Corrective Action Plans

Finding 5829 (2022-109)

Material Weakness 2022

State of Arizona

AZ

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.303 § 200.334

Assistance listing number and program name: 21.023 COVID-19 Emergency Rental Assistance Program Agency: Department of Economic Security Name of contact person and title: Molly Bright, DCAD Assistant Director Anticipated completion date: December 31, 2023 Agency’s Response: Concur The Department of...

Assistance listing number and program name: 21.023 COVID-19 Emergency Rental Assistance Program Agency: Department of Economic Security Name of contact person and title: Molly Bright, DCAD Assistant Director Anticipated completion date: December 31, 2023 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: 1. Develop and implement written policies and procedures to ensure the system used to process ERA claims and report program information produces summarized data on its federal reporting dashboard that are complete and accurate and comply with the federal agency’s reporting guidelines. The Department will develop written policies and procedures to ensure the information produced by the system used for processing ERA claims and program information is accurate and complete when providing this data to the federal reporting dashboard. These policies and procedures will bring the Department into compliance with the federal agency’s reporting guidelines. Department staff will be trained in accordance with the policies and procedures. 2. Follow its policies and procedures to retain all records relating to a federal award for a period of 3 years from the date of its submission of the final expenditure report. The Department will improve its compliance with its Record Retention policies and procedures, and will retain for 3 years all records that are required as outlined within the provisions of the federal awards received by the Department. 3. Verify the ERA-reported program information and the federal reporting dashboard to the underlying system data during each report’s review and approval process. The Department will, during each report’s review and approval process, sample the information from the underlying system prior to submitting it to the federal agency to verify its accuracy. This process will be included within the Department’s written policies and procedures created for ERA federal reporting. 4. Prepare and retain detailed documentation and submitted reports, such as system reports, queries, or screenshots, to support the program information it reports to the federal agency for each ERA award. The Department will assemble and retain all detailed documentation and submitted reports, such as but not limited to the aforementioned items, to provide support for the program information that the Department reports to the federal agency for each ERA award it receives. These documents and reports will be maintained in accordance with the Department’s Record Retention policies and procedures and federal requirements.

View Audit 7884

Finding 5818 (2022-103)

Material Weakness 2022

State of Arizona

AZ

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

Assistance listing number and program name: 21.019 COVID-19 Coronavirus Relief Fund Agency: Arizona Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Sarah Brown, Director Governor’s Office of Strategic Planning & Budgeting Anticipated completion date...

Assistance listing number and program name: 21.019 COVID-19 Coronavirus Relief Fund Agency: Arizona Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Sarah Brown, Director Governor’s Office of Strategic Planning & Budgeting Anticipated completion date: January 31, 2023 Agency’s response: Concur Completed. As of January 12, 2023, the State of Arizona’s final closeout report to the U.S. Department of the Treasury on uses of Coronavirus Relief Funds (CRF) was submitted and accepted. As part of this final closeout report’s preparation, the Office completed a reconciliation of all activity reported against the information in the State’s accounting system and obtained clarification from State agencies awarded funds, as necessary, to help ensure the final report was complete and accurate.

View Audit 7884

Finding 5804 (2022-110)

Material Weakness 2022

State of Arizona

AZ

Eligibility Internal Control / Segregation of Duties § 200.303

Assistance listing number and program name: 17.225 COVID-19 Unemployment Insurance Agency: Department of Economic Security Name of contact person and title: Sandra Canez, Unemployment Insurance Program Administrator Jacqueline Butera, Quality Assurance and Integrity Administrator Anticipated comple...

Assistance listing number and program name: 17.225 COVID-19 Unemployment Insurance Agency: Department of Economic Security Name of contact person and title: Sandra Canez, Unemployment Insurance Program Administrator Jacqueline Butera, Quality Assurance and Integrity Administrator Anticipated completion date: July 16, 2023 Agency’s Response: Concur The Department of Economic Security took the following actions to remediate finding 2022-110 and prior year finding 2021-108. In July 2023, the Department completed the wage evaluation of the claimants determined eligible to receive above the $117-minimum weekly UI benefit amount, as noted in the finding. Any resulting overpayment for the federal CARES Act programs was established by the Department, and where appropriate, waivers were considered and allowed following federal regulations and the state overpayment policy. As noted in the finding, the Department addressed the 7 sampled cases and will continue to follow well-established overpayment and recovery policy and procedures.

View Audit 7884

Finding 5764 (2022-001)

Significant Deficiency 2022

Stebbins Community Association

AK

Subrecipient Monitoring Reporting Significant Deficiency

Finding 2022-001 Significant Deficiency in Internal Control over Compliance, Noncompliance-Reporting Type of Finding: Significant Deficiency/Noncompliance Name of Contact: George Flynn Corrective Action Plan: Stebbins Community Association will strive to ensure that the future audits will be com...

Finding 2022-001 Significant Deficiency in Internal Control over Compliance, Noncompliance-Reporting Type of Finding: Significant Deficiency/Noncompliance Name of Contact: George Flynn Corrective Action Plan: Stebbins Community Association will strive to ensure that the future audits will be completed in time to file the form SD-SCA within the required nine months. We will schedule future audits to work with an accounting firm to occur within 100 days after fiscal year. Proposed Completion Date: December 4, 2023.

View Audit 7848

Finding 5717 (2022-001)

Significant Deficiency 2022

Hrc Cottages, Inc.

MT

Reporting Internal Control / Segregation of Duties

Action Taken: We concur with the recommendation, and it was implemented effective November 27, 2023.

View Audit 7731

Finding 5697 (2022-002)

Significant Deficiency 2022

Communities in Schools Memphis, Inc.

TN

Reporting Internal Control / Segregation of Duties

Action Taken: Director of Federal Programs, CEO and Director of Operations and Finance have all been made aware of this finding and will oversee the process to ensure the books are closed timely.

View Audit 7695

Finding 5609 (2022-004)

None 2022

City of Muldraugh

KY

Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN December 13, 2023 Department of Local Government The City of Muldraugh respectfully submits the following corrective action plan for the year ended June 30, 2022. SK LEE CPAS, P.S.C P.O. Box 958 Berea, KY 40403 The findings from the June 30, 2022 schedule of findings and q...

CORRECTIVE ACTION PLAN December 13, 2023 Department of Local Government The City of Muldraugh respectfully submits the following corrective action plan for the year ended June 30, 2022. SK LEE CPAS, P.S.C P.O. Box 958 Berea, KY 40403 The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS-FINANCIAL STATEMENT AUDIT MATERIAL WEAKNESS 2022 - 001 Financial Statement Preparation Recommendation: Management should continue to engage the audit firm to prepare a draft of the financial statements including the notes to the financial statements, or hire an accountant to perform these services. Action taken: Management concurs with the finding, however, due to limited economic resources cannot hire an accountant at this time and will continue to engage the audit firm to draft the financial statements including the notes to the financial statements. 2022- 002 Segregation of Duties Recommendation: The lack of segregation of duties is a common deficiency in cities the size of Muldraugh Action taken: Management concurs with the finding, however, due to limited economic resources cannot hire staff to properly segregate the duties required of the City. NON - COMPLIANCE 2022 - 003 Late Audit Report Recommendation: The City should engage audits with sufficient time to complete the engagement by the required date. Action taken: Management concurs with the finding and will have the audit completed by the required date. 2022 - 004 Late Submission of Data Collection Form Recommendation: The City should complete their DCF by the required date. Action taken: Management concurs with the finding and will have the data collection form completed by the required date. If the Department of Local Government has questions regarding this plan, please call Anthony Lee at (502) 942-2824. Sincerely yours, _____________________________________________________________ Anthony Lee, Mayor of Muldraugh, Kentucky

View Audit 7454

Finding 5582 (2022-003)

Significant Deficiency 2022

Rainbow Health

MN

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.328 § 200.512

Views of Responsible Officials and Planned Corrective Actions: We agree with this finding and have implemented the following internal control policies and procedures concerning the timeliness of financial activities: Rainbow Health Minnesota is reimplementing monthly board meetings that will includ...

Views of Responsible Officials and Planned Corrective Actions: We agree with this finding and have implemented the following internal control policies and procedures concerning the timeliness of financial activities: Rainbow Health Minnesota is reimplementing monthly board meetings that will include a financial review of income and expense reports and balance sheets. The lateness for the 2022 audit was partially due to staff turnover of the CFO and the subsequent review by the new Finance Director. Responsibility for administering this process resides with the Finance Director

View Audit 7441

Finding 5505 (2022-006)

Significant Deficiency 2022

Santa Fe Community Housing Trust

NM

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

The contractors hired to do the accounting and payroll functions are no longer under contract with the Housing Trust. All financial functions are now being taken care of in-house. The financials are already in the process of being adjusted and all numbers being accounted for with documentation. Thi...

The contractors hired to do the accounting and payroll functions are no longer under contract with the Housing Trust. All financial functions are now being taken care of in-house. The financials are already in the process of being adjusted and all numbers being accounted for with documentation. This will continue through 2023 and in 2024, the chart of accounts will be changed to reflect the current practices for a nonprofit organization. As the Executive Director prepares the 2024 budget, a reorganization of the business operations department has started. Staff changes will also need the Business Operations manager to provide a thorough monthly review. The current administrative assistant will take on the role of accounting technician to handle the day-to-day QuickBooks-related processes. Work has already started to develop checks and balances. Corrective Action Plan Timeline: Immediately Designated Employee Responsible for Corrective Action: Business Operations Manager

View Audit 7270

Finding 5501 (2022-002)

Material Weakness 2022

Santa Fe Community Housing Trust

NM

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.430

Response. Agreed. Where feasible, the Housing Trust will aim to improve management of all federal grants. A process of documentation verification prior to any requests made for financial draws will include employee, supervisor, business operations manager, and executive director level approvals to e...

Response. Agreed. Where feasible, the Housing Trust will aim to improve management of all federal grants. A process of documentation verification prior to any requests made for financial draws will include employee, supervisor, business operations manager, and executive director level approvals to ensure compliance and availability of funds. A monthly federal request for reimbursements with all grantee information will be used and reconciled monthly with QuickBooks. This report will mirror the SEFA form so auditors will receive the information in a timely manner. For any quarterly reports, the three months of reporting will again be reconciled prior to submission. All new processes and compliance will be updated in the policies and procedure manual. As the Executive Director prepares the 2024 budget, a reorganization of the business operations department will be sought. A new position to prepare and work on all federal grant tasks will be hired and report to the Business Operations Manager. In the meantime, the Business Operations Manager has started to develop checks and balances. Corrective Action Plan Timeline: Immediately Designation Of Employee Position Responsible For Meeting Deadline: Business Operations Manager

View Audit 7270 Questioned Costs: $1

Finding 4958 (2022-007)

Significant Deficiency 2022

City of Medford

MA

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring § 200.214

Condition: Suspension and debarment compliance is not verified for all covered transactions. Corrective Action Planned: The School Comptroller will ensure that all vendors are checked using SAM for suspension and debarment for all covered transactions in compliance with federal laws. The School C...

Condition: Suspension and debarment compliance is not verified for all covered transactions. Corrective Action Planned: The School Comptroller will ensure that all vendors are checked using SAM for suspension and debarment for all covered transactions in compliance with federal laws. The School Comptroller will print out the support and include with each grant. Anticipated Completion Date: Completed Contact: Robert Dickinson, City Auditor

View Audit 7220

Finding 4454 (2022-002)

Material Weakness 2022

Virginia Association of Recovery Residences INC

VA

Internal Control / Segregation of Duties

VARR agrees with the finding and as VARR grows, it will seek opportunities beginning November 27, 2023 to delegate responsibilities to qualified individuals to provide a greater level of segregation of duties that will enhance our internal control. We also believe that our integrity and relationship...

VARR agrees with the finding and as VARR grows, it will seek opportunities beginning November 27, 2023 to delegate responsibilities to qualified individuals to provide a greater level of segregation of duties that will enhance our internal control. We also believe that our integrity and relationship with the Virginia Department of Behavioral Health Development Services and our recovery community centers provide an external layer of control that when tied into our software system known as REC-CAP will alert management when an error occurs. We expect that we will enhance the development of our systems to capture and provide for the seamless integration of this finding by January 31, 2024. This action is in accordance with the requirements of Uniform Guidance 2 CFR §200.511(c).

View Audit 6879

Finding 4444 (2022-002)

Material Weakness 2022

West Monona Community School District

IA

Internal Control / Segregation of Duties Reporting

We continue to look for ways to improve our internal controls.

View Audit 6871

Finding 4420 (2022-002)

Material Weakness 2022

Community Counseling Solutions

OR

Reporting Internal Control / Segregation of Duties

Corrective Action Taken: The entity understands the importance of timely maintenance of the general ledger and has taken steps to document procedures, cross train the accounting team, and hire additional employees to assist with processing transactions.

View Audit 6868

Finding 4413 (2022-001)

Material Weakness 2022

Community Counseling Solutions

OR

Reporting Internal Control / Segregation of Duties

Corrective Action Taken: The entity understands the importance of timely maintenance of the general ledger and has taken steps to document procedures, cross train the accounting team, and hire additional employees to assist with processing transactions.

View Audit 6868

Finding 4407 (2022-002)

Material Weakness 2022

Central Decatur Community School District

IA

Internal Control / Segregation of Duties

The District reviews this audit finding internally on an annual basis, identifying control procedures and processes that would leverage movement toward the maximum internal control possible with available staffing although this is difficult with a limited number of employees

View Audit 6862

Finding 4385 (2022-002)

Material Weakness 2022

Schc Companies, Inc. and Affiliates

NY

Internal Control / Segregation of Duties Eligibility Reporting

2022-002 Reporting Recommendation: Our auditors recommend that we review and strengthen current procedures regarding review of reporting by an appropriate level of management prior to submission. As well as that we work with HRSA to take corrective action to rectify this reporting matter. Action Tak...

2022-002 Reporting Recommendation: Our auditors recommend that we review and strengthen current procedures regarding review of reporting by an appropriate level of management prior to submission. As well as that we work with HRSA to take corrective action to rectify this reporting matter. Action Taken: The accounting department had a significant turnover during 2022 which cause reporting errors go unreviewed. Since 2023, the appropriate accounting team has been assembled and proper policies, procedures, authorization, segregation of duties and reviews have been put in place so that going forward this will not be an issue. All reporting is now being reviewed prior to submission so that reporting requirements including proper period and proper information is reported correctly. We have proactively reached out to the PRF Reporting Help Desk to correct the reporting and communicated the noted reporting corrections needed. Name(s) of Contact Person(s) Responsible for Corrective Action: John Milligan, CFO, (315) 430-1708. Anticipated Completion Date: October 2023

View Audit 6819

Finding 4382 (2022-001)

Material Weakness 2022

Schc Companies, Inc. and Affiliates

NY

Internal Control / Segregation of Duties Subrecipient Monitoring HUD Housing Programs

2022-001 Sliding Fee Discounts Recommendation: Our auditors recommend we review and strengthen the current procedures in place for determining a patient’s financial responsibility for their visit using the sliding fee scale. This should include requiring a knowledgeable representative of the Organiz...

2022-001 Sliding Fee Discounts Recommendation: Our auditors recommend we review and strengthen the current procedures in place for determining a patient’s financial responsibility for their visit using the sliding fee scale. This should include requiring a knowledgeable representative of the Organizations’ signature approval on the documentation received and the fee calculated and provided to the applicant. All applications should contain support for the individual’s income level or documentation of no income, and the determination of the resulting fee. Action Taken: This finding was repeated in 2022. Since this was a repeat finding, an internal audit was performed on all 2023 approved sliding fee applications to ensure compliance with our policy. Any corrective actions to the 2023 application were address and the facility’s sliding fee scale was modified to reflect proper authorization and proper segregation of duties going forward. Going forward, all sliding fee scale applications are now reviewed and authorized by the Manager of Revenue Cycle. Future auditing procedures have been put in place to review applications and adjusted, if needed, in a timely manner between now and the end of the year. Name(s) of Contact Person(s) Responsible for Corrective Action: John Milligan, CFO, (315) 430-1708. Anticipated Completion Date: October 2023

View Audit 6819

Finding 4162 (2022-004)

Significant Deficiency 2022

Township of Bloomfield

NJ

Reporting Internal Control / Segregation of Duties

Description: The Township’s IDISC04PR29 Cash on Hand quarterly reports did not agree to the reconciled cash balance in the Community Development Trust bank account. Analysis: Policies and procedures be implemented to ensure the CDBG IDISC04PR29 cash on hand quarterly reports are prepared correctly ...

Description: The Township’s IDISC04PR29 Cash on Hand quarterly reports did not agree to the reconciled cash balance in the Community Development Trust bank account. Analysis: Policies and procedures be implemented to ensure the CDBG IDISC04PR29 cash on hand quarterly reports are prepared correctly and in agreement with the reconciled cash balances on hand. Corrective Action: Policies and procedures will be implemented to ensure the CDBG IDISC04PR29 cash on hand quarterly reports are prepared correctly and in agreement with the reconciled cash balances on hand. Implementation Date: Ongoing

View Audit 6483

Finding 4161 (2022-003)

Significant Deficiency 2022

Township of Bloomfield

NJ

Reporting Internal Control / Segregation of Duties

Description: The Township did not file the Community Development Block Grant program Annual Performance and Evaluation Report within 90 days after the end of the program year. Analysis: The Township implement policies and procedures to ensure all required reporting under the Community Development ...

Description: The Township did not file the Community Development Block Grant program Annual Performance and Evaluation Report within 90 days after the end of the program year. Analysis: The Township implement policies and procedures to ensure all required reporting under the Community Development Block Grant program is completed. Corrective Action: Township is working towards implementing reporting process to meet the 90 day filing deadline for CDGB Annual Performance and Evaluation Report. Implementation Date: Ongoing

View Audit 6483

Finding 4160 (2022-002)

Significant Deficiency 2022

Township of Bloomfield

NJ

Allowable Costs / Cost Principles Cash Management Equipment & Real Property Management

Description: Administrative charges to Community Development Block Grant program, are in some instances, not supported by detailed documentation nor are they charged to the correct program year in budgetary records Analysis: All administrative salary and wage and other administrative expenses be ch...

Description: Administrative charges to Community Development Block Grant program, are in some instances, not supported by detailed documentation nor are they charged to the correct program year in budgetary records Analysis: All administrative salary and wage and other administrative expenses be charged to the proper program year and be supported by detail documentation Corrective Action: Finance and Planning departments will coordinate to ensure administrative costs are charged to proper program year, and proper supporting documentation is maintained. Implementation Date: Ongoing

View Audit 6483

Finding 4121 (2022-003)

None 2022

The Bridge Over Troubled Waters, Inc.

TX

Internal Control / Segregation of Duties Reporting § 200.512

Finding 2022-003: Data Collection Form and Single Audit Reporting Package Finding: The Organization did not comply with the required submission date of the data collection form and reporting package to the FAC for the fiscal year ended December 31, 2022. Corrective Action: Prepare reports prior to d...

Finding 2022-003: Data Collection Form and Single Audit Reporting Package Finding: The Organization did not comply with the required submission date of the data collection form and reporting package to the FAC for the fiscal year ended December 31, 2022. Corrective Action: Prepare reports prior to due dates in case there is a computer issue. If a report is late, request an exception/extension in writing to file with report. Contact: Evelyn Vargas, Grants Compliance Manager Expected Completion Date: 11/30/2023 If you have any questions, please contact Evelyn Vargas at 713-472-0753 or by email at evargas@tbotw.org.

View Audit 6440

Finding 4038 (2022-002)

Significant Deficiency 2022

Granville Health System

NC

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System ensure that remaining statement balance for uninsured testing is not balance billed to the patient. Explanation of disagreement with audit finding: There is no di...

Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System ensure that remaining statement balance for uninsured testing is not balance billed to the patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We understand the finding. All balances remaining after HRSA payments will be reviewed and adjusted to zero. Name(s) of the contact person(s) responsible for corrective action: Adam McConnell, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2023

View Audit 6359 Questioned Costs: $1

Finding 4037 (2022-001)

Significant Deficiency 2022

Granville Health System

NC

Questioned Costs Cash Management Significant Deficiency

Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System review the submissions to HRSA to ensure that the patients they requested reimbursement for were in fact uninsured. Explanation of disagreement with audit finding...

Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System review the submissions to HRSA to ensure that the patients they requested reimbursement for were in fact uninsured. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We understand the finding. In future submissions, the System will review all patients to ensure that are uninsured. Name(s) of the contact person(s) responsible for corrective action: Adam McConnell, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2023

View Audit 6359 Questioned Costs: $1

Finding 3992 (2022-004)

Significant Deficiency 2022

City of Depere

WI

Reporting Significant Deficiency Internal Control / Segregation of Duties

Management has taken sufficient corrective action to resolve and does not believe this will be an issue in the future.

View Audit 6296

Corrective Action Plans

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