Corrective Action Plans

Finding 34864 (2022-003)

Significant Deficiency 2022

Giving Youth A Chance Initiative

TN

Questioned Costs Cash Management Significant Deficiency

Corrective Action ? Management will re-train and certify staff on the Internal Control policy.

View Audit 24343 Questioned Costs: $1

Finding 34807 (2022-010)

Material Weakness 2022

San Francisco Unified School District

CA

Special Tests & Provisions Material Weakness Internal Control / Segregation of Duties

Views of Responsible Officials: The District has not identified any payments that are the result of fraud. The District will work on developing procedures to identify and recover payments resulting from fraud. Name of Responsible Person: Pamela Geisler, Budget & Policy Director Implementation ...

Views of Responsible Officials: The District has not identified any payments that are the result of fraud. The District will work on developing procedures to identify and recover payments resulting from fraud. Name of Responsible Person: Pamela Geisler, Budget & Policy Director Implementation Date: Fiscal Year 2023-2024

View Audit 24006

Finding 34802 (2022-009)

Material Weakness 2022

San Francisco Unified School District

CA

Questioned Costs Cash Management Material Weakness

Views of Responsible Officials: During the COVID 19 pandemic the District experienced turnover in various key positions resulting from a lapse with record keeping. Management will work to ensure that records related to claim reimbursements are retained for a period of three years. Name of Respon...

Views of Responsible Officials: During the COVID 19 pandemic the District experienced turnover in various key positions resulting from a lapse with record keeping. Management will work to ensure that records related to claim reimbursements are retained for a period of three years. Name of Responsible Person: Jennifer LaBarre, Executive Director of Student Nutrition Services Implementation Date: Fiscal Year 2023-2024

View Audit 24006 Questioned Costs: $1

Finding 34796 (2022-008)

Material Weakness 2022

San Francisco Unified School District

CA

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.200 § 200.430

Views of Responsible Officials: District is reviewing the internal procedures related to documenting salaries and wages charged to federal programs and will work with our auditors to ensure we meet this requirement. Name of Responsible Person: Anne Marie Gordon, Interim Chief Financial Officer ...

Views of Responsible Officials: District is reviewing the internal procedures related to documenting salaries and wages charged to federal programs and will work with our auditors to ensure we meet this requirement. Name of Responsible Person: Anne Marie Gordon, Interim Chief Financial Officer Implementation Date: Fiscal Year 2023-2024

View Audit 24006 Questioned Costs: $1

Finding 34737 (2022-001)

Significant Deficiency 2022

Florida Southern College

FL

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

2022-001 Return to Title IV Recommendation: We recommend that the College review and implement procedures to ensure that withdrawals are properly communicated to all departments and processed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Act...

2022-001 Return to Title IV Recommendation: We recommend that the College review and implement procedures to ensure that withdrawals are properly communicated to all departments and processed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: So that we do not have to rely upon other offices to notify the Financial Aid Office of students not returning, the College has developed a report to detect this condition. We ran the report and no additional students were found to be in this condition. At a minimum, this report will be run on a monthly basis. Name(s) of the contact person(s) responsible for corrective action: William Healy Planned completion date for corrective action plan: July 2022

View Audit 33995

Finding 34734 (2022-002)

Material Weakness 2022

Edgewood-Colesburg Community School District

IA

Internal Control / Segregation of Duties

The District will continue to look for ways to improve segregation of duties.

View Audit 33564

Finding 34730 (2022-003)

Material Weakness 2022

Melbourne Housing Authority

FL

HUD Housing Programs Eligibility Material Weakness

2022-003 Eligibility: Public Housing Tenant Files Public and Indian Housing Program ? CFDA Number 14.850 Material Weakness in Internal Control Material Noncompliance Condition: Out of a total tenant population of approximately 145 tenant files, 15 files were selected for testing. Exceptions wer...

2022-003 Eligibility: Public Housing Tenant Files Public and Indian Housing Program ? CFDA Number 14.850 Material Weakness in Internal Control Material Noncompliance Condition: Out of a total tenant population of approximately 145 tenant files, 15 files were selected for testing. Exceptions were noted as follows: ? 1 tenant file where the Authority was unable to locate certain documents and therefore could not test items such as Form 9886, birth certificates, social security cards, income and deduction support, utility allowance schedules and EIV verification. ? 1 tenant file where dependent?s 214 affidavit was not signed. However, we did note that the dependent was a US Citizen (per review of birth certificate) and therefore eligible for the program. ? 1 tenant file where tenant?s reported income was incorrect on the Form 50058. However, this had no impact on tenant?s rent as this was a flat rent unit. We also noted as part of our new admissions testing (3 selected for testing out of population of 23 new admissions) the following: ? 1 new admission where the applicant and dependent?s Form 214 were not signed. However, it was noted that the applicants were citizens (per review of birth certificate information) and therefore eligible for the program. Auditor?s Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: We concur with the recommendation. Due to the COVID-19 pandemic and related staff absences and turnover, we were not able to locate certain documents. We will assure that files are complete and are supported with proper documentation.

View Audit 30288

Finding 34729 (2022-002)

Material Weakness 2022

Melbourne Housing Authority

FL

HUD Housing Programs Material Weakness Reporting

2022-002 Reporting ? Inaccurate and Late FDS Submission and Late OMB Data Collection Form Submission Public and Indian Housing Program ? CFDA Number 14.850 Material Weakness in Internal Control Material Noncompliance Repeat finding of 2021-002 from March 31, 2021 Condition: The Authority?s origi...

2022-002 Reporting ? Inaccurate and Late FDS Submission and Late OMB Data Collection Form Submission Public and Indian Housing Program ? CFDA Number 14.850 Material Weakness in Internal Control Material Noncompliance Repeat finding of 2021-002 from March 31, 2021 Condition: The Authority?s original unaudited FDS filing was materially misstated. In addition, the Authority did not report the CARES Act activity in a separate column of the FDS as required. Also, the unaudited FDS filings were not submitted within the timeframes specified by HUD. The Authority submitted the unaudited FDS filing on May 26, 2023 (of which the normal due date was May 31, 2022). The Authority was also required to submit the audited FDS filing and the OMB Data Collection form to the Federal Audit Clearinghouse (?FAC?) by December 31, 2022 at completion of the single audit, but it was not filed timely, as the audit was completed on August 16, 2023. Recommendation: The Authority should make every effort to file its REAC submissions accurately and timely and submit the OMB Data Collection form timely. Action Taken: We concur with the recommendation. Due to the COVID-19 pandemic and related staff absences and turnover, we were not able to accurately close the books before the HUD specified unaudited and audited FDS filing deadline and unable to timely file the OMB Data Collection Form. We are very focused on ensuring there is adequate staffing and sufficient processes in place in order to be able to close the books prior to submitting a materially accurate unaudited FDS submission for the following fiscal year as well as timely file the audited FDS and OMB Data Collection Form.

View Audit 30288

Finding 34728 (2022-001)

None 2022

Genesee Valley Presbyterian Nursing Center D/b/a Kirkhaven

NY

Questioned Costs HUD Housing Programs Material Weakness § 200.516

Cause Kirkhaven was experiencing significant cash constraints and was not able to make debt payments and escrow payments as they were due. Effect Kirkhaven is out of compliance with the HUD regulatory agreement. Recommendation We recommend that Kirkhaven utilize grant funding if allowable to becom...

Cause Kirkhaven was experiencing significant cash constraints and was not able to make debt payments and escrow payments as they were due. Effect Kirkhaven is out of compliance with the HUD regulatory agreement. Recommendation We recommend that Kirkhaven utilize grant funding if allowable to become up to date in debt principal payments and escrow payments. Management Response Kirkhaven was and continues to be in communication with both HUD and mortgage servicer (Berkadia) with regards to the lack of payment of the October to December mortgage and escrow required payments amounting to $192,947 due to the cash flow challenges. They are aware of the executed CHOW Letter of Intent. Subsequent to year-end, Kirkhaven has made the required interest only payments for October to December and continues to make the monthly interest payments. Kirkhaven also has applied for relief of the required escrow payments, but was subsequently denied. Management will continue to monitor cash flow and if feasible make mortgage principal and escrow payments as able, however, the VAPAP grant proceeds did not include funds for debt payments. Managements position is that since the executed CHOW, intention is to use proceeds to pay of the mortgage balance, that paying the principal earlier versus later is less critical.

View Audit 36313

Finding 34727 (2022-001)

Significant Deficiency 2022

Ecology Education, Inc.

ME

Student Financial Aid Reporting Significant Deficiency

Ecology Education, Inc. Corrective Action Plan For the Year Ended December 31, 2022 Finding 2022-001 Condition The School has not prepared written policies which could result in potential noncompliance. Corrective Action Taken or Planned Management is currently reviewing the 2022 compliance ...

Ecology Education, Inc. Corrective Action Plan For the Year Ended December 31, 2022 Finding 2022-001 Condition The School has not prepared written policies which could result in potential noncompliance. Corrective Action Taken or Planned Management is currently reviewing the 2022 compliance supplement (2 CFR PART 200, APPENDIX XI) which applies to most federal awards including USDA RD financing. Management understands this supplement is issued annually and can be obtained online. Specific review includes the matrix for federal programs on page 21, and details for ALN 10.766 (USDA Community facilities loans) which begins on page 275. Management has prioritized preparing written policies in direct alignment of the 2022 compliance supplement related to internal control and compliance with federal award requirements. The relevant compliance requirements for TES for 2022 for which policies are being drafted related to the USDA RD Community Facilities Program loan include reporting, reserve account funding, and minimum insurance and bonding coverage, per the agreement with USDA. Specific controls over compliance with these requirements will be documented.

View Audit 34660

Finding 34721 (2022-003)

None 2022

Illinois Humanities Council

IL

Questioned Costs Reporting Internal Control / Segregation of Duties

Illinois Humanities Council ? Single Audit Corrective Action Plan Finding 2022-003 ? Late Filing of 2021 Single Audit Reporting Package During audit testing it was discovered that the Single Audit reporting package for fiscal year 2021 was not submitted to the Federal Audit Clearinghouse (FAC) withi...

Illinois Humanities Council ? Single Audit Corrective Action Plan Finding 2022-003 ? Late Filing of 2021 Single Audit Reporting Package During audit testing it was discovered that the Single Audit reporting package for fiscal year 2021 was not submitted to the Federal Audit Clearinghouse (FAC) within the required timeframe. The Code of Federal Regulations 2 CFR 200 requires grantees to submit the Single Audit reporting package to the Federal Audit Clearinghouse (FAC) with the earlier of 30 calendar days after receiving the audit report or nine months after the fiscal year end. Corrective Action Plan The Illinois Humanities Council had been outsourcing their accounting and finance functions to a third-party contractor when this finding occurred. It has since been identified that this third-party contractor was insufficiently performing contracted duties and this contract has been terminated as of December 31, 2022. To ensure that all Single Audit reporting packages are submitted in a timely manner according to 2 CFR 200 the Director of Finance and the Executive Director will work closely with the audit firm on timing of audit reports so as to meet the FAC timing requirement. The Board Chair and Treasure will also be notified once the Single Audit reporting package has been submitted to the FAC for transparency that reporting timing requirements have been met. Planned Completion Date 05/01/2023 Individuals Responsible for Executing Corrective Action Vicki Garza, Director of Finance Gabrielle Lyon, Executive Director

View Audit 34656

Finding 34716 (2022-001)

Significant Deficiency 2022

Coos County Family Health Services, Inc.

ME

Questioned Costs Subrecipient Monitoring Significant Deficiency

Finding Number: 2022-001 Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Individual(s) Responsible for Corrective Action: Brenda Ladd-Front Office Manager Brandon Gilbert-Compliance Officer Corrective Ac...

Finding Number: 2022-001 Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Individual(s) Responsible for Corrective Action: Brenda Ladd-Front Office Manager Brandon Gilbert-Compliance Officer Corrective Action Planned: 1. The Front Office Manager will provide additional training to the Front Desk/Reception Staff. 2. Assign the Compliance Officer the task of performing monthly audits on 25 random sliding fee charges to verify patient eligibility and discount. The results of the monthly audits will be reported to the Chief Executive Officer, Chief Financial Officer, and the Revenue Cycle Manager. Anticipated Completion Date: 1. Retraining of Front Desk/Reception will begin immediately. 2. Monthly audits of 25 random sliding fee charges will begin immediately.

View Audit 32420

Finding 34710 (2022-007)

Significant Deficiency 2022

Sullivan County Community College

NY

Internal Control / Segregation of Duties

2022-07 Education Stabilization Fund 84.425 Plan for Remediation: The Vice President for Administrative Services will develop and implement a policy and appropriate internal controls for approved grant use by the end of fiscal year 2022-2023. Potential addition of staffing in grants accounting a...

2022-07 Education Stabilization Fund 84.425 Plan for Remediation: The Vice President for Administrative Services will develop and implement a policy and appropriate internal controls for approved grant use by the end of fiscal year 2022-2023. Potential addition of staffing in grants accounting area to bolster staffing in this arena and add in-house expertise and support for existing staff.

View Audit 35403

Finding 34708 (2022-005)

Significant Deficiency 2022

Sullivan County Community College

NY

Cash Management Internal Control / Segregation of Duties

2022-05 Education Stabilization Fund 84.425 Plan for Remediation: The College had to adapt to new territory and evolving guidelines and compliance requirements related to COVID 19 funding. Moving forward, compliance guidelines will be adhered to for all federal funding received by the Controller a...

2022-05 Education Stabilization Fund 84.425 Plan for Remediation: The College had to adapt to new territory and evolving guidelines and compliance requirements related to COVID 19 funding. Moving forward, compliance guidelines will be adhered to for all federal funding received by the Controller and the Vice President for Administrative Services.

View Audit 35403

Finding 34692 (2022-001)

Material Weakness 2022

Stedman Volunteer Fire Department, Inc.

NC

Internal Control / Segregation of Duties Questioned Costs Material Weakness

The Board will discuss these recommendations and consider implementing procedures to further segregate duties within our internal control system.

View Audit 36137

Finding 34673 (2022-004)

Significant Deficiency 2022

West Virginia Public Transit Association

WV

Questioned Costs Reporting Internal Control / Segregation of Duties

CONTROLS OVER GRANT REPORTING Department of Health and Human Services 93.788 Management within West Virginia Public Transit Association appreciates and shares the auditors? concern with integrity as it relates to controls over grant reporting. The State Opioid Response Transportation Project Manager...

CONTROLS OVER GRANT REPORTING Department of Health and Human Services 93.788 Management within West Virginia Public Transit Association appreciates and shares the auditors? concern with integrity as it relates to controls over grant reporting. The State Opioid Response Transportation Project Manager will submit all future grant reports to the West Virginia Public Transit Association Treasurer for review prior to submission to grantor. The Treasurer will document approval in writing. This will begin with the quarter ending September 29, 2023.

View Audit 31088

Finding 34669 (2022-003)

None 2022

Boys & Girls Clubs in Tennessee

TN

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.414 § 200.502

Name of Responsible Individual(s): Jason Penegar, BGCA Vice President ? Controller Shelby Mahoney, Accounting Manager - State Alliances Corrective Action: Management will review grant agreements to confirm whether funding received from private entities are federal funds that should be reported on th...

Name of Responsible Individual(s): Jason Penegar, BGCA Vice President ? Controller Shelby Mahoney, Accounting Manager - State Alliances Corrective Action: Management will review grant agreements to confirm whether funding received from private entities are federal funds that should be reported on the SEFA. Anticipated Completion Date: December 31, 2023

View Audit 34598

Finding 34663 (2022-002)

Significant Deficiency 2022

Fort Bragg Schools Cafeteria Fund

NC

Internal Control / Segregation of Duties Questioned Costs Significant Deficiency

Finding: 2022-002 Segregation of Duties Name of Contact Person: Mike Riles and John McKnight Corrective Action: Duties will be divided equally within the Central Office. Proposed Completion Date: August 21, 2023

View Audit 34592

Finding 34662 (2022-001)

Significant Deficiency 2022

Fort Bragg Schools Cafeteria Fund

NC

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Finding: 2022-001 Financial Statement Preparation Name of Contact Person: Ms. Robin Norwood Corrective Action: The Financial administration portion of the office will be turned over to NAF (Non appropriated Funds) at the start of school. Proposed Completion Date: August 21, 2023

View Audit 34592

Finding 34647 (2022-001)

Significant Deficiency 2022

South Carolina Victim Assistance Network

SC

HUD Housing Programs Reporting Significant Deficiency

THE DUTIES WILL BE SEGREGATED AS MUCH AS POSSIBLE AND THE BOARD OF DIRECTORS WILL REMAIN INVOLVED IN THE FINANCIAL AFFAIRS OF THE COMPANY TO PROVIDE OVERSIGHT AND INDEPENDENT REVIEW FUNCTIONS.

View Audit 29882

Finding 34632 (2022-020)

Significant Deficiency 2022

Commonwealth of Massachusetts

MA

Questioned Costs Special Tests & Provisions Eligibility § 200.303

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2022-020 Medicaid Cluster, COVID-19 ? Medicaid Cluster, Children?s Health Insurance Program ? Assistance Listing No. 93.775, 93.777, 93.778, 93.767 ...

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2022-020 Medicaid Cluster, COVID-19 ? Medicaid Cluster, Children?s Health Insurance Program ? Assistance Listing No. 93.775, 93.777, 93.778, 93.767 Action taken in response to the finding: MassHealth agrees with the recommendation and notes that all the identified findings relate to MassHealth?s Dental Third-Party Administrator DentaQuest. To address the findings and recommendation, MassHealth will require DentaQuest to implement a corrective action plan to review and improve internal controls for the retention of provider enrollment documentation. As part of this corrective action plan, MassHealth will require DentaQuest to ensure that all required documents are obtained and retained during validation and revalidation processes for both individual and group practices. To support this, DentaQuest will also be required to provide additional training to its provider enrollment staff on document retention. Name of the contact person responsible for corrective action: Tuyen Vu, Dental Program Manager Planned completion date for corrective action plan: EHS plans the completion date for the corrective action plan in July 2024.

View Audit 31118

Finding 34629 (2022-019)

Significant Deficiency 2022

Commonwealth of Massachusetts

MA

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.303

DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT 2022-019 Low-Income Home Energy Assistance, COVID-19 ? Low-Income ...

DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT 2022-019 Low-Income Home Energy Assistance, COVID-19 ? Low-Income Home Energy Assistance ? Assistance Listing No. 93.568 Action taken in response to the finding: The Department of Housing and Community Development (DHCD) implemented new policies and procedures for LIHEAP reporting requirements necessary to ensure the reports are submitted timely and with accurate data to US HHS reporting systems. The DHCD Community Service Unit Manager, or their delegee, will coordinate with the LIHEAP Coordinator and/or other staff as needed to track deadline dates for all LIHEAP reports. Additionally, prior to submission all reports will be reviewed and verified against data sources by a Community Service staff member not involved in the creation of the reports. Name of the contact person responsible for corrective action: Ed Kiely, Community Service Unit Manager Planned completion date for corrective action plan: June 1, 2023

View Audit 31118

Finding 34623 (2022-015)

Significant Deficiency 2022

Commonwealth of Massachusetts

MA

Questioned Costs Reporting Significant Deficiency § 200.303

DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT 2022-015 COVID-19 ? Emergency Rental Assistance ? Assistance Listing No. 21.023 ...

DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT 2022-015 COVID-19 ? Emergency Rental Assistance ? Assistance Listing No. 21.023 Action taken in response to the finding: As of June 2022, monthly reports are no longer required for ERA. All reports will be uploaded to treasury before the deadline. Name of the contact person responsible for corrective action: Molly Butman Planned completion date for corrective action plan: April 10, 2023

View Audit 31118

Finding 34609 (2022-011)

Material Weakness 2022

Commonwealth of Massachusetts

MA

Questioned Costs Subrecipient Monitoring Material Weakness § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-011 WIOA Cluster ? Assistance Listing No. 17.258, 17.259, 17.278 ...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-011 WIOA Cluster ? Assistance Listing No. 17.258, 17.259, 17.278 Action taken in response to the finding: Reporting has been built to notify responsible parties of the award periods of performance and highlight any issues for corrective action in accordance to previously filed FFATA reporting. In addition, FFATA reporting has been created in EOLWD?s DataMart application. Actions taken are as follows: ? Performed FFATA training ? Created accounts for employee access to FFATA ? Filed existing outstanding and new grant FFATA reports ? Used new reporting to notify responsible parties that a new grant/modification has arrived and requires a FFATA Subaward report filed ? Training for existing staff complete and new staff will be trained accordingly as part of their onboarding. Name of the contact person responsible for corrective action: Malachy Rice, Director of Federal Grants, EOLWD Planned completion date for corrective action plan: June 30, 2023

View Audit 31118

Finding 34608 (2022-010)

Material Weakness 2022

Commonwealth of Massachusetts

MA

Internal Control / Segregation of Duties Questioned Costs Material Weakness § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-010 WIOA Cluster ? Assistance Listing No. 17.258, 17....

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-010 WIOA Cluster ? Assistance Listing No. 17.258, 17.259, 17.278 Action taken in response to the finding: Staffing: Two new Budget Analysts will begin working for EOLWD at the end of June in 2023. These analysts will provide additional capacity for filing 9130s for WIOA. Training: In March and April 2023, EOLWD provided training to new staff on the preparation, certification, and submission of 9130 reports. Staff beginning in June 2023 will be trained during the next 9130 reporting period. Automating Business Practices: EOLWD refined its automated 9130 reporting for the March 31, 2023, reporting period and is finalizing further refinements that will be implemented prior to the next quarterly reporting period. Standard Operating Procedures: EOLWD developed job aides for the preparation of 9130 reports with its new automated processes and is in the process of drafting new Standard Operating Procedures (SOP). These SOPs will be finalized and submitted to DOL by October 1, 2023, as outlined in the corrective action plan schedule provided to DOL. An updated version of this schedule is provided below. Name of the contact person responsible for corrective action: Malachy Rice, Director of Federal Grants, EOLWD Planned completion date for corrective action plan: October 1, 2023

View Audit 31118

Corrective Action Plans

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