncompliance The DOH disagrees with this finding as they believe the MCO should have received a SOC 1 Type 1 and Type 2 Report. The DOH has requested this information from the MCO, however, it has not been provided yet due to the short time frame for gathering the requested information.

View Audit 302752

Finding 392413 (2022-001)

Material Weakness 2022

Puerto Rico Safe Drinking Water Treatment Revolving Loan Fund

PR

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

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

Financial Administration- Standards for Financial Management System Financial Internal Control Weakness and Noncompliance The PRDOH partially agrees with the finding. However, PRDOH has implemented various corrective actions. Regarding Project Costing Module, the PRDOH already has implemented the Travel and Expenses Module, Payment Management System, which integrates with the Account Receivable to streamline revenue records and Payroll Solutions. The effectiveness of these will be observed during the fiscal year 2024-2025. Also, the PRDOH and Central Government are currently working on ERP implementation in all Government Agencies. This new ERP will be in place in the fiscal year 2024-2025. Furthermore, the PRDOH has established control in order for all program to ensure the timely performed reconciliations between the finance office, the federal affair office, this procedure has started since august 2022. In the other hand the State Department of Treasury has begun a series of training with regard the new ERP that will, be in place by July 2024. This new system in order to close the monthly period all programs will need to reconcile first before closing of the period.

View Audit 302752

Finding 392382 (2022-002)

Material Weakness 2022

Impact Community Action Partnership, Inc.

IA

Internal Control / Segregation of Duties Material Weakness Reporting

Finding 2022-002: Journal Entry Review and Segregation of Duties Management’s Response: Management agrees with the finding. Contact Person Responsible for Corrective Action: Anne Bacon, CEO Corrective Action Plan: The auditor finding concludes that the cause of the finding is: “Rapid growth of new f...

Finding 2022-002: Journal Entry Review and Segregation of Duties Management’s Response: Management agrees with the finding. Contact Person Responsible for Corrective Action: Anne Bacon, CEO Corrective Action Plan: The auditor finding concludes that the cause of the finding is: “Rapid growth of new funding without a corresponding increase in fiscal personnel has resulted in additional responsibilities placed on the Chief Financial Officer and Chief Operating Officer. The transition to remote working has also resulted in difficulties with handling electronic documentation and approvals.” However, a primary cause was the CFO’s decision to by-pass the outlined process and not submit the journal entries for review. To address these causes, IMPACT Community Action Partnership will follow a rectifying course of action. 1. Remove CFO that was responsible for reconciliations (complete) 2. Hire an interim Controller to assess and rectify all fiscal internal controls (complete) 3. Do not grant check signing capability to the controller (complete) 4. Develop a written fiscal procedure for the review of journal entries (complete) 5. Procure a more robust fiscal software that permits more efficient electronic record review. (April 30, 2024) Anticipated Completion Date: April 30, 2024

View Audit 302731

Finding 392374 (2022-001)

Material Weakness 2022

Impact Community Action Partnership, Inc.

IA

Cash Management Material Weakness Matching / Level of Effort / Earmarking

Finding 2022-001: Fiscal Internal Controls Management’s Response: Management agrees with the finding. Contact Person Responsible for Corrective Action: Anne Bacon, CEO Corrective Action Plan: The auditor finding concludes that the cause of the finding is: “Rapid growth of new funding without a corre...

Finding 2022-001: Fiscal Internal Controls Management’s Response: Management agrees with the finding. Contact Person Responsible for Corrective Action: Anne Bacon, CEO Corrective Action Plan: The auditor finding concludes that the cause of the finding is: “Rapid growth of new funding without a corresponding increase in fiscal personnel, combined with the late issuance of the September 30, 2021, audited financial statements resulted in significant delays in reconciliations and preparing for the September 30, 2022 audit.” In order to address these causes, IMPACT Community Action Partnership will follow a rectifying course of action. 1. Remove CFO that was responsible for reconciliations (complete) 2. Hire an interim Controller to assess and rectify all fiscal internal controls (complete) 3. Hire an interim accounting specialist to assure 2023 reconciliations are completed in a timelier manner (complete) 4. Procure a more robust fiscal software that will create efficiencies around reconciliations. (April 30, 2024) 5. Complete all monthly reconciliations by the 10th of the following month (April 10, 2024) Anticipated Completion Date: April 30, 2024

View Audit 302731

Finding 392369 (2022-001)

Material Weakness 2022

St. John's Lutheran Home of Albert Lea

MN

Material Weakness Reporting Internal Control / Segregation of Duties

Management will continue to allow the audit firm to create the draft financial statements and related footnote disclosures, and will review and approve these prior to the issuance of the annual financial statements.

View Audit 302723

Finding 392319 (2022-001)

Significant Deficiency 2022

Odc

CA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

Management’s Response and Corrective Action Plan: We have expanded the ability of MIP Fund Accounting to track grants separately when needed. We have now implemented both exclusive preparation of grant financial reports along with any budget submitted at the application and/or progress budgets when ...

Management’s Response and Corrective Action Plan: We have expanded the ability of MIP Fund Accounting to track grants separately when needed. We have now implemented both exclusive preparation of grant financial reports along with any budget submitted at the application and/or progress budgets when multi-year grants. We are now using a segment exclusive for each federal grant.

View Audit 302668

Finding 392305 (2022-001)

Material Weakness 2022

Dewitt Medical District D.b.a. Cuero Regional Hospital

TX

Internal Control / Segregation of Duties Reporting

Corrective Action Plan for Finding 2022-001 We are in receipt of the Finding Required to be Reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting. Management agrees with the finding. Policies and procedures over federal grant reporting will be modified t...

Corrective Action Plan for Finding 2022-001 We are in receipt of the Finding Required to be Reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting. Management agrees with the finding. Policies and procedures over federal grant reporting will be modified to ensure rpeorts are prepared using complete and accurate information. We will increase compensating controls by introducing additional oversight and review for future COVID-19 Provider Relief Fund reporting. Lynn Falcone, CEO will be responsible to ensure this is accomplished The District had enough expenditures for Period 2 and 3 funding received so that no lost revenues were utilized as a basis for the funds received. The corrective action plan will be implemented by September 30, 2023.

View Audit 302649

Finding 392267 (2022-009)

Material Weakness 2022

Municipality of Juana Diaz

PR

HUD Housing Programs Reporting Internal Control / Segregation of Duties

Instructions were given to the Program staff to strengthen existing internal controls and procedures to ensure the equity balances were properly calculated and reported in the VMS. Also, the Program staff was instructed to analyze previous equity balances reported in the VMS, an realize any necessar...

Instructions were given to the Program staff to strengthen existing internal controls and procedures to ensure the equity balances were properly calculated and reported in the VMS. Also, the Program staff was instructed to analyze previous equity balances reported in the VMS, an realize any necessary corrections

View Audit 302533

Finding 392266 (2022-008)

Material Weakness 2022

Municipality of Juana Diaz

PR

HUD Housing Programs Internal Control / Segregation of Duties

Instructions were given to the Program staff to strengthening existing internal controls and procedures to ensure the required quality control re-inspections are performed annually.

View Audit 302533

Finding 392263 (2022-007)

Material Weakness 2022

Municipality of Juana Diaz

PR

HUD Housing Programs Reporting Internal Control / Segregation of Duties

Instructions were given to the Program staff to strengthening existing internal controls and procedures to ensure the submission of the Form HUD-50058, Family Report (OMB No. 2577-0083), and the financial reports according to applicable requirements. The audited financial data schedule for the fisca...

Instructions were given to the Program staff to strengthening existing internal controls and procedures to ensure the submission of the Form HUD-50058, Family Report (OMB No. 2577-0083), and the financial reports according to applicable requirements. The audited financial data schedule for the fiscal year 2021- 2022 will be submitted as soon as the Single Audit Report be finally issued by the external auditors.

View Audit 302533

Finding 392261 (2022-006)

Material Weakness 2022

Municipality of Juana Diaz

PR

HUD Housing Programs Subrecipient Monitoring Eligibility

Instructions were given to the Program staff to strengthening existing internal controls and procedures to ensure that the reexamination and HAP determination processes are performed according to program requirements and guidelines, and to obtain in a timely manner all of the required documentation ...

Instructions were given to the Program staff to strengthening existing internal controls and procedures to ensure that the reexamination and HAP determination processes are performed according to program requirements and guidelines, and to obtain in a timely manner all of the required documentation for each reexamination executed.

View Audit 302533

Finding 392260 (2022-005)

Material Weakness 2022

Municipality of Juana Diaz

PR

Cash Management Program Income Internal Control / Segregation of Duties

Instructions were given to the Program staff to ensure timely registration of program income transactions in the Integrated Disbursement and Information System (IDIS). During the fiscal year 2021-2022, changes occurred in the program's management staff, which may have led to the situation mentioned ...

Instructions were given to the Program staff to ensure timely registration of program income transactions in the Integrated Disbursement and Information System (IDIS). During the fiscal year 2021-2022, changes occurred in the program's management staff, which may have led to the situation mentioned in the finding.

View Audit 302533

Finding 392256 (2022-003)

Significant Deficiency 2022

Seventy-Five North Revitalization Corporation

NE

Procurement, Suspension & Debarment Internal Control / Segregation of Duties

We concur with the finding and agree that we should have written procurement policies to comply with 2 CFR 200 Subpart D. Our plan is to implement written policies that include the provisions of 2 CFR 200 Subpart D and other relevant sections. These policies will be included in the organizational a...

We concur with the finding and agree that we should have written procurement policies to comply with 2 CFR 200 Subpart D. Our plan is to implement written policies that include the provisions of 2 CFR 200 Subpart D and other relevant sections. These policies will be included in the organizational accounting procedures and policy manual. Procedures are being implemented in 1st Quarter 2024 and will continue indefinitely.

View Audit 302519

Finding 392254 (2022-002)

Material Weakness 2022

Community Development Project, Inc.

NY

Allowable Costs / Cost Principles Cash Management Material Weakness

The Organization had not previously been subjected to the Uniform Guidance standards. The internal controls over time and effort reporting did not operate as designed resulting in instances of noncompliance with the reconciliation of actual time worked versus vouchered reimbursement requests. The Or...

The Organization had not previously been subjected to the Uniform Guidance standards. The internal controls over time and effort reporting did not operate as designed resulting in instances of noncompliance with the reconciliation of actual time worked versus vouchered reimbursement requests. The Organization plans to enhance its controls over time and effort reporting and ensure that payroll costs are reported and vouchered based on actual rather than budgeted allocations.

View Audit 302493

Finding 392240 (2022-005)

Significant Deficiency 2022

Catholic Community Services, INC

AK

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.430

Finding: 2022-005: Significant Deficiency in Internal Controls over Compliance – Allowability– Payroll Transactions Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Corrective Action: • All payroll journal entries will be reviewed and ...

Finding: 2022-005: Significant Deficiency in Internal Controls over Compliance – Allowability– Payroll Transactions Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Corrective Action: • All payroll journal entries will be reviewed and approved by program staff and the Controller since the Staff Accountant prepares the journal entries. • CCS will implement a process for Controller to review payroll entries after they are imported for accuracy between Paycor and the accounting system. • CCS will be looking into whether program staff should start direct charging their time. CCS will set up an after- payroll review to be done by program and finance/HR to review for any possible errors missed prior to running payroll. If errors are found, corrective entries will be made immediately. Also, we will be looking into whether an indirect rate would simply our very complicated allocation system we currently use. Additionally, program staff will review all new or adjusted allocations in Paycor. • Program staff will review all new or changed payroll allocations for employees they supervise. • Detailed allocation reports will be sent to program staff for review. • Program staff are to review preliminary and final reports monthly to check for any discrepancies. • The finance staff currently looks at reports monthly for discrepancies. Proposed Completion Date: 2/28/23

View Audit 302460

Finding 392232 (2022-003)

Significant Deficiency 2022

Catholic Community Services, INC

AK

Subrecipient Monitoring Reporting Significant Deficiency § 200.303 § 200.334

FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT Finding: 2022-003: Significant Deficiency in Internal Controls over Compliance – Reporting Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Controller reviews and corre...

FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT Finding: 2022-003: Significant Deficiency in Internal Controls over Compliance – Reporting Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Controller reviews and corrects reports received which includes backup by the Staff Accountant, then CFO reviews reports created by Controller prior to submission. Proposed Completion Date: 6/30/23

View Audit 302460

Finding 392231 (2022-004)

Material Weakness 2022

Catholic Community Services, INC

AK

Internal Control / Segregation of Duties Material Weakness Reporting § 200.512

Finding: 2022-004: Material Weakness in Internal Controls over Compliance – Single Audit Report Submission Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 CCS will work with its audit firm to ensure the audit is submitted in a timely manne...

Finding: 2022-004: Material Weakness in Internal Controls over Compliance – Single Audit Report Submission Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 CCS will work with its audit firm to ensure the audit is submitted in a timely manner. Proposed Completion Date: 6/30/24

View Audit 302460

Finding 392219 (2022-005)

Material Weakness 2022

Western Prairie Human Services

MN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.303

Finding Number: 2022-005 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Tracy Bowman Corrective Action Planned: All quarterly DHS reports will be reviewed and signed following completion. Documentation for all will be mai...

Finding Number: 2022-005 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Tracy Bowman Corrective Action Planned: All quarterly DHS reports will be reviewed and signed following completion. Documentation for all will be maintained. Anticipated Completion Date: 12/31/2022

View Audit 302433

Finding 392218 (2022-004)

Significant Deficiency 2022

Western Prairie Human Services

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2022-004 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Crystal Zaviska Corrective Action Planned: Implement semi-annual trainings including asset verifications, timelines, and income verifications. Anti...

Finding Number: 2022-004 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Crystal Zaviska Corrective Action Planned: Implement semi-annual trainings including asset verifications, timelines, and income verifications. Anticipated Completion Date: 12/31/2023

View Audit 302433

Finding 392139 (2023-003)

Material Weakness 2022

Mahnomen Area Assisted Living Center INC

MN

Material Weakness Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit findi...

Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review policies and procedures to ensure compliance is met going forward and will establish a debt service fund in accordance with the letter of conditions. Name(s) of the contact person(s) responsible for corrective action: Lori Guenther, CFO Planned completion date for corrective action plan: Q2 of 2023

View Audit 302363

Corrective Action Plans

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