Corrective Action Plans

Finding 7386 (2022-006)

Significant Deficiency 2022

Change, Inc.

MN

Reporting Significant Deficiency Internal Control / Segregation of Duties

Infrequently, the Executive or Associate Director prepares and submits reports. As the organization’s report reviewer, the Executive Director submitted the report as preparer and reviewer. Going forward, the Executive Director will have the Associate Director or Business Director review any Executiv...

Infrequently, the Executive or Associate Director prepares and submits reports. As the organization’s report reviewer, the Executive Director submitted the report as preparer and reviewer. Going forward, the Executive Director will have the Associate Director or Business Director review any Executive Director prepared reports.

View Audit 9524

Finding 7381 (2022-007)

Material Weakness 2022

Change, Inc.

MN

Material Weakness Reporting Internal Control / Segregation of Duties

This was a finding on our most recent audit as well (2021-007). Throughout FY23, we worked with our FPO and the Department of Labor to better understand the requirement and have adjusted our procedure as required. All errors have been corrected as of December 31, 2022.

View Audit 9524

Finding 7379 (2022-003)

Material Weakness 2022

Change, Inc.

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.318 § 200.326

Our Associate Director, Business Director and Operations Director will attend procurement, suspension, and debarment training to better learn the 2 CFR sections 200.318 through 200.326. Upon training completion, the team will provide the Finance Committee of the Board of Directors suggested updates ...

Our Associate Director, Business Director and Operations Director will attend procurement, suspension, and debarment training to better learn the 2 CFR sections 200.318 through 200.326. Upon training completion, the team will provide the Finance Committee of the Board of Directors suggested updates to our current policy.

View Audit 9524

Finding 7352 (2022-002)

Significant Deficiency 2022

The Housing Collective, Inc.

CT

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding No. 2022-002: Annual Audit Submission Assistance Listing Program Title and Number: All Federal Agency: All Pass-through Entity: All Description of Finding: As per the Code of Federal Regulations, Section 200.512 - Report Submission, the audit must be completed and the data collection form an...

Finding No. 2022-002: Annual Audit Submission Assistance Listing Program Title and Number: All Federal Agency: All Pass-through Entity: All Description of Finding: As per the Code of Federal Regulations, Section 200.512 - Report Submission, the audit must be completed and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditors' report, or nine months after the end of the audit period. The due date for the submission was September 30, 2023. The audit and reporting package were not submitted by the due date September 30, 2023. Statement of Concurrence or Nonconcurrence: The organization agrees with the audit finding. Corrective Action: The organization intends to become fully staffed in the Finance Department in order to conduct its financial tasks in a timely fashion. It also intends to have its Finance staff cross-trained to ensure required tasks are conducted in a timely fashion. A timeline has been established and activities have begun for the 2023 audit. This will ensure that the 2023 report is submitted within the timeframe required. Name of Contact Person: David Rich, Executive Director david@shworks.org 860-671-1715 Projected Completion Date: December 12, 2023, this corrective action has been completed and will be maintained.

View Audit 9499

Finding 7331 (2022-001)

Material Weakness 2022

The Housing Collective, Inc.

CT

Internal Control / Segregation of Duties Material Weakness Reporting

Finding No. 2022-001: Financial Reporting Assistance Listing Program Title and Number: All Federal Agency: All Pass-through Entity: All Description of Finding: In fiscal year 2022, the Organization's accounting processes and internal controls over financial reporting were not functioning timely to s...

Finding No. 2022-001: Financial Reporting Assistance Listing Program Title and Number: All Federal Agency: All Pass-through Entity: All Description of Finding: In fiscal year 2022, the Organization's accounting processes and internal controls over financial reporting were not functioning timely to support generating complete and accurate financial information. The year end was not closed in accordance with the Organization's financial close policy. The books and records were not closed and finalized until many months after year end. Statement of Concurrence or Nonconcurrence: The organization agrees with the audit finding. Corrective Action: The organization intends to become fully staffed in the Finance area in order to conduct its financial tasks in a timely fashion. It also intends to have its Finance staff cross-trained to ensure required tasks are conducted in a timely fashion. This will ensure that the year-end was closed in accordance with the organization's financial close policy and repeated revisions will not be necessary. Name of Contact Person: David Rich, Executive Director david@shworks.org 860-671-1715 Projected Completion Date: December 12, 2023, this corrective action has been completed and will be maintained.

View Audit 9499

Finding 7225 (2022-007)

Significant Deficiency 2022

MacOn and Piatt Counties Regional Office of Education No. 39

IL

Reporting Internal Control / Segregation of Duties § 200.303 § 200.510

CONDITION: The ROE did not have sufficient internal controls over the preparation of the Schedule of Expenditures of Federal Awards (SEFA) to ensure all federal expenditures during the fiscal year were reported and information in the SEFA was accurately reported. PLAN: The ROE will work with the...

CONDITION: The ROE did not have sufficient internal controls over the preparation of the Schedule of Expenditures of Federal Awards (SEFA) to ensure all federal expenditures during the fiscal year were reported and information in the SEFA was accurately reported. PLAN: The ROE will work with their contracted accounting firm to review financial statements, including the schedule of expenditures of federal awards, to ensure program titles, assistance listing numbers and other pertinent information is accurate for financial statement presentation. ANTICIPATED DATE OF COMPLETION: The anticipated date of completion is December 2023. CONTACT PERSON: Ms. Jill Reedy, Regional Superintendent

View Audit 9381

Finding 7223 (2022-005)

Significant Deficiency 2022

MacOn and Piatt Counties Regional Office of Education No. 39

IL

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

CONDITION: The ROE did not ensure costs or expenditures were adequately documented, reviewed, and approved to ensure allowability under the federal award. PLAN: Past practice and policy during the FY22 audit, allowed for the Business Manager to sign off on purchase orders and requisitions rel...

CONDITION: The ROE did not ensure costs or expenditures were adequately documented, reviewed, and approved to ensure allowability under the federal award. PLAN: Past practice and policy during the FY22 audit, allowed for the Business Manager to sign off on purchase orders and requisitions related to monthly, reoccurring bills. New management is working on updated fiscal policies. A new Accounts Payable employee was hired in March 2023 by ROE management and trained by the Business Manager, along with Program Directors, on procedures for expenditures. Procedures have been put into place to ensure that all expenditures are signed by the Program Director or Assistant/Regional Superintendent to indicate review and approval of expenditures. After being signed by a Program Director or Assistant/Regional Superintendent, the expenditure goes to the Business Office where the Business Manager will check for appropriate signatures and will pass on to Accounts Payable for a final check for appropriate signatures and supporting invoices prior to payment. ANTICIPATED DATE OF COMPLETION: This was implemented in March 2023. CONTACT PERSON: Ms. Jill Reedy, Regional Superintendent

View Audit 9381

Finding 7222 (2022-002)

None 2022

MacOn and Piatt Counties Regional Office of Education No. 39

IL

Internal Control / Segregation of Duties Period of Performance Reporting § 200.303

CONDITION: The ROE did not submit or timely submit the required reports to the Illinois State Board of Education. PLAN: New ROE management is providing close oversight for the timely submission of grant expenditure and performance reports. The Regional Superintendent has created a shared calendar...

CONDITION: The ROE did not submit or timely submit the required reports to the Illinois State Board of Education. PLAN: New ROE management is providing close oversight for the timely submission of grant expenditure and performance reports. The Regional Superintendent has created a shared calendar of submission due dates with the Business Manager and Program Directors. Reminders are sent out via email in advance of the due dates, and then management reviews the grant report submissions in IWAS for accuracy and completion before approving and submitting to ISBE. ANTICIPATED DATE OF COMPLETION: This plan was initiated during the new Regional Superintendent’s appointment to office in October 2022 and has been fully implemented since January 2023. CONTACT PERSON: Ms. Jill Reedy, Regional Superintendent

View Audit 9381

Finding 7159 (2022-002)

Significant Deficiency 2022

New Beginning International Ministry Inc.

TN

Reporting Internal Control / Segregation of Duties

The Organization is working with their financial institution to see if statement closing dates can better align with the reporting period. The Organization will perform the reconciliation if no changes can be made with the bank

View Audit 9222

Finding 7158 (2022-001)

Significant Deficiency 2022

New Beginning International Ministry Inc.

TN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties

The Organization is in the process of working to obtain a general ledger system and someone that can assist the Organization in maintaining the system

View Audit 9222

Finding 7096 (2022-004)

Significant Deficiency 2022

The Fishing Partnership Health Plan Corporation D/b/a Fishing Partnership

MA

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.430

Finding 2022-004 - Strengthen controls surrounding program-related record keeping including increasing the frequency of reconciliation's and program wage allocation procedures to match the payroll cycle. Program Affected Under the U.S. Department of Health and Human Services - Award Year October 1,...

Finding 2022-004 - Strengthen controls surrounding program-related record keeping including increasing the frequency of reconciliation's and program wage allocation procedures to match the payroll cycle. Program Affected Under the U.S. Department of Health and Human Services - Award Year October 1, 2021 - September 30, 2022: Assistance Listing 93.262 Occupational Safety and Health Program Corrective Action The Organization agrees with the finding. The Organization has implemented both time and effort reporting by pay period and wage reconciliations as part of a monthly close process. Responsible individual - JJ Bartlett Completion 9/30/2023

View Audit 9150 Questioned Costs: $1

Finding 7034 (2022-002)

Material Weakness 2022

Isaiah House

NJ

Allowable Costs / Cost Principles Material Weakness Reporting

The Executive Director and Deputy Director will review and approve all reporting submissions to ensure they are being reported timely in accordance with grant requirements.

View Audit 9025

Finding 7008 (2022-001)

Significant Deficiency 2022

The Roskamp Institute, Inc.

FL

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTION: Management agrees with the finding and will implement a process to maintain all payroll allocations.

View Audit 9020

Finding 6965 (2022-004)

Material Weakness 2022

Fredericksburg Area Health and Support Services, Inc.

VA

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.430

Finding: The Organization allowed payroll related costs to be submitted for reimbursement under the grant for time that did not match approved timesheets. This is not in compliance with program allowable cost requirements. The amount of payroll and related costs discovered to be incorrect was a net...

Finding: The Organization allowed payroll related costs to be submitted for reimbursement under the grant for time that did not match approved timesheets. This is not in compliance with program allowable cost requirements. The amount of payroll and related costs discovered to be incorrect was a net amount of $25, which when projected onto the remaining payroll and related costs that were not tested, amounted to $1,038. Corrective Action Taken or Planned: The Organization will review audit findings and ensure accurate future reimbursements, develop a comprehensive process for verifying time sheets against service delivery, and implement a paper timesheet system in which supervisors must enter time based on timesheets, ensuring 1:1 reimbursement. Name of Contact Person: Jacob Ducey, Grants Manager Phone Number of Contact Person: (540) 907-4555 Projected Completion Date: October 31, 2023

View Audit 9001 Questioned Costs: $1

Finding 6889 (2022-001)

Significant Deficiency 2022

Lakeshore Regional Entity

MI

Subrecipient Monitoring Internal Control / Segregation of Duties Significant Deficiency § 200.332

2022-001 – Communications with Subrecipients Finding Type: Significant Deficiency in internal control over compliance Program: ALN 93.959 – SAPT COVID Supplement ALN 93.959 – Prevention, Women’s Specialty Services, Administration ALN 93.959 – Treatment/AMS Criteria: As required by 2 CFR 200....

2022-001 – Communications with Subrecipients Finding Type: Significant Deficiency in internal control over compliance Program: ALN 93.959 – SAPT COVID Supplement ALN 93.959 – Prevention, Women’s Specialty Services, Administration ALN 93.959 – Treatment/AMS Criteria: As required by 2 CFR 200.332, the pass-through entity must communicate specific information to subrecipients, as applicable. Condition: Contracts with subrecipients did not include portions of required disclosures. Cause/Effect: Inadequate internal controls over compliance. Select contracts were not in compliance with 2 CFR 200.332. Questioned Cost: None. Recommendation: We recommend that the Entity update all contracts with subrecipients to include required language. View of Responsible Official: Management is in agreement with this recommendation. Planned corrective action: FY2023 contracts with subrecipients have been partially updated with the required language and all required language will be included in the FY2024 contracts with subrecipients. Responsible party: Chief Financial Officer Anticipated completion date: September 30, 2024

View Audit 8866

Finding 6843 (2022-004)

Material Weakness 2022

Community Health and Emergency Services, Inc.

IL

Reporting Internal Control / Segregation of Duties

FINDING NO. 2022-004: Ineffective Internal Controls over Expenditure Report Preparation Condition: The Organization’s internal controls over the preparation and review of grant expenditure reports were not properly followed during the current fiscal year. Certain expenditure reports submitted to ...

FINDING NO. 2022-004: Ineffective Internal Controls over Expenditure Report Preparation Condition: The Organization’s internal controls over the preparation and review of grant expenditure reports were not properly followed during the current fiscal year. Certain expenditure reports submitted to HRSA were not timely filed: • The Medicaid cost report is due to Illinois Healthcare and Family Services (HFS) within 180 days after the close of the Clinic’s fiscal year. The Organization filed this report on September 8, 2022 for year-end June 30, 2021. • The Medicare cost report is due to Centers for Medicare & Medicaid Services (CMS) on November 30th, 2021 but was not submitted until December 6, 2021 Plan: CHESI is implementing procedures to ensure all reports are filed timely to avoid being out of compliance. Anticipated Date of Completion: December 31, 2023 Name of Contact Person: Kanci Houston, CEO

View Audit 8765

Finding 6842 (2022-003)

Material Weakness 2022

Community Health and Emergency Services, Inc.

IL

Internal Control / Segregation of Duties Special Tests & Provisions Eligibility

FINDING NO. 2022-003: Ineffective Internal Controls over Sliding Fee Revenues Condition: During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted the following exceptions: • Three (3) out of thirty-four (34) were miss...

FINDING NO. 2022-003: Ineffective Internal Controls over Sliding Fee Revenues Condition: During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted the following exceptions: • Three (3) out of thirty-four (34) were missing applications. • Fourteen (14) out of thirty-four (34) sliding fee adjustments were calculated incorrectly based on the sliding fee schedule. • One (1) out of thirty-four (34) sliding fee adjustments were not properly applied to the patient’s account. Plan: CHESI has implemented a new workflow process to ensure compliance with the program requirements of the sliding fee program. CHESI has developed a new sliding fee procedure and trained all staff to ensure the applications are complete and signed by the patient, income is verified, the proper discount is calculated based on the sliding fee schedule, the proper amount of discount is applied to the patient’s account, and the application is approved and signed by the Billing Manager. All sliding fee applications will also be scanned into the patient’s chart once completed and approved. Anticipated Date of Completion: December 31, 2023 Name of Contact Person: Kanci Houston, CEO

View Audit 8765

Finding 6673 (2022-001)

Material Weakness 2022

Human Resource Development Institute

IL

Questioned Costs Material Weakness Reporting

Criteria Human Resources Development, Inc. and Affiliates’ (HRDI) is responsible for keeping an accurate accounting of its financial information. Views of Responsible Officials and Planned Corrective Actions: HRDI will implement the following corrective actions for the FY 2023-24 to remediate the fi...

Criteria Human Resources Development, Inc. and Affiliates’ (HRDI) is responsible for keeping an accurate accounting of its financial information. Views of Responsible Officials and Planned Corrective Actions: HRDI will implement the following corrective actions for the FY 2023-24 to remediate the finding and address the cause of the finding. HRDI will implement an established month-end checklist for all monthly entries to be completed by assigned finance staff. We will ensure that all staff are trained adequately to manage any assigned task. All monthly entries that are required will be reviewed and approved by the Chief Financial Officer prior to posting to the general ledger within our new Accounting Software. All appropriate backup documentation will be saved and stored within the accounting software. •HRDI will implement balance sheet reconciliations to be prepared and completed by Finance Staff Accountants monthly with a monthly review performed by the Chief Financial Officer. All balance sheet accounts will be reconciled to external data for verification monthly. All revenue accounts will be reconciled to external data for verification monthly. •The Chief Financial Officer has been hired in December 2023 and will begin full time employment January 1, 2024. In addition, all Finance responsibilities currently handled by outsourced resources will be transitioned to full-time employed Finance staff. •HRDI will document accounting policies and procedures to reflect the new month-end processes and provide training to staff on current and future policies. •HRDI will ensure that Finance staff will receive at minimum of 25 hours of training each year related to GASB, GAAP, Governmental Financial Reporting, or other related accounting trainings annually. •HRDI will ensure that any staff involved in Financial Reporting has the technical expertise to help with the preparation, review, and analysis of the financial statements. •HRDI has implemented a new accounting system – Sage Intacct. Additionally, we have implemented a grants project tracking module to better help with grants, contracts reporting, and compliance. The target date for implementation is March 31, 2024. The responsible party for the planned resources will be Gail ViJuk, Chief Financial Officer (708) 288-7897. Our address is 340 E. 51st St., Chicago, IL 60615.

View Audit 8675 Questioned Costs: $1

Finding 6606 (2022-003)

Significant Deficiency 2022

Agricultural Enterprises Development Administration

PR

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

We designated and trained personnel to work with the bank statements to identify timely any voucher in which the farmer identifier is not stamped. In those cases, a copy of the voucher must be sent to the Auxiliary Market Director to proceed to identify the farmer appropriately and request from the...

We designated and trained personnel to work with the bank statements to identify timely any voucher in which the farmer identifier is not stamped. In those cases, a copy of the voucher must be sent to the Auxiliary Market Director to proceed to identify the farmer appropriately and request from the farmer a certification attesting that he/she redeemed the voucher. Also, we instructed the Auxiliary Market Director to review all the farmer files to ensure they are completed and signed by the farmer and an Agency representative.

View Audit 8540

Finding 6598 (2022-003)

Significant Deficiency 2022

Sheboygan Senior Community, Inc.

WI

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Management will open a separate account and deposit the required funds as required by the loan resolutions.

View Audit 8533

Finding 6575 (2023-002)

Significant Deficiency 2022

Wind River Development Fund

WY

Reporting Internal Control / Segregation of Duties

WRDF will develop a new system for monitoring and tracking grant reporting requirements and deadlines. In addition, WRDF will utilize QuickBooks to track each grant, d~velop workflows to ensure that all deadlines are met, monitor its performance, and provide regular updates to its Board of Directors...

WRDF will develop a new system for monitoring and tracking grant reporting requirements and deadlines. In addition, WRDF will utilize QuickBooks to track each grant, d~velop workflows to ensure that all deadlines are met, monitor its performance, and provide regular updates to its Board of Directors.

View Audit 8520

Finding 6497 (2022-003)

Material Weakness 2022

Palo Alto County Hospital

IA

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Rural Communities Opioid Response Program – Medication Assisted Treatment (MAT) Expansion – Assistance Listing No. 93.912 Recommendation: We recommend that management implement more formal control process surrounding the use of federal awards where there is segregation between individuals identifyin...

Rural Communities Opioid Response Program – Medication Assisted Treatment (MAT) Expansion – Assistance Listing No. 93.912 Recommendation: We recommend that management implement more formal control process surrounding the use of federal awards where there is segregation between individuals identifying or proposing expenditures/uses of funds and an individual reviewing and approving that expenditure/use. We also recommend for any formal reporting required under federal awards that there be a formal review process where an individual is reviewing and approving the report who did not prepare the report. Documentation of review and approval should be retained in both cases. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Health System implemented a formal grant management policy in November 2022. Name(s) of the contact person(s) responsible for corrective action: Collette Johnson, CFO Planned completion date for corrective action plan: November 1, 2022

View Audit 8469

Finding 6496 (2022-002)

Significant Deficiency 2022

Ballet Hawaii

HI

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

Corrective actions: i. Documented approval of expenditures 1. Approval of expenditures will be documented and retained. 2. Responsible individuals: Kenny Lee (Treasurer), Shaina Gonsalves (Office Manager) 3. Anticipated completion date: June 30, 2024

View Audit 8468

Finding 6489 (2022-001)

None 2022

Puerto Aqueduct and Sewer Authority

PR

Reporting Internal Control / Segregation of Duties § 200.512

The Authority did not receive in a timely manner the information from the Employee Retirement System of the Commonwealth of Puerto Rico to properly recognize the pension liability, delaying the issuance of the financial statements. The Central Government, throughout the Department of Treasury has es...

The Authority did not receive in a timely manner the information from the Employee Retirement System of the Commonwealth of Puerto Rico to properly recognize the pension liability, delaying the issuance of the financial statements. The Central Government, throughout the Department of Treasury has established a task force in order to maximize the efforts to timely issue the actuarial valuation report from the Employee Retire System and the Audited Financial Statements of the Commonwealth of Puerto Rico, which will provide to the Authority with the corresponding information in a timely manner. Additionally, the Authority is not exempt of the lack of resources resulting in delays in the process. The Authority expects to issue and submit the 2023 financial statements and single audit reports by June 2024. For subsequent fiscal years the Authority expect to issue its financial statements and single audit reports, within the established due date.

View Audit 8449

Finding 6440 (2022-004)

Material Weakness 2022

Every Woman's Place

MI

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

Recommendation: The Organization should follow its cash disbursements policy to maintain invoices and have them approved by the appropriate levels of management prior to the issuance of checks. Action Taken: EWP has reviewed its current cash disbursement policy and re-implemented procedures to mai...

Recommendation: The Organization should follow its cash disbursements policy to maintain invoices and have them approved by the appropriate levels of management prior to the issuance of checks. Action Taken: EWP has reviewed its current cash disbursement policy and re-implemented procedures to maintain invoices and have them approved by the appropriate levels of management prior to the issuance of checks. Agency leadership staff have been reviewing allowable and unallowable costs to ensure accurate administration of awards. Responsible Person and Anticipated Completion Date: Executive Director, October 2023.

View Audit 8377 Questioned Costs: $1

Corrective Action Plans

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