Corrective Action Plans

Finding 12323 (2022-001)

None 2022

ME

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

Corrective Action Plan for Current Year Findings 2022-001 ? Data Collection Form Late Filing Corrective Action Plan To ensure proper timing of the Data Collection Form filing, the CFO will certify and file the data collection form for FY2022 with the Federal Audit Clearinghouse on May 31, 2023, afte...

Corrective Action Plan for Current Year Findings 2022-001 ? Data Collection Form Late Filing Corrective Action Plan To ensure proper timing of the Data Collection Form filing, the CFO will certify and file the data collection form for FY2022 with the Federal Audit Clearinghouse on May 31, 2023, after receiving notification from the auditors that it is ready. The CFO will send a confirmation email to the auditing firm, as well as the CEO upon filing. WMCA will ensure the Accounting Policies and Procedures for WMCA reflect that we must submit within 30 days after receipt of the auditor?s report or nine months after the end of their audit period ? whichever comes first, as required by Federal law. Person(s) Responsible: Rebecca Gage, CFO Timing for Implementation: Implement immediately. Submit within the same day of auditors notice for FY2023. Check and revise policy and procedures, if necessary, within 90 days.

View Audit 16716

Finding 12322 (2022-002)

Significant Deficiency 2022

Brunswick Housing Authority

GA

HUD Housing Programs Internal Control / Segregation of Duties

2022-2 Condition: Deficiencies Noted in Examination of Section Eight (8) Tenant Files Steps to resolve: We concur with this finding and the Auditor?s recommendation. We will review the internal control procedures over tenant file re-certifications and documents. Management will implement proced...

2022-2 Condition: Deficiencies Noted in Examination of Section Eight (8) Tenant Files Steps to resolve: We concur with this finding and the Auditor?s recommendation. We will review the internal control procedures over tenant file re-certifications and documents. Management will implement procedures to clear this finding in FY 2023. Individual responsible for correction: Executive Director Timeframe: As of June 30, 2023

View Audit 16696

Finding 12321 (2022-001)

Significant Deficiency 2022

Brunswick Housing Authority

GA

HUD Housing Programs Internal Control / Segregation of Duties

2022-1 Condition: Deficiencies Noted In Examination Of Section Eight (8) Management Assessment Program (SEMAP) Certification Steps to resolve: We concur with this finding and the Auditor?s recommendation. We will review the internal control procedures over tenant file re-certifications and docum...

2022-1 Condition: Deficiencies Noted In Examination Of Section Eight (8) Management Assessment Program (SEMAP) Certification Steps to resolve: We concur with this finding and the Auditor?s recommendation. We will review the internal control procedures over tenant file re-certifications and documents. Management will implement procedures to clear this finding in FY 2023. Individual responsible for correction: Executive Director Timeframe: As of June 30, 2023

View Audit 16696

Finding 12318 (2022-001)

Significant Deficiency 2022

Ucc Iii, Inc. D/b/a Oakhaven Community

OH

HUD Housing Programs Internal Control / Segregation of Duties Eligibility

"""Condition: HUD guidelines regarding the EIV system were not followed and the EIV system reports were not utilized timely during 2022. Planned Corrective Action: Management has implemented guidelines and trainings surrounding the use of the EIV system. Management will continue to monitor the appro...

"""Condition: HUD guidelines regarding the EIV system were not followed and the EIV system reports were not utilized timely during 2022. Planned Corrective Action: Management has implemented guidelines and trainings surrounding the use of the EIV system. Management will continue to monitor the appropriate use of the EIV system. Contact person responsible for corrective action: Julie Reed, Housing Accounting Manager Anticipated Completion Date: December 31, 2023 "" "

View Audit 16679

Finding 12307 (2022-002)

Significant Deficiency 2022

Upper Palmetto Ymca, Inc.

SC

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

Finding 2022-002 ? Form RD-442-2 Quarterly Reporting Requirement ? Management agrees with the findings outlined in the Schedule of Findings and Questioned Costs for the Year Ended December 31, 2022 ? With the exception of the following elements: Schedule 1 page 1 Column 2 Names, Addresses, and Te...

Finding 2022-002 ? Form RD-442-2 Quarterly Reporting Requirement ? Management agrees with the findings outlined in the Schedule of Findings and Questioned Costs for the Year Ended December 31, 2022 ? With the exception of the following elements: Schedule 1 page 1 Column 2 Names, Addresses, and Terms of Office for the Board Chair and Board of Directors (4th Qtr only) All other elements were included in the Q1 2023 reporting file to the USDA ? Other corrections will be made within 30 days of the audit report and will be included in the next required USDA reporting file.

View Audit 16675

Finding 12306 (2022-001)

Significant Deficiency 2022

Upper Palmetto Ymca, Inc.

SC

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

Finding 2022-001 ? Form RD-442-2 Annual Reporting Requirement ? Management agrees with the findings outlined in the Schedule of Findings and Questioned Costs for the Year Ended December 31, 2022 ? Missing elements listed under the ?conditions? section will be added to the next USDA reporting file....

Finding 2022-001 ? Form RD-442-2 Annual Reporting Requirement ? Management agrees with the findings outlined in the Schedule of Findings and Questioned Costs for the Year Ended December 31, 2022 ? Missing elements listed under the ?conditions? section will be added to the next USDA reporting file. ? Corrections will be made within 30 days of the audit report and will be included in the next required USDA reporting file.

View Audit 16675

Finding 12305 (2022-001)

None 2022

Ahs Hospital Corp.

NJ

Reporting Internal Control / Segregation of Duties

Management?s Views and Corrective Action Plan December 31, 2022 2022-001: Provider Relief Fund Reporting Federal Agency: Department of Health and Human Services Health Resources and Services Administration (HRSA) Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assist...

Management?s Views and Corrective Action Plan December 31, 2022 2022-001: Provider Relief Fund Reporting Federal Agency: Department of Health and Human Services Health Resources and Services Administration (HRSA) Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing Number: 93.498 Management agrees with the facts as presented in the auditor?s finding. Within the PRF Reporting Portal under its Reporting Period 3 requirement for Practice Associates Medical Group (PAMG), management inadvertently continued to report budgeted quarterly data beyond fiscal year end December 31, 2020 (the year for which the budget was approved prior to March 27, 2020). Management?s interpretation of the PRF Reporting Portal guidance was that if Option 2 was chosen, all data including budgets needed to be entered in the portal instead of leaving the budget data blank for the periods where the budget was not approved prior to March 27, 2020. Management contacted HRSA, who advised us that there is no corrective action needed to the previously reported submissions. The losses reported in the fiscal year ended December 31, 2020 far exceeded the total PRF funds received by PAMG through the period of availability for Reporting Period 3. Any future required reporting under the program will not include budgeted data. Management responsible for corrective action plan: Katharine Driebe, Vice President ? Finance (kay.driebe@atlantichealth.org)

View Audit 16670

Finding 12300 (2022-004)

Significant Deficiency 2022

Dundy County Stratton Public Schools District No. 117

NE

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN October 25, 2022 Dundy County Stratton Public Schools District No. 117, respectfully submits the following corrective action plan for the year ended August 31, 2022, for the findings identified by Dana F. Cole & Company, LLP, Grand Island, Nebraska. The findings from the sc...

CORRECTIVE ACTION PLAN October 25, 2022 Dundy County Stratton Public Schools District No. 117, respectfully submits the following corrective action plan for the year ended August 31, 2022, for the findings identified by Dana F. Cole & Company, LLP, Grand Island, Nebraska. The findings from the schedule of findings and questioned costs are discussed below and are numbered consistently with the numbers assigned in that schedule. FINANCIAL STATEMENT FINDINGS 2022-004 INTERNAL CONTROL OVER SCHEDULE OF EXPENDUTRES OF FEDERAL AWARDS PREPARATION AND REVIEW Recommendation: The District should review and approve the proposed auditor adjusting entries and the adequacy of schedule of the expenditures of federal awards disclosures prepared by the auditors and apply analytic procedures to the draft financial statements, among other procedures as considered necessary by management. Action Taken: The District relies on the auditor to propose adjustments necessary to prepare the financial statements including the related note disclosures. The District reviews such financial statements and approves all adjustments. The District also uses analytic procedures, and other procedures determined necessary. If the Nebraska Department of Education has questions regarding this plan, please call Mrs. Anderson at 308.423.2738. Sincerely yours, Mrs. Jackie Anderson Superintendent

View Audit 16666

Finding 12299 (2022-002)

Significant Deficiency 2022

Ballardsville Rural Fire Protection District

KY

Reporting Internal Control / Segregation of Duties

Response: The Fire District does not believe that hiring a professional consultant to aid in financial reporting would be cost effective or economically feasible at this time.

View Audit 16663

Finding 12298 (2022-001)

Significant Deficiency 2022

Ballardsville Rural Fire Protection District

KY

Reporting Internal Control / Segregation of Duties

Response: The Fire District does not believe that hiring a professional consultant to aid in financial reporting would be cost effective or economically feasible at this time.

View Audit 16663

Finding 12287 (2022-001)

Material Weakness 2022

Cerro Gordo County

IA

Internal Control / Segregation of Duties

See Corrective Action Plan for chart.

View Audit 16624

Finding 12284 (2022-001)

Material Weakness 2022

Winner School District No. 59-2

SD

Internal Control / Segregation of Duties Material Weakness Reporting

The Winner School District Business Manager, Laura Root, is the contact person responsible for the corrective action plan for this finding. We are aware of this weakness in internal controls and continue to analyze the processes and procedures to minimize the risk to the Winner School District. Du...

The Winner School District Business Manager, Laura Root, is the contact person responsible for the corrective action plan for this finding. We are aware of this weakness in internal controls and continue to analyze the processes and procedures to minimize the risk to the Winner School District. Due to the size and limited funding of the Winner School District, we cannot staff at a level sufficient to provide an ideal environment for internal controls. Several procedures have been set into place to have more than one individual count cash/checks before it is receipted and deposited by the Business Manager. The district has put an internal control policy into place and will continue to analyze different policies and procedures to address this ongoing issue. I have attached a copy of our internal control policy.

View Audit 16623

Finding 12283 (2022-001)

Material Weakness 2022

Toledo Alliance for the Performing Arts

OH

Material Weakness Reporting Internal Control / Segregation of Duties

Material Weakness in Internal Control over Financial Reporting Recommendation: Toledo Alliance for the Performing Arts should evaluate their financial reporting processes and controls to determine whether additional controls over the preparation of annual financial statements should be implemented ...

Material Weakness in Internal Control over Financial Reporting Recommendation: Toledo Alliance for the Performing Arts should evaluate their financial reporting processes and controls to determine whether additional controls over the preparation of annual financial statements should be implemented to provide reasonable assurance that financial statements are prepared in accordance with GAAP and the requirements of UPMIFA. Explanation of disagreement with audit finding: Toledo Alliance for the Performing Arts received guidance from previous auditors as well as CPA Board Members that endowments organized as a Trust Agreement and held at a for-profit entity, i.e. a bank, did not need to comply with UPMIFA. The originating documents identify TAPA's Endowment at a Trust and the funds are being managed by a bank. Given this information, TAPA did not adopt UPMIFA. At no time were TAPA's overall financial statements misstated. Action taken in response to finding: Due to consultation with the current auditors, TAPA is in agreement that the Endowment should be reported in accordance with GAAP as it related to the UPMIFA guidelines. TAPA has researched UPMIFA and will continue to review and update the Endowment in accordance with GAAP. Name(s) of the contact person(s) responsible for corrective action: Randi Dier Planned completion date for the corrective action plan: ongoing

View Audit 16604

Finding 12275 (2022-003)

Material Weakness 2022

St. Thomas East End Medical Center Corporation

VI

Special Tests & Provisions Subrecipient Monitoring Eligibility

CORRECTIVE ACTION PLAN March 27, 2023 Health Resources and Services Administration St. Thomas East End Medical Center Corporation and Affiliate respectfully submits the following corrective action plan for the year ended February 28, 2022. ___________________________________________________________...

CORRECTIVE ACTION PLAN March 27, 2023 Health Resources and Services Administration St. Thomas East End Medical Center Corporation and Affiliate respectfully submits the following corrective action plan for the year ended February 28, 2022. ____________________________________________________________________________________ CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: February 28, 2022 The findings from the February 28, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS ? FINANCIAL STATEMENT AUDIT Finding 2022-001 ? Pension MATERIAL WEAKNESS Recommendation We recommend that the Center implement policies and procedures that allow for the timely payments of the pension plan payments. Action Taken & Completion Date The Center is working hard to make sure that all pension payments are made on time by strengthening our controls to ensure that the pension payments process is monitored properly. Completion Date October 1, 2023 Finding 2022-002 ? Account Analyses MATERIAL WEAKNESS Recommendation We recommend that the Center ensure that all accounting records are analyzed and reconciled on a monthly basis. Action Taken & Completion Date Management is working with staff to ensure that all accounting records are reviewed, analyzed and reconciled on a monthly basis. A new Chief Financial Officer started working at the Center on April 3, 2023. We are in the process of working together to create tighter protocols within the financial department. COMPLETEION DATE: October 1, 2023 FINDINGS ? FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Centers Program Cluster (Assistance Listing Number 93.224/93.527) Finding 2022-003 ? Special Tests and Provisions MATERIAL WEAKNESS Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee scale is calculated properly. Action Taken St. Thomas East End Medical Center has already provided some training to staff regarding the Sliding Fee Discount Program and is in the process of developing a training area within the Business Office to ensure the staff is appropriately trained regarding the scale. We are also creating new processes for quality improvement and compliance. Completion Date October 1, 2023 Finding 2022-004 ? Reporting MATERIAL WEAKNESS Recommendation We recommend that the Center establish controls to ensure all accounting records are analyzed and proper support is available in order to ensure that the financial statement audit is submitted on a timely basis to the federal government. Action Taken & Completion Date St. Thomas East End Medical Center is currently onboarding new leadership. As a part of this change, we are working diligently to ensure that the Business Office is restructured, to include development of quality controls, appropriate processes and procedures surrounding analysis and reconciliation of accounts. We are also working with team to ensure that all reporting is done on time. Completion October 1, 2023 If the Health Resources and Services Administration has questions regarding this plan, please call Tess G. Richards, M.D. Interim Executive Director at 340-775-3700, ext. 3023. Sincerely yours,

View Audit 16572

Finding 12265 (2022-004)

Material Weakness 2022

Epilepsy Foundation of America

MD

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

Finding 2022-004: Material Weakness over Allowable Costs - Review of Non-Payroll Expenditures Information on the Federal Program: Department of Human and Health - Center for Disease Control: Improving Epilepsy Programs, Services and Outcomes Through Partnerships. Finding: The Uniform Guidance req...

Finding 2022-004: Material Weakness over Allowable Costs - Review of Non-Payroll Expenditures Information on the Federal Program: Department of Human and Health - Center for Disease Control: Improving Epilepsy Programs, Services and Outcomes Through Partnerships. Finding: The Uniform Guidance requires organizations to establish internal controls to detect potential noncompliance. Management has an established control in place, in that all expenditures paid through the Concur system were reviewed and approved by an appropriate project manager, but did not retain evidence of this approval occurring during the year for 9 non-payroll expenditures chosen for testing. Planned Corrective Action: We had a number of technical issues with Concur which resulted in a cessation of use in January 2022 and a transition to PN3 which was being used for payables. We transitioned to PN3 in January 2022 and are no longer using Concur. PN3 maintains all audit trails. Name and Person Responsible: Caro Marie Brown (Senior Director of Finance), June Nolan (Accounts Payable Accountant), and Lindey Camerata (Controller). Anticipated Completion Date: January 2022.

View Audit 16547

Finding 12262 (2022-004)

Significant Deficiency 2022

Village of Armada

MI

Reporting Internal Control / Segregation of Duties

THE VILLAGE OF ARMADA WILL CREATE A FEDERAL AWARD ADMINISTRATION POLICY. DUE TO THE VERY MINIMAL TIMES THAT A SINGLE AUDIT IS REQUIRED, THE VILLAGE WILL LOCATE A SIMPLIFIED VERSION TO SUIT OUR REQUIREMENTS.

View Audit 16522

Finding 12251 (2022-001)

None 2022

Hartford Healthcare Corporation

CT

Questioned Costs Subrecipient Monitoring Reporting § 200.303

Management believes additional expenditures are available to offset the duplication of expenses as well as lost revenue which would remediate the duplication.

View Audit 16503 Questioned Costs: $1

Finding 12249 (2022-003)

Material Weakness 2022

Alamance County, North Carolina

NC

Questioned Costs Material Weakness Internal Control / Segregation of Duties

Finding: 2022-003 Name of Contact Person: Nicole Alston Corrective Action/Management?s Response: The WIC Director or Clerical Supervisor will provide training to the clerical team members regarding incoming transfers/certification periods. The training will include corrective action/work arou...

Finding: 2022-003 Name of Contact Person: Nicole Alston Corrective Action/Management?s Response: The WIC Director or Clerical Supervisor will provide training to the clerical team members regarding incoming transfers/certification periods. The training will include corrective action/work around in the event that the Crossroads system will not accept the correct certification dates indicated on the Verification of Certification from the previous WIC site. WIC will complete this training by 12/31/22 as evidenced by the meeting minutes and staff signatures. For quality assurance, the Clerical Supervisor will keep VOCs on file and will indicate if there were any issues with certification dates along with a follow-up date for auditing the client record. Proposed Completion Date: Immediately and Ongoing

View Audit 16498 Questioned Costs: $1

Finding 12248 (2022-002)

Material Weakness 2022

Alamance County, North Carolina

NC

Eligibility Material Weakness Internal Control / Segregation of Duties

Finding: 2022-002 Name of Contact Person: Nicole Alston Corrective Action/Management?s Response: The WIC Director, Clerical Supervisor or designee will randomly audit a minimum of 10 Crossroads records at least quarterly for quality assurance. WIC has revised the audit tool to include additio...

Finding: 2022-002 Name of Contact Person: Nicole Alston Corrective Action/Management?s Response: The WIC Director, Clerical Supervisor or designee will randomly audit a minimum of 10 Crossroads records at least quarterly for quality assurance. WIC has revised the audit tool to include additional eligibility criteria (attached for review). Proposed Completion Date: Immediately and Ongoing

View Audit 16498

Finding 12244 (2022-002)

Significant Deficiency 2022

Housing Authority of the City of Washington

GA

HUD Housing Programs Eligibility Internal Control / Segregation of Duties

2022-2 Condition: Deficiencies Noted in Examination of New Construction Section 8 Tenant Files Steps to resolve: We will review the internal control procedures over tenant file re-certifications and documents. Management has implemented procedures in order t...

2022-2 Condition: Deficiencies Noted in Examination of New Construction Section 8 Tenant Files Steps to resolve: We will review the internal control procedures over tenant file re-certifications and documents. Management has implemented procedures in order to clear this finding in FY 2023. Timeframe: By FYE December 31, 2023 Individual responsible for correction: Ms. Zena Zahran, Executive Director

View Audit 16463

Finding 12243 (2022-001)

Significant Deficiency 2022

Housing Authority of the City of Washington

GA

HUD Housing Programs Internal Control / Segregation of Duties

2022-1 Condition: Deficiencies Noted in Cash Disbursements Steps to resolve: We will review the cash disbursement documentation process in order to ensure that each disbursement is fully documented. We will update internal control policies to ensure complete compliance with HUD regulations. Manag...

2022-1 Condition: Deficiencies Noted in Cash Disbursements Steps to resolve: We will review the cash disbursement documentation process in order to ensure that each disbursement is fully documented. We will update internal control policies to ensure complete compliance with HUD regulations. Management has implemented procedures to clear this finding in FY 2023. Timeframe: By FYE December 31, 2023 Individual responsible for correction: Ms. Zena Zahran, Executive Director

View Audit 16463

Finding 12242 (2022-004)

Significant Deficiency 2022

Pioneer Housing Development Inc. Dba John Paul Apartments 092-11212

MN

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

Finding 2022-004 Special Tests and Provisions Noncompliance and Significant Deficiency in Internal Control over Compliance U.S. Department of Housing and Urban Development CFA #14.134 Section 207 Insured Loan Balance Finding Summary: Upon termination of lease, Minnesota statutes require that th...

Finding 2022-004 Special Tests and Provisions Noncompliance and Significant Deficiency in Internal Control over Compliance U.S. Department of Housing and Urban Development CFA #14.134 Section 207 Insured Loan Balance Finding Summary: Upon termination of lease, Minnesota statutes require that the Project refund tenant security deposits within 21 days of termination of tenancy. The Project did not pay out one deposit within the 21 day requirement for termination of tenancy. Responsible Individuals: Brenda Weller, Director of Finance Corrective Action Plan: Management agrees with the finding and will work to refund tenant security deposits within 21 days of termination of tenancy. Anticipated Completion Date: December 31, 2023

View Audit 16461

Finding 12229 (2022-004)

Significant Deficiency 2022

Minnesota Prairie County Alliance

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding Number: 2022-004 Finding Title: Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Jeremy Allen Corrective Action Planned: Agency will correct the cases that were cited for errors. Supervisor will re...

Finding Number: 2022-004 Finding Title: Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Jeremy Allen Corrective Action Planned: Agency will correct the cases that were cited for errors. Supervisor will review relevant policies for assets and child support non-coop with Eligibility workers on the Family Team to provide additional support and guidance for processing of these cases. Anticipated Completion Date: 8/31/2023

View Audit 16416

Finding 12228 (2022-003)

Significant Deficiency 2022

Minnesota Prairie County Alliance

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding Number: 2022-003 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Jeremy Allen Corrective Action Planned: Agency will correct the cases that were cited for errors. Supervisor will review relevant poli...

Finding Number: 2022-003 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Jeremy Allen Corrective Action Planned: Agency will correct the cases that were cited for errors. Supervisor will review relevant policies for assets and child support non-coop with Eligibility workers on the Family Team to provide additional support and guidance for processing of these cases. Anticipated Completion Date: 8/31/2023

View Audit 16416

Finding 12222 (2022-001)

Significant Deficiency 2022

Benevolent Corporation Cedar Community

WI

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting

Finding #2022-001: Internal Controls Over Compliance Related to Payroll; Federal Program: Provider Relief Fund (93.498); Response: We will review department documentation of hours allocated to grants; Responsible party: Kevin Sander, Controller; Estimated Completion: The very next payroll submission...

Finding #2022-001: Internal Controls Over Compliance Related to Payroll; Federal Program: Provider Relief Fund (93.498); Response: We will review department documentation of hours allocated to grants; Responsible party: Kevin Sander, Controller; Estimated Completion: The very next payroll submission.

View Audit 16382

Corrective Action Plans

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