Corrective Action Plans

Finding 38824 (2022-003)

Significant Deficiency 2022

Young Women's Christian Association of St. Paul and Affiliates

MN

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

Finding Summary: For one employee tested, there was no formal documentation of a secondary review of the payroll allocation calculation. Responsible Individuals: Lisa Gochanour, Accounting Manager ? Stephanie Kilian, CFO Corrective Action Plan: Going forward the Accounting Manager will ensure that a...

Finding Summary: For one employee tested, there was no formal documentation of a secondary review of the payroll allocation calculation. Responsible Individuals: Lisa Gochanour, Accounting Manager ? Stephanie Kilian, CFO Corrective Action Plan: Going forward the Accounting Manager will ensure that any payroll allocation changes have an appropriate status change form accompanying the change in payroll allocation. Any change in allocation lacking an approved status change form will be reported to the CFO who can work with the appropriate manager to secure the necessary documentation. All new employees will have the initial allocation documented on the status change form as part of the new hire process. Anticipated Completion Date: 08/01/2023 ? 12/31/2023

View Audit 34493

Finding 38786 (2022-002)

Material Weakness 2022

City of Terre Haute

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.303

FINDING 2022-001 Contact Person Responsible for Corrective Action: Leslie Ellis Contact Phone Number: 812-244-2359 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: New procedures have been established to track and monitor all grants that the City recei...

FINDING 2022-001 Contact Person Responsible for Corrective Action: Leslie Ellis Contact Phone Number: 812-244-2359 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: New procedures have been established to track and monitor all grants that the City receives. The Controller?s office will receive all grant documents (Funding Approval Agreements, Award Letters, etc.) from City Departments as grants are awarded. All grant documents will be reviewed to determine which grants are federal grants. When federal reimbursement requests or draws are made, the department will submit a copy to the Controller?s office. The Senior Financial Analyst in the Controller?s office tracks all grant receipts and disbursements. At the end of each year a grant worksheet will be sent to each department to complete with the year?s federal grant information. The Senior Financial Analyst will reconcile the worksheets to the Controller?s office records. Once reconciled, the Chief Deputy Controller will review the documents for approval. The Senior Financial Analyst will then enter the federal grant information into the Annual Financial Report in the State?s Gateway website. The Chief Deputy Controller will review and approve the information entered into Gateway. The Controller will perform a final review before the information is submitted and authorized in Gateway. Anticipated Completion Date: March 1, 2024

View Audit 46222

Finding 38783 (2022-001)

Significant Deficiency 2022

Stamford Health, Inc.

CT

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding 2022 ? 001 Reporting Identification of the Federal Program: Grantor: Department of Health and Human Services Program Name: COVID-19 ? Provider Relief Fund Assistance Listing No.: 93.498 Views of Responsible Individuals: Management concurs with the audit finding above. The method utilized to...

Finding 2022 ? 001 Reporting Identification of the Federal Program: Grantor: Department of Health and Human Services Program Name: COVID-19 ? Provider Relief Fund Assistance Listing No.: 93.498 Views of Responsible Individuals: Management concurs with the audit finding above. The method utilized to calculate lost revenue is allowable, however a budget used in the lost revenue calculation was not approved by the date specified in the terms and conditions of Option II, so the incorrect method was selected in the PRF portal submission. Management will refine its existing controls and implement additional controls to ensure that the lost revenue reporting method selected within future PRF portal submissions is consistent with the methodology utilized to calculate lost revenue. These existing controls will be refined, and the new controls will be implemented, by fiscal year ending September 30, 2023. Name of responsible individual: Nicholas Jamieson, Corporate Controller

View Audit 44142

Finding 38772 (2022-001)

Material Weakness 2022

Laconia Housing & Redevelopment Authority

NH

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

Material Weaknesses identified was from 2022-01 - Housing Quality Standards Inspections During audit procedures, it was identified that the Unit's Inspections were completed but if there was a failure, re-inspections were not completed as required within the 30-day period. The cause was identified ...

Material Weaknesses identified was from 2022-01 - Housing Quality Standards Inspections During audit procedures, it was identified that the Unit's Inspections were completed but if there was a failure, re-inspections were not completed as required within the 30-day period. The cause was identified that we did not have the necessary internal controls over compliance in place. That we are not re-inspecting units timely. The failure rate of 40 units examined during audit resulted in 14 failures for re-inspection. The recommendation was that we implement internal control processes and procedures to ensure that re-inspections are completed on a timely basis. Management Response: We became aware of a concern and performance issues with our HCV manager in the summer of 2021. She provided her notice of intent to resign effective December 31, 2021. We began a search for a manager in the fall of 2021 through many processes, including posting the position, inquiring of other housing authorities of our open position and networking. Additionally, we brought in a consultant to complete requirements of our contract effective January 1, 2022. This is a specialized position and one that requires experience for the position. We hired an experienced manager in May 2022 to organize the HCV program. During this audit period HUD had in place a moratorium on inspections due to COVID outbreak. We did not at this.time need to inspect units. However we did inspect units, of the 40 that had inspections we recognize as a result of the audit that we failed 14. We requested a listing of the 14 failed inspected units as a result of the audit. Senior Management was not informed during the audit process, rather during the reporting phase of the audit. Once we received the 14 names we reviewed them. Upon first inspection two of the names immediately were known. One of the persons was living in a situation where she would not have been able to pass inspection, she was a Choice for Independent living recipient approved for services by Medicaid. She was assigned to a case manager and should have been receiving services in her existing housing, however area agencies were unable to provide services per her eligibility requirements and therefore we placed her on our waitlist and worked towards housing her. She was transferred to our housing and is receiving services effective January 2022. During her first months with us she received inspections regularly to ensure that she would not fail and be in jeopardy of eviction. She is now receiving services, doing well and passing inspections. The second person was one of our Choice for Independent living residents in one of our units, his unit failed inspection on Sept. 20, 2021 and a work order for repairs was completed on October 14, 2021, which was within the 30 day re-inspection process. However this was not reported in our housing software, rather was in our work order software. We identified that three of the additional tenants that failed inspection had been re- inspected in May of 2021 and had passed within a few days of their inspection which was under 30 days, however once again was not reflected in our software. During our review process it became known to us that there is a flaw in our software package that we have been addressing with PHA Web for some time. We are working towards accurate notifications within our software. Additionally, during the period of time reviewed we had staff shortages due to COVID positive employees and a needed to change work schedules to maintain our properties effectively. We had created a practice of quarantining due to exposure and or symptoms which affected our HCV inspection staff members, both having tested positive with symptoms. Corrective Actions: We recognize and appreciate the information to work towards improvement of our HCV program. In May 2022 we hired a new Manager for our HCV program. The new Manager is working on preparing a new administration plan to be implemented for our HCV program. The new Manager is working on hiring a team and organizing existing staff to ensure that necessary details including inspections and follow up inspections are kept on track as required and documented properly. There is a process in place for HQS inspections to be followed and reports will be utilized. We have worked on training additional staff members and certifying them in HQS inspection process to ensure inspections are done timely. All our current voucher holders will be receiving a scheduled inspection to create a baseline and to move forward effectively. We anticipate completion of inspections according to our plan to be within six months of this report.

View Audit 37086

Finding 38768 (2022-003)

Material Weakness 2022

Administrative School District No 1

OR

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Cash Management

The District submitted, for reimbursement via the Emergency Connectivity Grant Fund (ECF), approximately $210,000 dollars for ipads, which had been received prior to the eligibility date of the grant, July 1, 2021. These ipads having been received by the IT department, at the Districts main Educati...

The District submitted, for reimbursement via the Emergency Connectivity Grant Fund (ECF), approximately $210,000 dollars for ipads, which had been received prior to the eligibility date of the grant, July 1, 2021. These ipads having been received by the IT department, at the Districts main Education Center office, after July 1, 2021, were reported and recorded as July 2021 eligible transactions. It was subsequently determined this shipment was actually received on June 29, 2021 at the Districts distribution center, therefore making this specific shipment ineligible for grant reimbursement. Upon identification of this error, the District immediately contacted the grant management organization, appraised them of the situation, and were allowed to provide other eligible ipad purchases, as reimbursement backup. Management has proposed additional cutoff testing processes as part of our year end processing, including review and audit of material transactions to ensure recording in proper year. Management has also provided additional training to staff members, on correct cutoff processing and the requirement for original shipping documents and receiving support. The District has also implemented a change in process, whereby all technology purchases will be delivered directly to the IT department at the main Education Center location to ensure appropriate receipt dates and documentation is provided.

View Audit 36784

Finding 38725 (2022-001)

Significant Deficiency 2022

Horsham Water and Sewer Authority

PA

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

State Memorandum of Agreement Program for the Reimbursement of Technical Services ? ALN 21.113; U.S. Department of the Navy Cooperative Agreement #N40085-15-2-8711 Condition: Reports required by the federal program were not prepared and submitted timely and internal controls were not followed to en...

State Memorandum of Agreement Program for the Reimbursement of Technical Services ? ALN 21.113; U.S. Department of the Navy Cooperative Agreement #N40085-15-2-8711 Condition: Reports required by the federal program were not prepared and submitted timely and internal controls were not followed to ensure timely filing occurred. Planned Corrective Action: Tina M. O?Rourke, Business Manager, will ensure quarterly performance and financial reports are prepared and submitted 30 days following the end of each calendar quarter. Management?s Response: The Authority disagrees with this finding because periodic payment applications reflect the level of completion and outstanding for each budget line item. The Authority has implemented the recommendation for the year ending December 31, 2023. Individuals of the Authority management performing reporting will be aware of the requirements and follow established controls to ensure reports are prepared and submitted timely.

View Audit 47151

Finding 38723 (2022-002)

Significant Deficiency 2022

Koinonia, Inc. 053-11202

NC

HUD Housing Programs Procurement, Suspension & Debarment Reporting § 200.302 § 200.303

Koinonia, Inc. Lenoir, North Carolina CORRECTIVE ACTION PLAN June 26, 2023 U.S. Department of Housing and Urban Development Charles Bennett Federal Building 400 West Bay Street, Suite 1015 Jacksonville, Florida 32202 Koinonia, Inc. respectfully submits the fol...

Koinonia, Inc. Lenoir, North Carolina CORRECTIVE ACTION PLAN June 26, 2023 U.S. Department of Housing and Urban Development Charles Bennett Federal Building 400 West Bay Street, Suite 1015 Jacksonville, Florida 32202 Koinonia, Inc. respectfully submits the following Corrective Action Plan for the year ended December 31, 2022. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings from the year ended December 31, 2022 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDING - Financial Statement Audit and Federal Award Program Audit Finding 2022-001: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Projects (Section 223(f)/207) Recommendation: We recommend that the Project funds are only used for expenses of the Project. Additionally, we recommend the related entity reimburse the operating cash of the Project $2,000 for the accounting fees paid. Action Taken: Management acknowledges the Project funds were used for expenses of another entity. Management will ensure the related entity reimburses the operating cash of the Project $2,000 for the accounting fees paid and ensure that the Project funds are only used for expenses of the Project. Finding 2022-002: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects (Section 223(f)/207) Recommendation: We recommend management review/enhance its accounting and internal control procedures to ensure that all key accounts are reconciled and reviewed with supporting evidence of such review. Action Taken: We agree with Finding 2022-002 and the recommendation described in the accompanying schedule of findings and questioned costs. Management will review the accounting and financial procedures, system of internal controls and policies. FINDING - Federal Award Program Audit Finding 2022-003: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects (Section 223(f)/207) Recommendation: We recommend that the Project continuously monitor cash balances to ensure that funds are always covered by FDIC insurance limits, collateral agreements are obtained, or funds are invested in government securities. Action Taken: Management acknowledges the Project funds were in excess of FDIC insured limits and will transfer funds to provide adequate FDIC insurance coverage for all cash accounts. If HUD has questions regarding this corrective action plan, please call 828-758-2617. Sincerely yours, Chassidy Triplett Project Administrator Koinonia, Inc.

View Audit 47149

Finding 38691 (2022-002)

Significant Deficiency 2022

New Mexico Rural Water Association

NM

Procurement, Suspension & Debarment Cash Management Internal Control / Segregation of Duties

It is management?s policy to update and distribute travel reimbursement forms with new mileage and per diem rates the first of each calendar year, and at any other time the rates may change. Federal per diem and travel rates will be verified on a monthly basis to ensure that the most current rates a...

It is management?s policy to update and distribute travel reimbursement forms with new mileage and per diem rates the first of each calendar year, and at any other time the rates may change. Federal per diem and travel rates will be verified on a monthly basis to ensure that the most current rates are being used.

View Audit 46638

Finding 38678 (2022-003)

Material Weakness 2022

Transitional Resources

WA

Material Weakness Internal Control / Segregation of Duties

2022-003 Material Weakness in Internal Control, Finding related to Compliance with Federal Regulations Finding: Internal Control over Representative Payee Accounts Condition: The Representative Payee account had a number of budget sheets or check requests that were signed by phone with no addition...

2022-003 Material Weakness in Internal Control, Finding related to Compliance with Federal Regulations Finding: Internal Control over Representative Payee Accounts Condition: The Representative Payee account had a number of budget sheets or check requests that were signed by phone with no additional notation of date of contact, one was missing an authorizing signature, and one was missing a document. Cause: There was significant turnover in the Representative Payee accounting position, as well as with Case Management staff that work with Transitional Resources? clients to budget and receive Social Security funds. Effect: As a result of the above, internal controls were weakened that minimize the risk to client accounts. Response: Effective July 12th, 2023, the Representative Payee accounting staff, Case management staff and the Supervisor that authorizes fund distribution shall receive training on the proper procedures for completing budget sheets and check requests. To ensure the process is being followed correctly, an internal review process shall be developed. The Representative Payee staff member shall check each budget sheet or check request for completion before distributing any funds and prior to filing documents at month end. Any missing information shall be returned for completion. Patterns of incomplete information shall be brought to the Supervisor?s attention for additional training. To better monitor Transitional Resources? internal control processes, a year-end risk assessment report shall be provided to the Finance Committee to ensure progress has been made on the areas identified above. Submitted by: Darcell Slovek-Walker, LMHC Chief Executive Officer

View Audit 44203

Finding 38677 (2022-002)

Material Weakness 2022

Transitional Resources

WA

Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking § 200.303

2022-002 Material Weakness in Internal Control Finding: Internal Control over Reconciliation of Accounting Records Condition: The audit confirmation process did not go smoothly and resulted in confirmations being sent multiple times. Cause: The Accounting Manager did not have the adequate skills,...

2022-002 Material Weakness in Internal Control Finding: Internal Control over Reconciliation of Accounting Records Condition: The audit confirmation process did not go smoothly and resulted in confirmations being sent multiple times. Cause: The Accounting Manager did not have the adequate skills, knowledge, and experience to complete the audit confirmation process independently as previously believed to be the case by the Supervisor. Due to turnover in the accounting department, this was the first year for the Accounting Manager to send the confirmations independently. The Supervisor assessed that the Accounting Manager was ready to perform this task, however, this was not the case. Effect: The audit confirmation errors delayed the audit process. Additional oversight should have been provided to the Accounting manager. Response: Effective, August 1, 2023 or within 60 days of hire, the agency?s Accounting Manager shall receive training on the appropriate procedures for completing an audit confirmation. The Accounting Manager?s Supervisor shall review all confirmations for completeness prior to sending until such time it is determined that the Accounting Manager is able to perform this task independently.

View Audit 44203

Finding 38676 (2022-001)

Material Weakness 2022

Transitional Resources

WA

Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking § 200.303

Transitional Resources submits the following corrective action plan for the year ending December 31, 2022. Name and address of independent accounting firm: Lindley & Associates LLC, 1603 116th Ave NE, Suite 100, Bellevue, WA 98004-9003, Bellevue, WA 98004-9003 Audit period: January 1, 2022 to Dece...

Transitional Resources submits the following corrective action plan for the year ending December 31, 2022. Name and address of independent accounting firm: Lindley & Associates LLC, 1603 116th Ave NE, Suite 100, Bellevue, WA 98004-9003, Bellevue, WA 98004-9003 Audit period: January 1, 2022 to December 31, 2022 Contact person responsible for corrective action: Deb Orsillo, Director of Administration 2022-001: Material Weakness in Internal Control Finding: Internal Control over Timely Bank Reconciliations Condition: Transitional Resources? bank reconciliations were not completed in a timely manner. While supervisory personnel were aware the Accounting Manager was behind in accounting functions, they were unaware the bank reconciliations had not been completed in a timely manner. Cause: There was turnover in Transitional Resources? Accounting department which resulted in delays in completing the bank reconciliations. Due to the delay of the monthly accounting packets, which contain the bank reconciliations, Supervisory personnel did not initially identify those reconciliations were not completed in a timely manner. Effect: Safeguards of the agency?s accounts were in place by a thorough review of monthly bank statements by Supervisory personnel, however these reviews did not provide the same level of internal control as having timely bank reconciliations. Response: Effective June 26, 2023, bank reconciliations shall be prepared within 30 days of the receipt of the statement. The bank statement and bank reconciliation shall be reviewed by a person other than the preparer, initialed, and dated. The bank reconciliation balance shall agree with the general ledger balance. Both statements shall be initialed and dated as approved by supervisory personnel. In most cases, bank reconciliations shall be prepared by the Accounting Manager and reviewed by the Director of Administration. The Director of Administration shall not only ensure that monthly reviews of bank reconciliations are conducted but shall ensure all accounting information provided to the auditor is verified as complete, accurate, and timely.

View Audit 44203

Finding 38610 (2022-002)

Significant Deficiency 2022

Alamosa County

CO

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

Finding 2022-002: Airport Improvement Program, CFDA No. 20.106 U.S. Department of Transportation Compliance Requirement: Special Tests and Provisions Grant No.: Not Applicable Type of Finding: Internal Control (significant deficiency) and Compliance (noncompliance) Recommendation: The County should ...

Finding 2022-002: Airport Improvement Program, CFDA No. 20.106 U.S. Department of Transportation Compliance Requirement: Special Tests and Provisions Grant No.: Not Applicable Type of Finding: Internal Control (significant deficiency) and Compliance (noncompliance) Recommendation: The County should develop policies and procedures to implement monitoring controls over the federal program wage rate requirements. Action Taken: Management will develop a quarterly process to implement monitoring controls needed to ensure proper federal program wage requirements on or before year end close of December 31, 2024.

View Audit 34681

Finding 38609 (2022-003)

Material Weakness 2022

Alamosa County

CO

Reporting Internal Control / Segregation of Duties

Finding 2022-003: Airport Improvement Program, CFDA No. 20.106 U.S. Department of Transportation Compliance Requirement: Reporting Grant No.: Not Applicable Type of Finding: Internal Control (material weakness) and Compliance (material noncompliance) Recommendation: The County should strengthen its ...

Finding 2022-003: Airport Improvement Program, CFDA No. 20.106 U.S. Department of Transportation Compliance Requirement: Reporting Grant No.: Not Applicable Type of Finding: Internal Control (material weakness) and Compliance (material noncompliance) Recommendation: The County should strengthen its internal controls with adopted policies and procedures to ensure accurate financial reporting in compliance with AlP requirements. Action Taken: ? Initiate a secondary review by administrator by December 31, 2024 ? Develop necessary internal controls needed to ensure proper reporting by December 31, 2024

View Audit 34681

Finding 38596 (2022-001)

Material Weakness 2022

Nisqually Land Trust

WA

Procurement, Suspension & Debarment Cash Management Reporting

The Nisqually Land Trust agrees with the findings reported and will take corrective actions to rectify the findings. All of the below actions will be in place by October 20, 2023. 2022-001 GRANT ACCOUNTING The financial operating procedures will be revised to reflect an improved level of internal ...

The Nisqually Land Trust agrees with the findings reported and will take corrective actions to rectify the findings. All of the below actions will be in place by October 20, 2023. 2022-001 GRANT ACCOUNTING The financial operating procedures will be revised to reflect an improved level of internal controls and procedures in the finance department, including the following: o Implementation of a monthly procedure for reconciling and reviewing all accounting functions and reporting. o Executive level leadership has been given access to review reports within the accounting software. Notes and reports from monthly review between the Finance and Operations Manager, bookkeeper, and program directors will be provided to the Executive Director for review monthly. o The Finance and Operations Manager position description will be updated to make clear that they have a responsibility to ensure all processes are being followed & to identify training gaps. Monthly self-monitoring is part of the Finance and Operations Manager duties to oversee or delegate as needed. The purpose of the self-monitoring is to spot check various aspects of accounting tasks to ensure processes are being followed and training is provided immediately. ? Reporting on grant activities will be updated and standardized for all programs and for the Nisqually Land Trust in its entirety. This will allow Nisqually Land Trust?s finance processes to be more transparent to program directors and the Board. ? Training plans are being improved and implemented for all finance positions as well as identifying necessary training for program management. o A training plan for each finance position will be developed and initiated in the current year. It will be evaluated annually and updated to stay current with training needs. o The training plans and progress are monitored by the Finance and Operations Manager and the Executive Director. o Nisqually Land Trust will continue to prioritize budgeting for training of fiscal staff

View Audit 31354

Finding 38591 (2022-002)

Material Weakness 2022

Greene County Community School District

IA

Internal Control / Segregation of Duties

We continue to search for ways to spread the duties amongst available staff. The Superintendent?s secretary has become more involved. She opens the mail, logs checks that are received and writes the cash receipts for those. She continues to log all checks written as well and holds the Board Presi...

We continue to search for ways to spread the duties amongst available staff. The Superintendent?s secretary has become more involved. She opens the mail, logs checks that are received and writes the cash receipts for those. She continues to log all checks written as well and holds the Board President?s signature stamp in a locked drawer.

View Audit 37933

Finding 38582 (2022-001)

Significant Deficiency 2022

The Bailey Foundation

MO

Internal Control / Segregation of Duties Significant Deficiency

View of Responsible Official and Planned Corrective Action. The outsourced CFO engagement ended due to cash flow issues related to program deferral and a lapse in federal programming. Re-engagement attempts failed as the CFO no longer had capacity to service The Bailey Foundation. The Bailey Foun...

View of Responsible Official and Planned Corrective Action. The outsourced CFO engagement ended due to cash flow issues related to program deferral and a lapse in federal programming. Re-engagement attempts failed as the CFO no longer had capacity to service The Bailey Foundation. The Bailey Foundation is actively seeking a skilled accountant for essential internal controls. Meanwhile, the board is organizing additional oversight to manage risks in federal program operations.

View Audit 36753

Finding 38574 (2022-001)

Significant Deficiency 2022

Menomonie Housing Authority

WI

Internal Control / Segregation of Duties Reporting

2022-001 - Lack of Segregation of Duties Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organiz...

2022-001 - Lack of Segregation of Duties Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongoing

View Audit 30354

Finding 38563 (2022-001)

None 2022

118 East 111th Street Corporation

NY

Cash Management HUD Housing Programs Internal Control / Segregation of Duties

118 East 111th Street Corporation 290 Lenox, 3rd Floor New York, NY 10027 AUDITEE?S CORRECTIVE ACTION PLAN Name and Number of Project 118 East 111th Street Corporation, FHA Project Number 012-HD010 Auditor/Audit Firm PKF O?Connor Davies LLP Audit Period June 30, 2022 Finding 2022-001 ? Timely ...

118 East 111th Street Corporation 290 Lenox, 3rd Floor New York, NY 10027 AUDITEE?S CORRECTIVE ACTION PLAN Name and Number of Project 118 East 111th Street Corporation, FHA Project Number 012-HD010 Auditor/Audit Firm PKF O?Connor Davies LLP Audit Period June 30, 2022 Finding 2022-001 ? Timely Deposit of Surplus Cash A. Comments on Finding and Recommendations Recommendation ? We recommend that management ensures the surplus cash deposit is done timely in the future. B. Actions Taken or Planned Auditee agrees with this finding. Our policy has been to make surplus cash deposits after the final audit has been issued. Going forward our focus will be to work with the auditor and owner to get the audits finalized earlier so adequate time is left for the deposits to be made. In instances where the final is not going to be issued and allow enough time, the deposit will be made based on the reviewed draft. C. Status of Corrective Action on Prior Findings No prior findings. Ezra Miller, CFO

View Audit 32759

Finding 38553 (2022-039)

Significant Deficiency 2022

State of Vermont

VT

Special Tests & Provisions Reporting Significant Deficiency § 200.303

Corrective Action Plan: The Agency has submitted the Medical Loss Ratio report for the year ending 12/31/2021 no later than 12/31/2022. The report was delivered on 12/29/2022. Department of Vermont Health Access (DVHA) and the Agency of Human Services (AHS) have worked together over the past year t...

Corrective Action Plan: The Agency has submitted the Medical Loss Ratio report for the year ending 12/31/2021 no later than 12/31/2022. The report was delivered on 12/29/2022. Department of Vermont Health Access (DVHA) and the Agency of Human Services (AHS) have worked together over the past year to define the roles and responsibilities needed to deliver the Medical Loss Ratio (MLR) to AHS by the due date. AHS has agreed to provide Medicaid summaries, and once December enrollment is available, provide capitation rates multiplied by final enrollment for total calendar year expenditures. Additional to AHS deliverables, DVHA has updated its Standard Operating Procedures (SOP) to reflect the deliverables from AHS, additional detail to support each step in the process, and validation steps for AHS upon completion of the report by DVHA. The steps that have been added to the process allow for a more comprehensive review of the deliverable by both departments which will allow for an on-time delivery in its entirety by the due date of December 31. Scheduled Completion Date of Corrective Action Plan: December 29, 2022 Contacts for Corrective Action Plan: Patrick Rooney, DVHA Financial Director patrick.rooney@vermont.gov Allison Nowak, DVHA Financial Director allison.jensen@vermont.gov Tracy O?Connell, AHS-CO Financial Director tracy.oconnell@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 30446

Finding 38552 (2022-038)

Material Weakness 2022

State of Vermont

VT

Subrecipient Monitoring Material Weakness Reporting § 200.303

Corrective Action Plan: Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (AL No. 93.775, 93.777, 93.778) that is shared between all AHS departments. To address omissions and timeliness of subawards and subaward modificat...

Corrective Action Plan: Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (AL No. 93.775, 93.777, 93.778) that is shared between all AHS departments. To address omissions and timeliness of subawards and subaward modifications reporting to FSRS, IAG will conduct additional training tailored to each AHS Department to examine the results of FFATA testing conducted internally, and reemphasize the FFATA compliance regulations. This will ensure the Internal Audit Group (IAG) is provided with complete, accurate and timely subaward information for reporting in FSRS going forward. Further, on at least an annual basis, IAG will conduct a review of current federal rules and regulations pertaining to FFATA reporting for FSRS to assure the Agency?s procedures are up-to-date. Coincidentally, IAG will also select a random sample of subawards and subawards modifications that meet the required threshold for FFATA reporting to ensure they are reported in FSRS system on a complete, accurate and timely basis. Scheduled Completion Date of Corrective Action Plan: Annual review of FFATA rules and regulations including subawards sample testing December 31, 2022 Individualized training for each AHS Department January 31, 2023 Contact for Corrective Action Plan: Peter Moino AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 30446

Finding 38547 (2022-034)

Significant Deficiency 2022

State of Vermont

VT

Student Financial Aid Eligibility Significant Deficiency § 200.303

Corrective Action Plan: The Child Development Division (CDD) has recently switched to a new IT system, Child Development Division Information System (CDDIS), that will check for the child?s IV-E eligibility and check to make sure that the child is in an eligible placement. With these checks it will...

Corrective Action Plan: The Child Development Division (CDD) has recently switched to a new IT system, Child Development Division Information System (CDDIS), that will check for the child?s IV-E eligibility and check to make sure that the child is in an eligible placement. With these checks it will allow the child to be marked as IV-E eligible or not and draw down the appropriate funding to match the eligibility. Scheduled Completion Date of Corrective Action Plan: July 31, 2023 Contacts for Corrective Action Plan: Karolyn Long ? Karolyn.Long@vermont.gov Emily Hazard ? Emily.Hazard@vermont.gov

View Audit 30446

Finding 38544 (2022-033)

Significant Deficiency 2022

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Corrective Action Plan: The Financial Administrator will ensure that subrecipient grants containing federal funding that meet the FFATA reporting threshold are marked as ?required for entry into the FSRS system? upon grant execution. The Financial Administrator and Manager will then confirm that al...

Corrective Action Plan: The Financial Administrator will ensure that subrecipient grants containing federal funding that meet the FFATA reporting threshold are marked as ?required for entry into the FSRS system? upon grant execution. The Financial Administrator and Manager will then confirm that all executed agreements that meet the FFATA reporting requirement have been entered and submitted into the FSRS system by the last business day of each month. Scheduled Completion Date: 2/1/2023 Contacts for Corrective Action Plan: Jessica Brown, Financial Administrator, Vermont Department of Health Karen Clark, Financial Manager, Vermont Department of Health Megan Hoke, Financial Director, Vermont Department of Health Peter Moino, Director of Internal Audit, Vermont Agency of Human Services

View Audit 30446

Finding 38530 (2022-026)

Material Weakness 2022

State of Vermont

VT

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

Corrective Action Plan: The Agency will identify if a new ESEA Federal grant (or a grant based on an ESEA program) includes an Equitable Service requirement during the program completion of the ?New Grant Checklist?. If a new grant includes an Equitable Service requirement, the ESEA Equitable Servic...

Corrective Action Plan: The Agency will identify if a new ESEA Federal grant (or a grant based on an ESEA program) includes an Equitable Service requirement during the program completion of the ?New Grant Checklist?. If a new grant includes an Equitable Service requirement, the ESEA Equitable Service?s Ombudsman will be notified and will work with the grant program manager to ensure the build of the GMS application includes the correct level of detail and controls to meet the SEA requirements for oversight. When appropriate, the Agency will use its process for handling of Equitable Services associated with the Consolidated Federal Programs as models for determining the correct calculation method. The Agency will utilize built in business rules and internal controls within the Grants Management System (GMS) to gather the following information in the grant application for AOE review and approval prior to issuing a grant award agreement: 1. Calculation of the total proportionate share dollars an LEA must set aside for Equitable Services 2. Identification of Independent Schools participating in Equitable Services applicable to each LEA 3. Calculation of the dollars available for Equitable Services for each participating Independent School For each Federal grant that requires an equitable services component, the Agency will document the review and approval of the Equitable Services information through one of two processes prior to the grant award agreement: 1. A dedicated review assignment specific to equitable services, or 2. Verification statements on the review checklist for a general application reviewer Position Responsible for Implementation of Corrective Action: Anne Bordonaro, Division Director, Federal & Education Support Programs anne.bordonaro@vermont.gov 802-828-1388 Date of Implementation of Corrective Action: July 1, 2023

View Audit 30446

Finding 38529 (2022-029)

Significant Deficiency 2022

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Corrective Action Plan: To address the accuracy and timeliness of our entries into the FFATA system, we will use the USASPENDING.GOV website to assist us in reconciling what has been entered into the FFATA system. This will allow us to ensure that our grant ledgers agree with what is entered into ...

Corrective Action Plan: To address the accuracy and timeliness of our entries into the FFATA system, we will use the USASPENDING.GOV website to assist us in reconciling what has been entered into the FFATA system. This will allow us to ensure that our grant ledgers agree with what is entered into FFATA. This will be a reconciliation completed at least quarterly (following SOV fiscal year quarters) and will be completed by the Deputy CFO or position assigned by the Deputy CFO. We will also implement a process that will have all the steps necessary for a grant award or an amendment to ensure it is posted properly within our internal files and the external systems. This will ensure that new awards and amendments get routed and entered in the FFATA system timely. Our finance team also attended a FFATA training on February 3, 2023 for additional training on the FFATA system. We will look into the Batch upload process which was described in that training. Position Responsible for Implementation of Corrective Action Name: Sean Cousino Position: Deputy Chief Financial Officer Email: sean.cousino@vermont.gov Phone Number: 802 595-3693 Date of Implementation of Corrective Action: First Reconciliation to be completed March/April 2023 Full Implementation June 1,2023

View Audit 30446

Finding 38491 (2022-008)

Material Weakness 2022

Osborne County Memorial Hospital

KS

Material Weakness Reporting Internal Control / Segregation of Duties

Condition Management should have a process in place to ensure the internal completion of the schedule of federal expenditures (SEFA) including all required disclosures. Views of responsible officials and planned corrective actions We will continue to monitor and, although we have limited personnel...

Condition Management should have a process in place to ensure the internal completion of the schedule of federal expenditures (SEFA) including all required disclosures. Views of responsible officials and planned corrective actions We will continue to monitor and, although we have limited personnel, we will continue to enhance our internal controls over the completion of the SEFA. Anticipated completion date Ongoing

View Audit 36422

Corrective Action Plans

Filters