Corrective Action Plans

Finding 58751 (2022-003)

Material Weakness 2022

IN

Allowable Costs / Cost Principles Material Weakness Period of Performance § 200.1 § 200.303

FINDING 2022-003 Contact Person Responsible for Corrective Action: Pia O?Connor, Auditor Contact Phone Number: (812) 565-5719 Views of Responsible Official: I agree with the findings as stated Description of Corrective Action Plan: The County will develop a policy and procedure to ensure we have com...

FINDING 2022-003 Contact Person Responsible for Corrective Action: Pia O?Connor, Auditor Contact Phone Number: (812) 565-5719 Views of Responsible Official: I agree with the findings as stated Description of Corrective Action Plan: The County will develop a policy and procedure to ensure we have complete and accurate information for the P & E report. In addition to the policy and procedure, an added person will assist with these reports by creating the reports through our financial software and reviewing before giving the reports to the Auditor who will prepare the P & E reports and then the Commissioner?s will review before the Auditor submits the report to the Treasury. The Bartholomew County Auditor?s Office is continually designing and implementing a proper system of internal controls so that any errors are detected and corrective measures are made as needed, Anticipated Completion Date: December 31, 2023

View Audit 55034

Finding 58749 (2022-001)

Material Weakness 2022

Ascentria Care Alliance, Inc.

MA

Questioned Costs Material Weakness Reporting

United States Department of Health and Human Services Ascentria Care Alliance respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. Th...

United States Department of Health and Human Services Ascentria Care Alliance respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS United States Department of Health and Human Services 2022-001 COVID-19 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: The Organization should review the PRF Reporting Portal instructions detailing how to complete individual schedules in the Reporting Portal, and ensure that all costs claimed are fully supported. The Organization should also ensure that an individual with sufficient training and experience is assigned to review and approve all grant reports submitted through the Reporting Portal. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement controls over reviewing and approving schedules to ensure that all schedules are complete before submission on the reporting portal. Name(s) of the contact person(s) responsible for corrective action: Sergio Plaza Planned completion date for corrective action plan: 6/30/2023 If the United States Department of Health and Human Services has questions regarding this plan, please call Sergio Plaza at 508-688-5608.

View Audit 54611 Questioned Costs: $1

Finding 58714 (2022-001)

None 2022

Puerto Rico Safe Drinking Water Treatment Revolving Loan Fund

PR

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.512

Finding No. 2022-001 Audit Requirements for Auditees ? Report Submission Condition found The data collection form and the reporting package for the year ended on June 30, 2022 was not submitted to the Federal Audit Clearinghouse within the timeframe prescribed by the Uniform Guidance. Views of Resp...

Finding No. 2022-001 Audit Requirements for Auditees ? Report Submission Condition found The data collection form and the reporting package for the year ended on June 30, 2022 was not submitted to the Federal Audit Clearinghouse within the timeframe prescribed by the Uniform Guidance. Views of Responsible Officials and Corrective Action PlanPuerto Rico Department of Health (DOH), Puerto Rico Infrastructure Financing Authority (PRIFA), Puerto Rico Aqueduct and Sewer Authority (PRASA), entered on December 30, 2016, into a Memorandum of Understanding (MOU), subsequently amended on September 17, 2018, to include the Fiscal Agency and Financial Advisory Authority (FAFAA). Under the MOU, as amended, each party has agreed to assume specific responsibilities in connection with the operations of the Revolving Fund pursuant to the Operating Agreement entered between the EPA and the DOH on September 28, 2018. Pursuant to the MOU, as amended, DOH will remain as the administrator for the Revolving Fund, PRIFA will act as the operating agent to provide assistance with the financial and accounting activities, and FAFAA will conduct the financial capabilities analysis of any eligible assistance recipient of funds, provide the necessary information to the DOH and PRIFA to the extent as possible for the development of the different programs compliance reports reviews, provide assistance as fiscal agent, financial advisor and information agent of the Commonwealth to ensure that the monies are safeguarded in a trust structure and to assist the DOH as deemed necessary with the administration of the program. The data collection form and the reporting package were not file on time due to lack and availability of funds to cover expenses related to the audit process and other expenses related to the administrative responsibilities assigned in the MOU, as amended, to PRIFA. Management is requiring DOH to formalize a Subaward, as established in the MOU, as amended, to facilitate and respond to the lack of funding to cover all the related expenses for the administrative responsibilities assigned to PRIFA. EPA has been informed and communication will be maintained until the Subaward is finally signed. Management plans are to file the data collection form for the fiscal year ended on June 30, 2022 on or before June 30, 2023, and the data collection form for the fiscal year ending on June 30, 2023 on or before December 31, 2023, which will result in elimination of the finding. Name (s) of the Contact Person (s) Responsible for Corrective Action Francisco Pares, Secretary of the Treasury Department, Eduardo Rivera Cruz, Executive Director Puerto Rico Infrastructure Financing Authority and Dr. Carlos Mellado, Secretary Puerto Rico Department of Health Anticipated Completion Date June 2023

View Audit 56665

Finding 58706 (2022-005)

Material Weakness 2022

Jackson County, Florida

FL

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.303

FINDING 2021-003 COMMENT: Per the County's grant agreements with Florida Division of Emergency Management (FDEM), quarterly reports are required to be submitted through FloridaPA.com that include project costs and expenditures for each large project. Amounts in the quarterly reports should reconcile...

FINDING 2021-003 COMMENT: Per the County's grant agreements with Florida Division of Emergency Management (FDEM), quarterly reports are required to be submitted through FloridaPA.com that include project costs and expenditures for each large project. Amounts in the quarterly reports should reconcile to the County's accounting records and represent actual expenditures. The two large projects were tested for compliance with this requirement, including all quarterly reports submitted during the 2021 fiscal year for these projects. This was not a statistically valid sample. For all quarterly reports tested, the reported expenditures per quarter were unable to be reconciled to actual expenditures in the quarter per the invoices and other supporting documentation in the County's files. RESPONSE: Rett Daniels, Deputy Administrator, Sarah Suhn, Budget Director, and Tony Pumphrey, Finance Officer, will develop controls that will be effective July 31, 2023, to ensure quarterly reports submitted are reconciled to actual quarterly expenditures per invoices and other supporting documentation.

View Audit 56597

Finding 58705 (2022-002)

Significant Deficiency 2022

Housing Authoirty of the City of Salem

OR

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Finding 2022-002: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Programs Federal Catalog Numbers: 14.871 Noncompliance ? N. Special Tests and Provisions - Housing Quality Standards Non Compliance Material to the Financial ...

Finding 2022-002: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Programs Federal Catalog Numbers: 14.871 Noncompliance ? N. Special Tests and Provisions - Housing Quality Standards Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions Criteria: Housing Quality Standards Inspections. The PHA must inspect the unit leased to a family at least annually to determine if the unit meets the Housing Quality Standards (HQS) and the PHA must conduct quality control re-inspections. The PHA must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). For units that fail inspection the PHA must correct all life threatening HQS deficiencies within 24 hours and all other deficiencies within 30 days. Condition: Based upon inspection of the Authority?s files and on discussion with management, there were failed inspections that did not pass reinspection within 30 days without penalty. Context: There were approximately 741 failed inspections during the audit period. Of a sample size of twenty-five (25) failed inspections, four (4) failed inspections did not pass reinspection within 30 days. HAP was not abated nor was the tenant evicted. Our sample size is statistically valid. Cause: There is a significant deficiency in internal controls over the compliance for the special tests and provisions type of compliance related to HQS inspections. The Authority has not properly performed HQS inspections in compliance with program requirements following the expiration of HUD waivers as a result of insufficient staffing . Effect: The Section 8 Housing Choice Vouchers Program is in non-compliance with the special tests and provisions type of compliance related to HQS inspections. Recommendation: We recommend the Authority design and implement a corrective action plan that will assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: The Authority accepts the recommendation of the auditor, and will make the following changes to its inspection process to ensure enforcement of Housing Quality Standards (or any subsequent replacement): ? On or before July 1, 2023: o The standard notice used to notify the program participant and property owner of deficiencies will be updated to include the following language: ? HAP will be abated as early as the 1st of the month following the date of the scheduled reinspection. ? This will mitigate the need for additional notice prior to the abatement period. ? ?Tenant-caused? fail items may result in termination of rental assistance. ? The letter will include language notifying the program participant that they may request an extension or reasonable accommodation if additional time is needed to correct deficiencies. ? This will create a clear trail of documentation for the file to allow SHA to demonstrate when extensions are provided as a reasonable accommodation. ? Additionally, this will provide SHA with additional information that may facilitate referrals to community supports to assist with specific tenant-caused circumstances, such as ?high fuel load? (high amount of tenant possessions creating risk of fire/injury/damage to unit). Melanie Fletcher will be responsible to implement this corrective action by September 30, 2023.

View Audit 56513

Finding 58704 (2022-001)

Significant Deficiency 2022

Housing Authoirty of the City of Salem

OR

HUD Housing Programs Eligibility Significant Deficiency

Corrective Action Plan For the year ended September 30, 2022 U.S. Department of Housing and Urban Development: Housing Authority of the City of Salem respectfully submits the following corrective action plan for the year ended September 30, 2022. Auditor: Novogradac and Company, LLP Certified...

Corrective Action Plan For the year ended September 30, 2022 U.S. Department of Housing and Urban Development: Housing Authority of the City of Salem respectfully submits the following corrective action plan for the year ended September 30, 2022. Auditor: Novogradac and Company, LLP Certified Public Accountants 1144 Hooper Avenue Suite 203 Toms River, New Jersey 08753 The findings from the September 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Federal Award Findings and Questioned Costs Finding 2022-001: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Catalog Numbers: 14.871 Noncompliance ? E. Eligibility ? Tenant Files Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Eligibility Criteria:Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority?s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 2,723 Section 8 Housing Choice Vouchers units and 123 Mainstream Vouchers units. Of a sample size of forty-seven (47) tenant files, the following was noted: ? Lead based paint form was missing in 14 files ? Annual inspection report was missing in 1 file Our sample size is statistically valid. Cause: There is a significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers Program is in non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation:We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: The Authority accepts the recommendations of the auditor and has issued the following directives to staff in order to prevent future recurrence of similar issues: ? Administrative Advisory 2023-02 ? This Administrative Advisory requires staff, effective June 12, 2023, to obtain the Lead Based Paint (LBP) Disclosure form for any new leases / moves related to units built before 1978, as well as requiring staff to review files at annual recertification and request the LBP Disclosure form for those units built prior to 1978 as part of the recertification process. Using this method, all LBP disclosures shall be present in tenant files by the end of calendar year 2025 (SHA is moving to biennial recertifications as part of its Moving to Work Initiative). ? Administrative Advisory 2023-03 ? This Administrative Advisory directs staff to ensure that original applications and initial eligibility documentation are scanned when files are archived, or new volumes are created. Additionally, staff have been advised to pull the original application and initial eligibility forward into new volumes. If the original application and initial eligibility information are found to be incomplete or missing at the time the file is archived, staff have been instructed to document the file and replace the missing information with the best available documentation to demonstrate date of original application and that initial eligibility criteria were met. Due to the conditions of the COVID-19 pandemic, SHA was unable to contract a third party inspector to conduct inspections of units that it owns and operates, as required by HUD regulations. This led to a gap of more than 24 months between an initial inspection and a biennial inspection for a resident living in a SHA-owned unit. Inspections of SHA-owned units have since been completed under an agreement with a neighboring housing authority and will continue to be completed in accordance with HUD regulations and requirements going forward. Melanie Fletcher will be responsible to implement this corrective action by September 30, 2023.

View Audit 56513

Finding 58701 (2022-002)

Material Weakness 2022

Southeast Georgia Consolidated Housing Authority

GA

Eligibility HUD Housing Programs Internal Control / Segregation of Duties

2022-002 Internal Controls over Documentation in Tenant Files We will implement controls and procedures to ensure proper verification of tenant information and rent calculations are performed. We will also implement a review process to detect errors timely. Date of completion: Ongoing

View Audit 56178

Finding 58699 (2022-001)

Significant Deficiency 2022

Rowan County Housing Authority

NC

Questioned Costs HUD Housing Programs Reporting

Section II - Financial Statement Findings None Reported Section III - Federal Award Findings and Questioned Costs Finding 2022-001 Name of Contact Person: Sara Potts Executive Director Corrective Action: We concur. Management will review the internal control procedures as they relate to Reports ...

Section II - Financial Statement Findings None Reported Section III - Federal Award Findings and Questioned Costs Finding 2022-001 Name of Contact Person: Sara Potts Executive Director Corrective Action: We concur. Management will review the internal control procedures as they relate to Reports and will implement procedures to insure all Reports are submitted timely. Proposed Completion Date: Immediately

View Audit 56173 Questioned Costs: $1

Finding 58690 (2022-002)

Significant Deficiency 2022

City of Cosmos

MN

Internal Control / Segregation of Duties

Segregation of Duties Name of Contact Person: John Douville, City Administrator Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providin...

Segregation of Duties Name of Contact Person: John Douville, City Administrator Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providing some of these controls. Proposed Completion Date: The City Council will implement the above procedures immediately.

View Audit 56170

Finding 58688 (2022-001)

Significant Deficiency 2022

Washington Housing Authority

NC

Eligibility HUD Housing Programs Reporting

Corrective Action Plan For the Year Ended September 30, 2022 Section II - Financial Statement Findings: None Reported Section III - Federal Award Findings and Questioned Costs Finding 2022-001 Name of Contact Person: Michael Best Executive Director Corrective Action: We will implement proper intern...

Corrective Action Plan For the Year Ended September 30, 2022 Section II - Financial Statement Findings: None Reported Section III - Federal Award Findings and Questioned Costs Finding 2022-001 Name of Contact Person: Michael Best Executive Director Corrective Action: We will implement proper internal control procedures for the Public and Indian Housing program eligibility requirements. Proposed Completion Date: Immediately

View Audit 54770

Finding 58679 (2022-003)

Material Weakness 2022

Open Door Health Services, INC

IN

Special Tests & Provisions Internal Control / Segregation of Duties

2022-003 Findings Reported by Uniform Guidance ? The following steps have been taken or will be taken to address Finding 2022-003: ? Open Door Health Services, Inc. continues to evaluate controls around monitoring of the sliding fee discounts that are applied. ? Open Door Health Services, Inc. wi...

2022-003 Findings Reported by Uniform Guidance ? The following steps have been taken or will be taken to address Finding 2022-003: ? Open Door Health Services, Inc. continues to evaluate controls around monitoring of the sliding fee discounts that are applied. ? Open Door Health Services, Inc. will actively review past and current discounts to ensure errors are corrected in a timelier manner.

View Audit 54258

Finding 58619 (2022-003)

Material Weakness 2022

Tippecanoe School Corporation

IN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.303

FINDING 2022-003 Contact Person Responsible for Corrective Action: Amanda M. Brackett, Chief Financial Officer Contact Phone Number: (765) 269-8218 Views of Responsible Official: We agree with the findings identified. Description of Corrective Action Plan: In order to mitigate future findings regard...

FINDING 2022-003 Contact Person Responsible for Corrective Action: Amanda M. Brackett, Chief Financial Officer Contact Phone Number: (765) 269-8218 Views of Responsible Official: We agree with the findings identified. Description of Corrective Action Plan: In order to mitigate future findings regarding suspension and debarment within the Greater Lafayette Area Special Services cooperative, the TSC will implement procedures to ensure better internal controls which includes monitoring. The Chief Financial Officer will monitor the progress of the Corrective Action Plan to ensure that we fulfill our requirements of the CAP. Anticipated Completion Date: July 2021. Completion of this has been remedied an only affected year 1 of the audit period.

View Audit 56365

Finding 58618 (2022-002)

Material Weakness 2022

Tippecanoe School Corporation

IN

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

FINDING 2022-002 Contact Person Responsible for Corrective Action: Amanda M. Brackett, Chief Financial Officer Contact Phone Number: (765) 269-8218 Views of Responsible Official: We agree with the findings identified. Description of Corrective Action Plan: In order to mitigate future findings regard...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Amanda M. Brackett, Chief Financial Officer Contact Phone Number: (765) 269-8218 Views of Responsible Official: We agree with the findings identified. Description of Corrective Action Plan: In order to mitigate future findings regarding activities allowed and allowable costs within the Greater Lafayette Area Special Services cooperative, the TSC will implement procedures to ensure better internal controls which includes monitoring. The Chief Financial Officer will monitor the progress of the Corrective Action Plan to ensure that we fulfill our requirements of the CAP. Anticipated Completion Date: July 2021. Completion of this has been remedied an only affected year 1 of the audit period.

View Audit 56365

Finding 58610 (2022-001)

None 2022

William R Moore College of Technology

TN

Questioned Costs Student Financial Aid Internal Control / Segregation of Duties

Instructors will do a better job communicating to the Registrar of student course drops and reporting LDAs. The Registrar has implemented a review of all data to ensure it is correct moving forward. Our third-party financial aid processer, FAME, has agreed to review all r2T4 forms going forward for ...

Instructors will do a better job communicating to the Registrar of student course drops and reporting LDAs. The Registrar has implemented a review of all data to ensure it is correct moving forward. Our third-party financial aid processer, FAME, has agreed to review all r2T4 forms going forward for accuracy.

View Audit 54926 Questioned Costs: $1

Finding 58605 (2022-001)

Significant Deficiency 2022

Union Baptist Church-School, Inc.

MD

Internal Control / Segregation of Duties

We concur with the finding and will implement a procedure that will include a second signatory (persons authorized as second signers, i.e. board chair, CEO) that approves EFT transactions within the invoice packet of purchases.

View Audit 54919

Finding 58602 (2022-001)

Material Weakness 2022

Stilwell School District I-25

OK

Internal Control / Segregation of Duties

FINDING 2022-01 INTERNAL CONTROL OVER MAJOR PROGRAMS-UNAUTHORIZED PAYROLL CHANGES. CRITERIA: AN EFFECTIVE INTERNAL CONTROL SYSTEM SHOULD INCLUDE BOTH DETECTIVE AND PREVENTATIVE CONTROLS IN ORDER TO PREVENT MISAPPROPRIATION OF CASH AND FRAUDULENT PAYMENTS. CONDITION: STILWELL SCHOOL DID NOT HAVE A PR...

FINDING 2022-01 INTERNAL CONTROL OVER MAJOR PROGRAMS-UNAUTHORIZED PAYROLL CHANGES. CRITERIA: AN EFFECTIVE INTERNAL CONTROL SYSTEM SHOULD INCLUDE BOTH DETECTIVE AND PREVENTATIVE CONTROLS IN ORDER TO PREVENT MISAPPROPRIATION OF CASH AND FRAUDULENT PAYMENTS. CONDITION: STILWELL SCHOOL DID NOT HAVE A PROCEDURE IN PLACE FOR CHANGING PAYROLL INFORMATION THAT INCLUDED REQUESTING THE CHANGE TO PAYROLL ON A STANDARD FORM THAT INCLUDES AN EMPLOYEE'S SIGNATURE AUTHORIZING THE CHANGE SIGNED IN FRONT OF AN ADMINISTRATIVE OFFICE EMPLOYEE AND APPROVED BY THE TREASURER. AS A RESULT, APPROXIMATELY $10,000 TO $14,000 OF PAYROLL PAYMENTS WERE MADE TO UNAUTHORIZED BANK ACCOUNTS. CAUSE AND EFFECT: THE TREASURER RECEIVED TWO EMAILS REQUESTING CHANGES TO DIRECT DEPOSIT ACCOUNT INFORMATION FROM ADMINISTRATIVE STAFF, WHICH RESULTED IN THE TREASURER CHANGING THE DIRECT DEPOSIT ACCOUNT NUMBERS TO FRAUDULENT ACCOUNTS. RECOMMENDATION: WE RECEOMMEND STILWELL SCHOOLS IMPLEMENT A PROCEDURE WHERE CHANGES TO PAYROLL INFORMATION MUST BE MADE IN PERSON BY COMPLETING A CHANGE FORM THAT THE EMPLOYEE SIGNS AND DATES IN ORDER TO AUTHORIZE CHANGES TO THEIR ACCOUNTS. RESPONSIBLE OFFICIAL'S RESPONSE: THE SCHOOL IMPLEMENTED SUCH A PROCEDURE, AND NO LONGER ALLOWS PAYROLL CHANGES BY EMAIL. CORRECTIVE ACTION PLANNED: STILWELL SCHOOLS WILL IMPLEMENT THE PROCEDURES IN PLACE THAT REQUIRES PAYROLL INFORMATION CHANGES BE MADE IN PERSON BY COMPLETING A CHANGE FORM THAT THE EMPLOYEE WILL SIGN AND DATE IN ORDER TO AUTHORIZE CHANGES TO THEIR ACCOUNTS. NAME OF CONTACT PERSON RESPONSIBLE FOR CORRECTIVE ACTION: MATTHEW BRUNK-SUPERINTENDENT. ANTICIPATED COMPLETION DATE: AUGUST 9TH, 2023.

View Audit 54217

Finding 58601 (2022-003)

Material Weakness 2022

City of Westby, Wisconsin

WI

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding 2022-003 Federal Procedures Manual Condition: The City did not have written policies, procedures and standards of conduct relative to federal awards as required by Uniform Guidance (2 CFR 200), Subparts D (Post Federal Award Requirements) and E (Cost Principles). Criteria: Uniform Guidance...

Finding 2022-003 Federal Procedures Manual Condition: The City did not have written policies, procedures and standards of conduct relative to federal awards as required by Uniform Guidance (2 CFR 200), Subparts D (Post Federal Award Requirements) and E (Cost Principles). Criteria: Uniform Guidance required nonfederal entities that receive federal awards establish written policies, procedures or standards of conduct. Cause: The City lacks written policies, procedures or standards of conduct required by the current federal regulations. Effect: Failure to establish these policies, procedures or standards of conduct puts the City. in noncompliance with Federal regulations and increases the likelihood of fraud, waste and abuse of federal funds. It also may increase the likelihood of findings in subsequent single audits due to lack of adequate internal controls. Auditor's Recommendation: We recommend that the City adopts written policies, procedures and standards of conduct relative to federal awards as required by Uniform Guidance. We have provided sample policies to review and consider. Management Response: The City has developed and adopted written grant procedures that are m accordance with the Uniform Guidance, effective 1/1/2023. Contact Person: Roxy Wedwick Anticipated Completion: December 31, 2023

View Audit 54216

Finding 58547 (2022-003)

Material Weakness 2022

Sicangu Oyate Ho, INC

SD

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

2022-003 Payroll (Material Weakness) New Finding This Year Recommendation: Management should restrict payroll module access to those with a logical need for such access. Action Taken: St. Francis Indian School has checks and balances in place when changes need to be made in the payroll module. The o...

2022-003 Payroll (Material Weakness) New Finding This Year Recommendation: Management should restrict payroll module access to those with a logical need for such access. Action Taken: St. Francis Indian School has checks and balances in place when changes need to be made in the payroll module. The only employees who have access are those who need to input data and make changes such as Human Resources and of course Payroll.

View Audit 55377

Finding 58526 (2022-002)

Material Weakness 2022

Fort Dodge Housing Agency

IA

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

View of the Responsible Officials of the Auditee: The auditee's management agrees with the finding. The Agency has reviewed, assessed, and will follow the current Agency Financial Administration Policy.

View Audit 54138

Finding 58486 (2022-007)

Material Weakness 2022

Regional West Health Services

NE

Reporting Internal Control / Segregation of Duties § 200.303

Material Weakness: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the feder...

Material Weakness: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: RWHS selected option I to calculate lost revenue for its subsidiary, which consists of reporting quarterly net revenue by payor during the period of availability. Net revenue was determined by projecting payor deductions instead of using actual deductions as required by the terms and conditions of the award. Planned Corrective Action: Management will refine processes to more diligently review the lost revenue calculation to ensure such amounts are in accordance with the terms and conditions of the federal award. Contact Person: Alan Townsend, CFO Anticipated Completion Date: Ongoing

View Audit 54656

Finding 58485 (2022-006)

Material Weakness 2022

Regional West Health Services

NE

Reporting Internal Control / Segregation of Duties § 200.303

Material Weakness: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the feder...

Material Weakness: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: RWHS selected option II to calculate lost revenue for its subsidiary, which consists of a comparison of actual results during the period of availability to the approved budget in 2020 and 2021. The budget was required to be approved by March 27, 2020. The budget used for 2021 and 2022 was not approved by the required date. Planned Corrective Action: Management will refine processes to more diligently review the lost revenue calculation to ensure such amounts are in accordance with the terms and conditions of the federal award. Contact Person: Alan Townsend, CFO Anticipated Completion Date: Ongoing

View Audit 54656

Finding 58484 (2022-005)

Material Weakness 2022

Regional West Health Services

NE

Reporting Internal Control / Segregation of Duties § 200.327 § 200.328

Material Weakness: Criteria: RWHS must establish and maintain effective internal control over federal awards that provides reasonable assurance that RWHS is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2...

Material Weakness: Criteria: RWHS must establish and maintain effective internal control over federal awards that provides reasonable assurance that RWHS is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with program requirements. Terms and conditions of the federal award require the quarterly revenue on an actual and budgeted basis to be reported to the federal agency by March 31, 2023. Condition: RWHS submitted instances of inaccurate actual revenue for quarters 3 and 4 of 2021 and 2022 and inaccurate budgeted revenue for quarters 2 and 3 of 2021. Planned Corrective Action: Management will implement procedures to ensure that the required revenue totals are reported accurately in accordance with the terms and conditions of the federal award. Contact Person: Alan Townsend, CFO Anticipated Completion Date: December 31, 2023

View Audit 54656

Finding 58481 (2022-001)

Material Weakness 2022

Municipality of Skagway

AK

Questioned Costs Special Tests & Provisions Material Weakness

Finding 2022-001 ? Special Tests and Provisions ? Internal Control Over Compliance ? Material Weakness in Internal Control Over Financial Reporting and Material Noncompliance Issue: A missing application from the audit sample was shredded in error before being scanned into the patient?s Electronic H...

Finding 2022-001 ? Special Tests and Provisions ? Internal Control Over Compliance ? Material Weakness in Internal Control Over Financial Reporting and Material Noncompliance Issue: A missing application from the audit sample was shredded in error before being scanned into the patient?s Electronic Health Records (EHR) chart, resulting in a documentation gap. Objective: To prevent the recurrence of missing sliding fee applications by implementing a revised process that ensures all applications are properly documented and stored in the Electronic Health Records (EHR) system. Corrective Action Plan: Reception staff will continue to manage applications and supporting documentation, but once an application is complete and scanned to the patient?s chart, it will be stamped ?SCANNED? and passed to the Accounts and Benefits Specialist (ABS). The ABS will verify that the packet has been added to the patient?s EHR chart and the correct slide is placed on the account. Only application packets that are stamped ?SCANNED? will be shredded by the ABS. If the packet is not stamped, another review will be done by ABS to ensure a complete record in EHR prior to shredding. All incomplete applications will continue to be kept in a physical file by reception staff with date stamps and notes of what documentation is missing. Once an application is complete it will follow the steps outlined above. Expected Completion Date: Fiscal Year 2023

View Audit 54032 Questioned Costs: $1

Finding 58478 (2022-001)

Material Weakness 2022

Elbert County, Colorado

CO

Subrecipient Monitoring Internal Control / Segregation of Duties Material Weakness

Finding 2022-001: Material Weakness, Internal Control Over Compliance and Compliance Person(s) Responsible: Tiffany Hermes, Finance Manager Anticipated Completion Date: 9/30/2023 Corrective Action Plan: The County has taken steps to restructure and increase the in-house capabilities of the finan...

Finding 2022-001: Material Weakness, Internal Control Over Compliance and Compliance Person(s) Responsible: Tiffany Hermes, Finance Manager Anticipated Completion Date: 9/30/2023 Corrective Action Plan: The County has taken steps to restructure and increase the in-house capabilities of the finance department and overall County management. Several hiring actions have occurred, and the finance department is now full. ? There are steps in place now pertaining to internal controls which include having two employees with access to federal reports and submission capability. ? Upon an employee leaving, a structure will be in place to passalong the access to the correct position for future reporting.

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Finding 58477 (2022-001)

Significant Deficiency 2022

Derry Housing & Redevelopment Authority

NH

HUD Housing Programs Internal Control / Segregation of Duties § 200.305 § 200.514

CORRECTIVE ACTION PLAN (Concerning Finding 2022-001) Contact Person Responsible for Corrective Action: Melody Ackerman, Executive Director Corrective Action: The Derry Housing and Redevelopment Authority will take the following actions to address finding 2022-001; The Derry Housing and Redev...

CORRECTIVE ACTION PLAN (Concerning Finding 2022-001) Contact Person Responsible for Corrective Action: Melody Ackerman, Executive Director Corrective Action: The Derry Housing and Redevelopment Authority will take the following actions to address finding 2022-001; The Derry Housing and Redevelopment Authority (DHRA) will select an accurate Rent Reasonableness system to use. Once an accurate NH022 Rent Reasonableness system has been selected, the PHA must update HCV Administrative Plan, including receiving Board approval, to document the use of this new system. The PHA must perform Rent Reasonableness determinations utilizing the Board approved methodology on all currently leased vouchers. The DHRA expects to have all corrections in place by December 1, 2023.

View Audit 56077

Corrective Action Plans

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