Corrective Action Plans

Finding 408 (2022-004)

Significant Deficiency 2022

Pioneercare

MN

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: There was no formal documented review over the reserve fund reconciliation for the federal program. Re...

Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: There was no formal documented review over the reserve fund reconciliation for the federal program. Responsible Individuals: Nathan Johnson, CEO and Dan Stone, CFO Corrective Action Plan: We have adopted a policy to enhance internal control to ensure the reserve fund reconciliation has a secondary review and approval that is documented. Anticipated Completion Date: August 31, 2023

View Audit 857

Finding 400 (2022-001)

None 2022

City of Hartwell, Georgia

GA

Subrecipient Monitoring Cash Management Material Weakness § 200.502 § 200.510

RE: Single Audit Corrective Action Plan The City of Hartwell, Georgia respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Williamson and Company, CPAs 611 N Tennessee Street ...

RE: Single Audit Corrective Action Plan The City of Hartwell, Georgia respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Williamson and Company, CPAs 611 N Tennessee Street Cartersville, GA 30120 Audit Period: Year ended December 31, 2022 The findings from the December 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule of findings and questioned costs. Findings – Financial Statement Audit MATERIAL WEAKNESS None Reported SIGNIFICANT DEFICIENCY None Reported Findings – Federal Award Programs Audit MATERIAL WEAKNESS None Reported SIGNIFICANT DEFICIENCY None Reported 2022-001 Clean Water State Revolving Fund – ALN: 66.458 Finding: Schedule of Expenditures of Federal Awards Preparation Recommendation: Procedures should be implemented to ensure completion of an entry to the Schedule of Federal Expenditures of Federal Awards to achieve a reliable reporting of total expenditures for an audit period. Action Taken: We acknowledge our responsibility to present the Schedule of Expenditures of Federal Awards and related notes in accordance with Uniform Guidance requirements. To ensure future implementation of this requirement, the City of Hartwell will record all expenditures on the schedule of federal expenditures going forward on for all federally funded projects. Please call or write if there are any questions/suggestions that you may have to help us further enhance the City’s operations. Sincerely, Audrey Segars Finance Director City of Hartwell, Georgia

View Audit 835

Finding 393 (2022-002)

Material Weakness 2022

Clear Lake Community School District

IA

Internal Control / Segregation of Duties

We will continue to monitor our procedures and implement additional controls where possible.

View Audit 828

Finding 384 (2022-002)

Material Weakness 2022

Union Community School District

IA

Internal Control / Segregation of Duties Reporting

The District will review our procedures and implement additional controls where possible.

View Audit 813

Finding 378 (2022-003)

Material Weakness 2022

Iowa Falls Community School District

IA

Internal Control / Segregation of Duties

We will continue to review our control procedures to obtain the maximum internal control possible under the circumstances.

View Audit 809

Finding 366 (2022-004)

Material Weakness 2022

East Liberty Family Health Care Center INC

PA

Eligibility Internal Control / Segregation of Duties

Since taking over the financial management of ELFHCC in December 2022, sliding fee schedule policy has been updated and training has been implemented and ongoing to assure accurate sliding fee discounts are appropriately distributed onto a patients account. Check lists of what is required from each ...

Since taking over the financial management of ELFHCC in December 2022, sliding fee schedule policy has been updated and training has been implemented and ongoing to assure accurate sliding fee discounts are appropriately distributed onto a patients account. Check lists of what is required from each patient applying for a sliding fee discount have been prepared and staff trained on how to enter the proof requirement into ELFHCC’s patient record.

View Audit 750

Finding 363 (2022-001)

Material Weakness 2022

East Liberty Family Health Care Center INC

PA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Since taking over the financial management of ELFHCC in December 2022 we have reorganized the financial reporting process and have been able to ensure meaningful analysis on a regular basis. Policies and procedures have been created, changed, and board approved. All financial reporting is prepared, ...

Since taking over the financial management of ELFHCC in December 2022 we have reorganized the financial reporting process and have been able to ensure meaningful analysis on a regular basis. Policies and procedures have been created, changed, and board approved. All financial reporting is prepared, analyzed and presented each month without delay.

View Audit 750

Finding 322 (2022-002)

Material Weakness 2022

Lake County Crisis Center D/b/a A Safe Place

IL

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness

Finding 2022-002 – Reporting-Control and Compliance Finding Personnel Responsible for Corrective Action: CFO and Accounting department staff Anticipated Completion Date: September 2023 Corrective Action Plan: A Safe Place will implement internal control procedures to ensure timely submission of all ...

Finding 2022-002 – Reporting-Control and Compliance Finding Personnel Responsible for Corrective Action: CFO and Accounting department staff Anticipated Completion Date: September 2023 Corrective Action Plan: A Safe Place will implement internal control procedures to ensure timely submission of all future reports. The CFO will review financial reporting prior to submission. Update: A Safe Place developed an infrastructure and implemented internal control procedures to ensure timely submission of all future reports. The CFO will review financial reporting prior to submission

View Audit 616

Finding 321 (2022-001)

Material Weakness 2022

Lake County Crisis Center D/b/a A Safe Place

IL

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness

Finding 2022-001 – Reporting-Control and Compliance Finding Personnel Responsible for Corrective Action: CFO and Accounting department staff Anticipated Completion Date: September 2023 Corrective Action Plan: A Safe Place will implement internal control procedures to ensure timely submission of all ...

Finding 2022-001 – Reporting-Control and Compliance Finding Personnel Responsible for Corrective Action: CFO and Accounting department staff Anticipated Completion Date: September 2023 Corrective Action Plan: A Safe Place will implement internal control procedures to ensure timely submission of all future reports. The CFO will review financial reporting prior to submission. Update: A Safe Place developed an infrastructure and implemented internal control procedures to ensure timely submission of all future reports. The CFO will review financial reporting prior to submission.

View Audit 616

Finding 314 (2022-003)

Significant Deficiency 2022

Palmer Senior Citizens Center, Inc.

AK

Internal Control / Segregation of Duties Subrecipient Monitoring Cash Management

Federal Award Finding: 2022-003 Significant Deficiency in Compliance and Internal Controls over Compliance - Reporting -Monitoring of Grant Budget and Expenditures Name and Contact Person: Heather Grato, Controller Corrective Action: The Controller with the help with of a hired consultant will gener...

Federal Award Finding: 2022-003 Significant Deficiency in Compliance and Internal Controls over Compliance - Reporting -Monitoring of Grant Budget and Expenditures Name and Contact Person: Heather Grato, Controller Corrective Action: The Controller with the help with of a hired consultant will generate a new policies and procedure that will help ensure the accounting is reviewed monthly and quarterly, and any errors are corrected before submission of grant reports. Once grant activity is adequately reviewed the Controller will create budget vs. actual financial reports to present to management and program managers or the Board. The accounting staff will file quarterly grant reports and drawdown funding before the deadline after transactions are prepared and reviewed. Proposed Completion Date: 6/30/2024

View Audit 588

Finding 307 (2022-009)

Significant Deficiency 2022

Hyde County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding: 2022-009: Inaccurate Information Entry Name of Contact Person: Laurie Potter, DSS Director Corrective Action: (Adult Medicaid) New caseworker brought into county from another county on 11/1/2022 who had more training provided from previous county of employment. She immediately begain review...

Finding: 2022-009: Inaccurate Information Entry Name of Contact Person: Laurie Potter, DSS Director Corrective Action: (Adult Medicaid) New caseworker brought into county from another county on 11/1/2022 who had more training provided from previous county of employment. She immediately begain reviewing cases & correcting as needed. In addition, all cases are now being 2nd partied to ensure nothing is being missed. New caseworker scans in documents immediately & uploads to case once completed to avoid hardcopies being lost. (MAGI) New supervisor will be hired & trained on what is needed to be entered into the system. New supervisor will complete 2nd party reviews & training as needed. Standard Operating Procedure put in place for both units. Proposed Completion Date: 10/31/23.

View Audit 581

Finding 304 (2022-002)

Significant Deficiency 2022

Caminar Latino Inc.

GA

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

Condition Upon review of the indirect cost calculations throughout the fiscal year, it was noted that there was no documentation of review and approval of three of the seven calculations tested. The auditors were able to review the drawdown reconciliations performed by the Caminar Latino and determi...

Condition Upon review of the indirect cost calculations throughout the fiscal year, it was noted that there was no documentation of review and approval of three of the seven calculations tested. The auditors were able to review the drawdown reconciliations performed by the Caminar Latino and determine the reports were materially accurate; however, no evidence of a formal supervisory review and approval of the reconciliation was maintained on-file in these three instances. Correction action As of Q4 2022, the Atlanta-based Co-CEO and the Chief of Programs and Administration have instituted a process of review and approval of drawdown reconciliations prior to drawdown to review for accuracy of calculations and to ensure that previous drawdown amounts are accurately recorded. A Finance Manager was hired in April 2023, and the responsibility of ongoing drawdown reconciliation and calculation of invoice amounts has shifted to the Finance Manager position. Monthly invoices and drawdowns are being reviewed and approved by the Co-CEO and Chief of Programs and Administration prior to drawdown. Responsible Person Co-CEO and Chief of Programs and Administration Anticipated completion date Completed - This process is currently in place.

View Audit 574

Finding 303 (2022-001)

Significant Deficiency 2022

Caminar Latino Inc.

GA

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Condition We reviewed all subawards made by the grantee during the audit period and found that 4 of them, totaling $224,000, were not reported to the FSRS. Correction action The FSRS will be submitted to the FFATA website. Responsible Person The Chief of Programs and Administration will submit the F...

Condition We reviewed all subawards made by the grantee during the audit period and found that 4 of them, totaling $224,000, were not reported to the FSRS. Correction action The FSRS will be submitted to the FFATA website. Responsible Person The Chief of Programs and Administration will submit the FSRS under the supervision of the Co-CEO. Anticipated completion date Within 30 days

View Audit 574

Finding 302 (2022-003)

Material Weakness 2022

Central Piedmont Community Action, Inc.

NC

Cash Management Material Weakness Internal Control / Segregation of Duties

Central Piedmont Community Action, Inc. (CPCA) will continue to submit requests for reimbursements before the 10th day of the month to help ensure timely payments from funding agencies. CPCA management staff will have a negative impact. CPCA’s Board of Directors, in conjunction with the Executive Di...

Central Piedmont Community Action, Inc. (CPCA) will continue to submit requests for reimbursements before the 10th day of the month to help ensure timely payments from funding agencies. CPCA management staff will have a negative impact. CPCA’s Board of Directors, in conjunction with the Executive Director, will continue to stress the importance of timely payments to funding agencies and how those untimely payments have a negative impact. CPCA’s Board of Directors, in conjunction with the Executive Director, will continue to raise funding and apply for unrestricted funding to maintain a steady cash flow and assist with administrative costs.

View Audit 566

Finding 301 (2022-003)

Significant Deficiency 2022

Rock Springs Village Office

WI

Reporting Internal Control / Segregation of Duties

Significant Deficiency 2022-003 Financial Reporting for Federal and State Assistance. Management Views – Management agrees with the finding and the recommendation. Corrective Action Planned – Management and the Common Council will continue to designate competent staff to oversee and review the finan...

Significant Deficiency 2022-003 Financial Reporting for Federal and State Assistance. Management Views – Management agrees with the finding and the recommendation. Corrective Action Planned – Management and the Common Council will continue to designate competent staff to oversee and review the financial reports and approve them before issuance. However, it is not feasible or cost effective to add staff with the competence to prepare these reports. Anticipated Completion Date – This action will be on going.

View Audit 561

Finding 300 (2022-002)

Significant Deficiency 2022

Rock Springs Village Office

WI

Internal Control / Segregation of Duties

Significant Deficiency 2022-002 Segregation of Duties. Management Views – Management agrees with the finding and the recommendation. Corrective Action Planned – Management and the Common Council will continue to be aware of this condition and continue to be involved in the matters relating to the Vi...

Significant Deficiency 2022-002 Segregation of Duties. Management Views – Management agrees with the finding and the recommendation. Corrective Action Planned – Management and the Common Council will continue to be aware of this condition and continue to be involved in the matters relating to the Village’s operations. However, it is not feasible or cost effective to add staff to achieve the desired level of internal control. Anticipated Completion Date – This action will be on going.

View Audit 561

Finding 299 (2022-002)

Significant Deficiency 2022

City of Parlier

CA

Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

The city staff managing the business loan will receive training on the job duties, with oversight from the Sr. Revenue Manager. The city is monitoring each loan to ensure that we’re up-to-date with information, and remain in compliance with all necessary requirements of the loan program.

View Audit 552 Questioned Costs: $1

Finding 290 (2022-002)

Significant Deficiency 2022

Town of Hempstead Housing Authority

NY

HUD Housing Programs Internal Control / Segregation of Duties

Finding 2022-002 Project-Based Budgeting and Accounting Auditee's Response and Planned Corrective Action The Authority will implement policies and procedures to ensure that the operating budget is on the January Board Agenda going forward. The budget will be presented to the board for review an ad...

Finding 2022-002 Project-Based Budgeting and Accounting Auditee's Response and Planned Corrective Action The Authority will implement policies and procedures to ensure that the operating budget is on the January Board Agenda going forward. The budget will be presented to the board for review an adoption and documented in the minutes. Planned Implementation Date of Corrective Action: December 2023 Person Responsible for Corrective Action: Ed Cumming, Executive Director

View Audit 514

Finding 289 (2022-001)

Material Weakness 2022

Town of Hempstead Housing Authority

NY

HUD Housing Programs Allowable Costs / Cost Principles Eligibility

Finding 2022-00 I - COCC deficit and the use of LIPH funds in violation of HUD Rule Auditee's Response and Planned Corrective Action The Authority is working to gather the information necessary to complete an analysis of the benefits charged to each AMP and COCC for the above referenced finding. T...

Finding 2022-00 I - COCC deficit and the use of LIPH funds in violation of HUD Rule Auditee's Response and Planned Corrective Action The Authority is working to gather the information necessary to complete an analysis of the benefits charged to each AMP and COCC for the above referenced finding. There is a meeting scheduled for October 16, 2023. HUD has been informed regarding the status of the finding. Planned Implementation Date of Corrective Action: December 2023 Person Responsible for Corrective Action: Ed Cumming, Executive Director

View Audit 514

Finding 248 (2022-001)

Material Weakness 2022

Triad Health Systems, Inc.

KY

HUD Housing Programs Material Weakness Reporting

September 29, 2023 U.S. Department of Health and Human Services Triad Health Systems, Inc. respectively submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Blue & Co., LLC 2650 Eastpoint Pkwy., Suite 300 Louisvill...

September 29, 2023 U.S. Department of Health and Human Services Triad Health Systems, Inc. respectively submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Blue & Co., LLC 2650 Eastpoint Pkwy., Suite 300 Louisville, Kentucky 40223 Audit period: Year ended December 31, 2022. The findings from the schedule of findings and questioned costs for the year ended December 31, 2022, are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. FINDINGS – FEDERAL AWARD PROGRAM AUDITS 2022-001 Condition: Improper reporting of lost revenues on Phase 4 PRF submission: When submitting information related to Phase 4 of the Provider Relief Fund (“PRF”) program to the Health Resources and Services Administration (“HRSA”), various quarters were not corrected from the incorrect prior year submission, resulting in an overstatement of lost revenues reported in the THS’s official filing. Action: Management will implement internal control procedures by December 31, 2023, to ensure the proper reporting of any potential lost revenues on future PRF program submission to HRSA. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Adam Craft, CEO, at (859) 567-1591. Sincerely, Adam Craft Chief Executive Officer

View Audit 491

Finding 218 (2022-001)

Material Weakness 2022

Valor Christian College

OH

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Comments on Findings and Recommendations: Valor Christian College concurs with the finding and recommendations in the finding. Actions T...

Comments on Findings and Recommendations: Valor Christian College concurs with the finding and recommendations in the finding. Actions Taken or Planned: The Valor Christian College Finance Department and the Valor Christian College CFO will increase controls over the process to ensure that no recruitment advertising expenses are attributed to CARES ACT funds. The amount of orginally atrributed advertising expenses has been reallocated to allowable items/expenses.

View Audit 443

Finding 208 (2022-003)

Material Weakness 2022

County of Mifflin

PA

Reporting Internal Control / Segregation of Duties

Finding 2022-003: Emergency Rental Assistance Program (ERAP) Contact Person: Michael R. Baker, Director of Fiscal Affairs Recommendation: The County should establish internal controls procedures over reporting requirements. Response: The County agrees with the finding and will work with the Hum...

Finding 2022-003: Emergency Rental Assistance Program (ERAP) Contact Person: Michael R. Baker, Director of Fiscal Affairs Recommendation: The County should establish internal controls procedures over reporting requirements. Response: The County agrees with the finding and will work with the Human Services Director and Human Services Financial Manager to revise and, where necessary, establish procedures to insure proper approval by all required parties prior to submission of said reports. Action Planned: Post-audit submission, the County Director of Fiscal Affairs will meet and discuss with the Human Services Director and Human Services Financial Manager all upcoming reporting requirement, and implement reporting procedures that require multiple signatures and approvals, including those required under the reporting guidelines and requirements, and the initials of the County Director of Fiscal Affairs, prior to submission of the subject reports. Date for Completion: December 31, 2023

View Audit 384

Finding 193 (2022-004)

Material Weakness 2022

Nulato Tribal Council

AK

Material Weakness Reporting Internal Control / Segregation of Duties § 200.512

Finding 2022-004 Late Reporting and Noncompliance with Reporting Requirements Name of Contact: Martha Turner, Tribal Administrator Corrective Action Plan: We concur with this recommendation. Initially Nulato Tribal Council thought that the audit was completed and ready for review in March 2023....

Finding 2022-004 Late Reporting and Noncompliance with Reporting Requirements Name of Contact: Martha Turner, Tribal Administrator Corrective Action Plan: We concur with this recommendation. Initially Nulato Tribal Council thought that the audit was completed and ready for review in March 2023. In April the unrecorded liabilities identified in Finding 2022-001 were discovered, which took some time with the parties involved to agree the actual balances owed. With the tying out of internal transactions monthly this should not be an issue in the future. Proposed Completion Date: June 30, 2024

View Audit 297

Finding 192 (2022-003)

Material Weakness 2022

Nulato Tribal Council

AK

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.305

Finding 2022-003 Lack of Internal Controls Over Cash Management Name of Contact: Martha Turner, Tribal Administrator Corrective Action Plan: We concur with the recommendation. Funds to transferred to NorthRim Bank on January 17, 2023 resulting in compliance with 2 CFR Section 200.305 advanced f...

Finding 2022-003 Lack of Internal Controls Over Cash Management Name of Contact: Martha Turner, Tribal Administrator Corrective Action Plan: We concur with the recommendation. Funds to transferred to NorthRim Bank on January 17, 2023 resulting in compliance with 2 CFR Section 200.305 advanced federal funding. The service being used to insure all deposits is called IntraFI Cash services. This is a sweep account that will automatically move all deposits to other financial institutions to assure that they are under the 250,000 limit. Funds are wholly available at any time. Proposed Completion Date: Already implemented.

View Audit 297

Finding 164 (2022-102)

Material Weakness 2022

Santa Cruz County

AZ

Questioned Costs Cash Management Eligibility § 200.303

The County is in the final stages of implementing grant policies, which will cover reimbursement procedures for all departmental grants. The County will work with the pass-through grantor to repay the amounts the County received in excess. The County will work with the Health Department director a...

The County is in the final stages of implementing grant policies, which will cover reimbursement procedures for all departmental grants. The County will work with the pass-through grantor to repay the amounts the County received in excess. The County will work with the Health Department director and staff to review grant policies and procedures.

View Audit 240 Questioned Costs: $1

Corrective Action Plans

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