Corrective Action Plans

Finding 19712 (2022-056)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding: The Department of Social and Health Services, Developmental Disabilities Administration, did not have adequate internal controls over and did not comply with requirements to ensure Medicaid payments to supported living providers were allowable and adequately supported. Questioned Costs:...

Finding: The Department of Social and Health Services, Developmental Disabilities Administration, did not have adequate internal controls over and did not comply with requirements to ensure Medicaid payments to supported living providers were allowable and adequately supported. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $237,404,150 Status: Corrective action not taken Corrective Action: The Department does not concur with the finding. The Department performed payment reconciliations, cost report reviews, and settlement assessments for all 140 cost reports received during the first half of fiscal year 2022 (July 1, 2021, through December 31, 2021). Of the cost reports received, 66 providers (47 percent) were subject to the Developmental Disabilities Administration (DDA) payroll verification review. The State Auditor?s Office (SAO) did not question any of the costs that were associated with the 66 providers. However, SAO is questioning all payments made to the 74 providers who did not receive a payroll verification review in the first half of the fiscal year. For the second half of the fiscal year (January 1, 2022, through June 30, 2022), even though the Department had the same internal controls in place, SAO asserted that every payment during this time frame was a questioned cost because the cost reports for calendar year 2022 had not yet been submitted for department review. The Department strongly disagrees that all these costs should be questioned. The Department reconciles payments on a calendar year basis, while SAO audits on a fiscal year basis and does not consider activities that fall outside of the audit period. The Developmental Disabilities Administration has numerous internal controls in place which provide sufficient assurance that the services paid for were provided. These include: ? Medicaid service verifications, ? Allowable costs payment reconciliations, ? Payroll verification processes, ? Review of rate payments and increases, ? Quality assurance reviews, ? Duplicate payment reports, ? Residential Care Services certification processes, ? Contract monitoring, ? Reconciliation processes for rates, cost reports, and settlements, ? Segregation of duties and other verification and approval processes. The Department strongly believes that its current oversight and monitoring procedures adequately confirm that services received by clients meet the certification standards for supported living providers. The Department continues its efforts to bring quality services to clients who receive habilitative residential support while following all program requirements, including reconciling the settlement amounts that were issued to providers in the cost report settlement process. Based on the information provided above, the Department maintains that the questioned costs for this audit finding are not substantiated. Unfortunately, SAO did not choose a more collaborative approach aimed at supporting the Department in its continuing quality improvement efforts. The Department continues to adjust its processes openly and appropriately as needed and remains open to partnering with SAO to resolve disagreements in this audit area and find common ground. The Department intends to send a request to the Centers for Medicare & Medicaid Services, through the audit resolution process, requesting the questioned costs reported by the SAO be rescinded. The conditions noted in this finding were previously reported in findings 2021-049, 2020-051, 2019-054, 2018-058, 2017-044, 2016-041, 2016-045, 2015-049, 2015-052, 2014-041, 2014-042, 2013-036, 2013-038 and 2012-039. The auditors determined findings 2016-041, 2015-052, 2014-041 and 2013-038 were resolved in fiscal year 2018. Completion Date: Not applicable Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

View Audit 23129 Questioned Costs: $1

Finding 19653 (2022-046)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Matching / Level of Effort / Earmarking Subrecipient Monitoring Internal Control / Segregation of Duties

Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with requirements to ensure potential child care fraud was correctly identified and reported for the Child Care and Development Fund Cluster. Questioned Costs: Assistance Listing ...

Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with requirements to ensure potential child care fraud was correctly identified and reported for the Child Care and Development Fund Cluster. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Status: Corrective action in progress Corrective Action: The Department concurs with the finding. As of January 2023: ? The Department updated the Barcode system algorithm to fix the improper scoring of the Fraud Early Detection (FRED) referrals. Referrals are now being scored, per the details of the algorithm, to include the additional four points for FRED referrals received from hotline calls. ? The Office of Fraud and Accountability sent a request to store the information for the prioritization tool to the Economic Services Administration, who maintains the Barcode system and server space. The Department anticipates the Barcode system will be updated and service space will be created by December 2023. Completion Date: Estimated December 2023 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

View Audit 23129

Finding 19633 (2022-025)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Finding: The Office of Superintendent of Public Instruction did not have adequate controls over and did not comply with requirements to ensure it met the earmarking requirements for the Special Education program. Questioned Costs: Assistance Listing # 84.027 84.027 COVID-19 84.173 Amount $18...

Finding: The Office of Superintendent of Public Instruction did not have adequate controls over and did not comply with requirements to ensure it met the earmarking requirements for the Special Education program. Questioned Costs: Assistance Listing # 84.027 84.027 COVID-19 84.173 Amount $188,873 Status: Corrective action complete Corrective Action: When the Special Education program underwent a fiscal leadership transition in 2021, the incoming director identified necessary changes in agency procedures for closing out the fiscal year for the program. Since that time, the Office has fully implemented internal controls to ensure spending plans do not exceed the maximum allowable amounts earmarked for administration and other state-level activities. The updated procedures require the director of Operations and the budget analyst to perform the following: ? Review criteria for spending plans at the beginning of the fiscal year. ? Review the Grant Award Notice and Grants to States Summary Table and Preschool Grants to States Summary Table. ? Review spending plans and update the maximum allowable amounts earmarked for administration and other state-level activities in the spending plan throughout the fiscal year. ? Meet weekly to review spending plans and update plans as requests are received. ? Review monthly expenditure reports during weekly meetings. These updated procedures have contributed to increased communication and partnership between the director of Operations and the budget analyst. These internal controls provide assurance that maximum allowable amounts earmarked for administration and other state-level activities will be in compliance with federal rules. The Office will consult with the federal grantor to discuss whether the questioned costs identified in the audit should be repaid. Completion Date: March 2023 Agency Contact: Tania May Assistant Superintendent, Special Education PO Box 47200 Olympia, WA 98504-7200 (360) 725-6075 tania.may@k12.wa.us

View Audit 23129 Questioned Costs: $1

Finding 19624 (2022-007)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.303 § 200.328

Finding: The Employment Security Department did not have adequate internal controls over and did not comply with requirements to ensure it submitted complete and accurate quarterly performance reports for the Workforce Innovation and Opportunity grant. Questioned Costs: Assistance Listing # ...

Finding: The Employment Security Department did not have adequate internal controls over and did not comply with requirements to ensure it submitted complete and accurate quarterly performance reports for the Workforce Innovation and Opportunity grant. Questioned Costs: Assistance Listing # 17.258 17.259 17.278 Amount $0 Status: Corrective action in progress Corrective Action: In response to the finding, the Department is in the process of developing a comprehensive system and set of protocols to strengthen internal controls over the completion and submission of quarterly performance reports for the Workforce Innovation and Opportunity Act (WIOA) grant. The Department: ? Executed a Workforce Integrated Technology Replacement Project that focuses on improving case management and data management internal controls. The Department estimates the project will be completed by December 2024. ? Initiated and is in the process of a statewide implementation of the U.S. Department of Labor (DOL) Quarterly Report Analysis data integrity and data quality internal controls system. The Department will: ? Continue to execute the Data Element Validation policy update for the Participant Individual Record Layout (PIRL) report per DOL expectations. ? Continue to provide technical assistance, training, and one-on-one coaching for the local areas, which cover WIOA Title I and WIOA Title III, PIRL reporting, data management, validation, quality, and integrity systems and processes. The conditions noted in this finding were previously reported in findings 2021-007 and 2020-012. Completion Date: Estimated December 2024 Agency Contact: Jay Summers External Audit Manager PO Box 9046 Olympia, WA 98507-9046 (360) 529-6718 Joshua.Summers@esd.wa.gov

View Audit 23129

Finding 16717 (2022-002)

Significant Deficiency 2022

Henry County

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Period of Performance § 200.1 § 200.303

FINDING 2022-002 Contact Person Responsible for Corrective Action: Debra G. Walker Contact Phone Number: 765-529-2800 Views of Responsible Official: We concur with the findings. Description of Corrective Action Plan: We have corrected and added the $47,363 to the expenditure report. Anticipated Comp...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Debra G. Walker Contact Phone Number: 765-529-2800 Views of Responsible Official: We concur with the findings. Description of Corrective Action Plan: We have corrected and added the $47,363 to the expenditure report. Anticipated Completion Date: Corrected on the March 2023 expenditure report.

View Audit 21367

Finding 16715 (2022-001)

Material Weakness 2022

Mount Ayr Community School District

IA

Internal Control / Segregation of Duties

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

View Audit 21350

Finding 16704 (2022-002)

Material Weakness 2022

Chippewa Hills School District

MI

Cash Management School Nutrition Programs Material Weakness

October 21, 2022 CORRECTIVE ACTION PLAN FINDING 2022-002 EXCESS FUND BALANCE IN FOOD SERVICE FUND (repeat comment) ? Material weakness in internal control/material noncompliance ? special tests and provisions. Over the 2022-2023 school year, the District will utilize the excess fund balance to impro...

October 21, 2022 CORRECTIVE ACTION PLAN FINDING 2022-002 EXCESS FUND BALANCE IN FOOD SERVICE FUND (repeat comment) ? Material weakness in internal control/material noncompliance ? special tests and provisions. Over the 2022-2023 school year, the District will utilize the excess fund balance to improve the quality of the food service program. Despite following the spend down plan submitted to the Department of Education last year, the District still has a food service balance that exceeds the allowable balance by $129,204. The food service department will use the excess balance to continue to offer more new food choices, and continue to improve the quality of the food served (including more fresh produce and better quality ingredients). These improvements will continue to be in conjunction with the Michigan Department of Education's Office of School Support Services which will again approve the spending plan. We will begin to implement this immediately

View Audit 21338

Finding 16689 (2022-003)

Significant Deficiency 2022

Tallahassee Housing Authority

FL

HUD Housing Programs Significant Deficiency Matching / Level of Effort / Earmarking

2022-003 Special Tests and Provisions ? Housing Quality Standards Section 8 Housing Voucher Cluster (Section 8): 14.871 Section 8 ? Housing Choice Vouchers 14.879 Mainstream Vouchers Significant Deficiency in Internal Control and Other Matter to be Reported Under the Uniform Guidance Condition: ...

2022-003 Special Tests and Provisions ? Housing Quality Standards Section 8 Housing Voucher Cluster (Section 8): 14.871 Section 8 ? Housing Choice Vouchers 14.879 Mainstream Vouchers Significant Deficiency in Internal Control and Other Matter to be Reported Under the Uniform Guidance Condition: Out of a total population of 166 failed inspections, 17 failed inspections were selected for testing in a statistically valid sample. Exceptions were noted as follows: ? 1 error where unit never passed inspection and the Authority continued to make HAP payments when the contract should have been abated. Recommendation: The Authority should more closely monitor failed inspections to make sure that any units that have not passed re-inspection are not issued HAP payments until all repairs are made, and the HAP contract is terminated for any unit for which the owner has not made repairs within the allowed timeframe. 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: The Authority concurs with this finding and will establish more review, oversight and training for the staff responsible for these procedures and assure that HAP payments are properly abated when repairs are not made within the required timeframes.

View Audit 21308

Finding 16688 (2022-002)

Significant Deficiency 2022

Tallahassee Housing Authority

FL

HUD Housing Programs Eligibility Significant Deficiency

2022-002 Eligibility ? Tenant Files Section 8 Housing Voucher Cluster (Section 8): 14.871 Section 8 ? Housing Choice Vouchers 14.879 Mainstream Vouchers Significant Deficiency in Internal Control and Other Matter to be Reported Under the Uniform Guidance Repeat finding from June 30, 2021 as Findin...

2022-002 Eligibility ? Tenant Files Section 8 Housing Voucher Cluster (Section 8): 14.871 Section 8 ? Housing Choice Vouchers 14.879 Mainstream Vouchers Significant Deficiency in Internal Control and Other Matter to be Reported Under the Uniform Guidance Repeat finding from June 30, 2021 as Finding 2021-001 (initially reported June 30, 2010) Condition: Out of a total tenant population of approximately 2,100 tenants, 25 files were selected for testing. Exceptions were noted as follows: ? 1 error where the wrong amount was used to calculate tenant?s wage income. This had no effect on HAP rent. ? 1 error where overtime earnings was not included in calculating tenant?s wage income. This caused HAP rent to decrease by $11. ? 1 error where the utility allowance was calculated incorrectly. This caused the HAP rent to decrease by $61. ? 1 error where the prior year utility allowance schedule was used instead of the current year. This had no effect on HAP rent. ? 1 error where adoption subsidy benefits were calculated incorrectly as well as the amount excluded from income. This decreased HAP rent by $9. ? 1 error where $1,753 in unreimbursed medical expenses was carried forward from the prior year 50058 and file had no support for any medical expenses in current year. This decreased HAP rent by $22 ? 1 error where there was no EIV report in file In addition to the above, we noted the following during our new admissions testing (21 new admissions tested): ? 1 error where there was no signed 214 affidavit in the file for one member of the household 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: The Authority concurs with this finding and has implemented a robust file review process, enhanced quality control procedures, and provided training on errors noted along with annual program training for all staff. The cited files were corrected.

View Audit 21308

Finding 16664 (2022-024)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions

Finding: The Charter School Commission did not have adequate internal controls over and did not comply with requirements to ensure charter schools with relationships to charter management organizations were monitored for conflicts of interest. Questioned Costs: Assistance Listing # 84.010 Am...

Finding: The Charter School Commission did not have adequate internal controls over and did not comply with requirements to ensure charter schools with relationships to charter management organizations were monitored for conflicts of interest. Questioned Costs: Assistance Listing # 84.010 Amount $0 Status: Corrective action complete Corrective Action: Although the Commission believes that a finding was not warranted, the Commission has begun implementing additional oversight requirements identified in the audit. As of May 2023, the Commission: ? Implemented a process to review all charter public school board members? F-1 Personal Financial Affairs Disclosure forms for potential conflict of interest using the Public Disclosure Commission (PDC) website. ? Required all charter public schools to submit each board member?s F-1 form to the Commission directly via the compliance software, Epicenter, as follows: o By April 15 of each year for current board members in alignment with the PDC?s annual submission deadline. o Within two weeks of appointment for new board members in alignment with PDC submission guidelines. The Commission created and will maintain a conflict-of-interest tracker, including dates forms are received, to ensure each board member?s potential conflict of interest is actively reviewed. The Commission will continue to work with the Office of Superintendent of Public Instruction (OSPI) on federal funding administered by OSPI and be informed of matters that may require additional actions by the Commission. Completion Date: May 2023 Agency Contact: Jessica de Barros Executive Director PO Box 40996 Olympia, WA 98501-0996 360-725-5511 charterschoolinfo@k12.wa.us

View Audit 23129

Finding 16663 (2022-023)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

Finding: The Office of Superintendent of Public Instruction did not have adequate internal controls over and did not comply with federal requirements to ensure Local Education Agencies implemented testing security measures. Questioned Costs: Assistance Listing # 84.010 Status: Corrective ac...

Finding: The Office of Superintendent of Public Instruction did not have adequate internal controls over and did not comply with federal requirements to ensure Local Education Agencies implemented testing security measures. Questioned Costs: Assistance Listing # 84.010 Status: Corrective action in progress Corrective Action: The Office monitors and ensures all Local Education Agencies (LEA) implement school testing security measures. All LEAs are required to submit a District Administration and Security Report (DASR) at the conclusion of the testing cycle to document the security training and that protocols have been followed. The Office will continue to communicate with LEAs to ensure they provide the DASR for all tests administered in the spring, as follows: ? Once per week for four weeks leading up to the end of the test administration window. ? Once per week for three weeks after the end of the test administration window. In August, the Office will receive the annual final list of all tests administered by each LEA and will be able to narrow its focus for sending out weekly reminders. If the Office has not received completed DASRs by mid-September, a management decision letter will be sent to the LEA?s Superintendent to inform them of the non-compliance and potential consequences as outlined in federal regulations. The conditions noted in this finding were previously reported in findings 2021-021 and 2020-026. Completion Date: Estimated October 2023 Agency Contact: Christopher Hanczrik Director, Assessment Operations and Select Assessments PO Box 47200 Olympia, WA 98504-7200 (360) 485-3580 Christopher.Hanczrik@k12.wa.us

View Audit 23129

Finding 16626 (2022-001)

Significant Deficiency 2022

Wake Forest University

NC

Questioned Costs Cash Management Eligibility § 200.303

Finding No. 2022-001: Allowability Corrective Action Planned The Uninsured Testing and Treatment Program ended as of March 31, 2022. As a result, Wake Forest has not implemented additional controls beyond the increased frequency at which we review accounts that are HRSA eligible and the increased ed...

Finding No. 2022-001: Allowability Corrective Action Planned The Uninsured Testing and Treatment Program ended as of March 31, 2022. As a result, Wake Forest has not implemented additional controls beyond the increased frequency at which we review accounts that are HRSA eligible and the increased education for our Financial Counseling Unit and Cash Control staff and leadership. In order to ensure compliance with future programs of this nature, Wake Forest will establish the controls necessary to review and monitor each account and ensure compliance is met with the program requirements. Each control will then be tested to ensure operating effectiveness.

View Audit 22102 Questioned Costs: $1

Finding 16624 (2022-001)

None 2022

13west 103rd Street CORP

NY

Questioned Costs Cash Management HUD Housing Programs

13 West 103rd Street Corporation 290 Lenox, 3rd Floor New York, NY 10027 AUDITEE?S CORRECTIVE ACTION PLAN Name and Number of Project 13 West 103rd Street Corporation, FHA Project Number 012-HD006 Auditor/Audit Firm PKF O?Connor Davies LLP Audit Period June 30, 2022 Finding 2022-001 ? Timely De...

13 West 103rd Street Corporation 290 Lenox, 3rd Floor New York, NY 10027 AUDITEE?S CORRECTIVE ACTION PLAN Name and Number of Project 13 West 103rd Street Corporation, FHA Project Number 012-HD006 Auditor/Audit Firm PKF O?Connor Davies LLP Audit Period June 30, 2022 Finding 2022-001 ? Timely Deposit of Surplus Cash A. Comments on Finding and Recommendations Recommendation ? We recommend that management ensures the surplus cash deposit is done timely in the future. B. Actions Taken or Planned Auditee agrees with this finding. Our policy has been to make surplus cash deposits after the final audit has been issued. Going forward our focus will be to work with the auditor and owner to get the audits finalized earlier so adequate time is left for the deposits to be made. In instances where the final is not going to be issued and allow enough time, the deposit will be made based on the reviewed draft. C. Status of Corrective Action on Prior Findings No prior findings. Ezra Miller, CFO

View Audit 21282

Finding 16551 (2022-002)

Material Weakness 2022

City of Sandusky

OH

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking § 200.302 § 200.328 § 200.329

All federal Project and Expenditure reports were filed timely and all actual expenditures were also reported correctly according to the report overview page. This finding deals with the body of the report which incorrectly listed the Justice Center Project twice, with the obligation amount of $880,0...

All federal Project and Expenditure reports were filed timely and all actual expenditures were also reported correctly according to the report overview page. This finding deals with the body of the report which incorrectly listed the Justice Center Project twice, with the obligation amount of $880,00 listed for the project. This duplicated project has been removed from future reports. The finding noted for $175,741, once again has all the correct totals in project overview report, which should be the summation of the report. We have been rehiring staff with American Rescue Plan funds since 2021, and this has been an ongoing project. Once again, the report overview page lists the correct expenditures, however the body of the report has the project listed twice. This duplicated project has been removed from future reports. The reporting software gives a total of expenditures before you hit submit on each report, this total has always displayed the correct cumulative expenditure total. If projects were entered twice, the total expenditures should of been over by these dollar amounts, and they were not.

View Audit 21781

Finding 16544 (2022-001)

Material Weakness 2022

Bonner General Hospital, Inc.

ID

Questioned Costs Material Weakness Reporting § 200.303

Finding 2022-001 Finding Summary: The Hospital excluded certain amounts from the amounts reported as "2021 actuals (Calendar Year)" patient care revenue within the Period 4 Department of Health and Human Services report submission process. Responsible Individuals: John Hennessy, CFO Corrective Acti...

Finding 2022-001 Finding Summary: The Hospital excluded certain amounts from the amounts reported as "2021 actuals (Calendar Year)" patient care revenue within the Period 4 Department of Health and Human Services report submission process. Responsible Individuals: John Hennessy, CFO Corrective Action Plan: The cause of the finding was due to management's review of the schedule did not identify that there was an adjustment to net patient revenue that was not incorporated within the 2021 actuals. Going forward, management will reconcile the internal generated financials used for quarterly reporting with the audited financials to ensure the schedule used includes all adjustments to net patient revenue. Anticipated Completion Date: September 28, 2023 Federal Agency Name: Department of Health and Human Services Program Name: COVJD-19 Provider Relief Funds and American Rescue Plan (ARP) Rural Distribution CFDA #93.498

View Audit 20452

Finding 16541 (2022-001)

Significant Deficiency 2022

Moka Corporation and Affiliate

MI

Procurement, Suspension & Debarment Cash Management Internal Control / Segregation of Duties

Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following are the findings as noted in MOKA Corporation and Affiliate's Single Audit report for the year ended September 30, 2022, and corrective actions to be completed. 2022-001 ?...

Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following are the findings as noted in MOKA Corporation and Affiliate's Single Audit report for the year ended September 30, 2022, and corrective actions to be completed. 2022-001 ? Written Policies and Procedures Required by the Uniform Grant Guidance Auditor Description of Condition and Effect. Although the Organization has processes in place to cover these areas, there are not formal written policies covering payments and allowability of costs charged to federal programs that address all of the areas required by the Uniform Guidance. As a result of this condition, the Organization did not fully comply with the Uniform Guidance. Auditor Recommendation. We recommend that the Organziation draft the required policies as soon as practical, but no later than the end of fiscal year 2023. Corrective Action. MOKA policies related to use and oversight of all funds available to the Organization will be reviewed and appropriate details included as needed to fully meet and comply with the Section 200.511 requirements. The adjustments to MOKA?s policies will be reviewed and completed prior to 9/30/2023. MOKA?s internal policy review structure will be followed to ensure ongoing compliance with these requirements. Responsible Person. Bryan Voss, Finance Director Anticipated Completion Date: September 30, 2023

View Audit 20448

Finding 16534 (2022-001)

Significant Deficiency 2022

Caritas Villa

OR

HUD Housing Programs Procurement, Suspension & Debarment Eligibility

Caritas Villa respectfully submits the following corrective action plan for the year ended June 30, 2022. Name & address of public accounting firm: Jones & Roth CPAs 260 Country Club Rd. Ste. 100 Eugene OR 97401 Audit Period: June 30, 2022 Major Federal Award Findings: Finding Reference #: 2022-001 ...

Caritas Villa respectfully submits the following corrective action plan for the year ended June 30, 2022. Name & address of public accounting firm: Jones & Roth CPAs 260 Country Club Rd. Ste. 100 Eugene OR 97401 Audit Period: June 30, 2022 Major Federal Award Findings: Finding Reference #: 2022-001 Significant deficiency Recommendation: We recommend management review the current internal control procedures and implement additional procedures to ensure annual recertifications are performed as required by HUD. Corrective Action: Management will work with Cascade Management to improve the internal control procedures to ensure annual recertifications are performed as required by December 31, 2022. Questions regarding this corrective action plan may be directed to Marci Pierce, Chief Financial and Administrative Officer, at (503) 688-2646.

View Audit 20424

Finding 16529 (2022-001)

Material Weakness 2022

Sea Mar Community Health Center and Subsidiaries

WA

Questioned Costs Special Tests & Provisions Material Weakness

Finding 2022-001 Sea Mar will retrain medical, dental and behavioral health department staff at all sites who conduct and/or oversee the patient registration and income verification process. This includes Health Center Administrators, Front Desk Supervisors, Dental Supervisors, Financial Specialist...

Finding 2022-001 Sea Mar will retrain medical, dental and behavioral health department staff at all sites who conduct and/or oversee the patient registration and income verification process. This includes Health Center Administrators, Front Desk Supervisors, Dental Supervisors, Financial Specialists and Receptionists. This training will be conducted via Relias (web-based training and testing). This training will be required for all staff including new hires to ensure compliance and consistency. A competency test will be administered after the training, which requires a score of I 00% to pass. If an employee does not pass the competency test, they will be retrained and will retake the test. We will track and run reports for all staff that are required to complete these tasks to ensure compliance. This log will demonstrate that staff at the sites were trained and have passed the competency test. Sea Mar will conduct an audit to determine the accuracy of income verifications. The audit will select a random sample of patients to test and verify accuracy and completeness. Sea Mar has set a goal to achieve accuracy percentage of 95%-100% and will conduct monthly audits to monitor accuracy and improvement. Sea Mar will also implement a process that will require supervisors to review and sign off on employee's income verifications to ensure they are accurate. Supervisors will be expected to ensure this process is being conducted accurately at their sites and to retrain staff who are not accurately verifying income. This review and sign off process will be verified during the quarterly audit. The quarterly audit will also identify sites and staff who need additional training. The contact person for the corrective action plan is Sea Mar's Chief Compliance Officer, Kristina Hoeschen, Kristina Hoeschen@seamarchc.org ,and the anticipated completion date of November 30, 2022.

View Audit 20416

Finding 16505 (2022-003)

Significant Deficiency 2022

Grand Rapids Christian Schools

MI

School Nutrition Programs Internal Control / Segregation of Duties Cash Management

#2022-003 - Significant Deficiency in Controls over Compliance: Lack of Review over Reporting Recommendations: We understand that many, if not all locations participating in the meal programs have since either reverted back to using the electronic system for counting students, or plan to do so in th...

#2022-003 - Significant Deficiency in Controls over Compliance: Lack of Review over Reporting Recommendations: We understand that many, if not all locations participating in the meal programs have since either reverted back to using the electronic system for counting students, or plan to do so in the near term. We recommend that any remaining manual reports/tally sheets be reviewed prior to submitting counts for reimbursement. Views of Responsible Officials and Planned Corrective Actions: ? Because student meals are no longer free in the 2022-23 school year, GRCS is returning to the electronic system for counting student meals.

View Audit 20389

Finding 16388 (2022-001)

None 2022

H.o.l.i.e. of Greenfield Avenue, Inc. - Valentino Square Apartments

WI

Questioned Costs HUD Housing Programs Reporting

Management increased the security deposit bank account by $500 on September 15, 2022 to correct this finding.

View Audit 19955

Finding 16325 (2022-005)

Significant Deficiency 2022

Moorhead Public Housing Agency

MN

Internal Control / Segregation of Duties Eligibility Significant Deficiency

Contact Person Dawn Bacon, Executive Director Corrective Action Plan Staff will perform quality control review for the Public and Indian Housing program. Going forward a sample of files will be reviewed on a semi-annual basis. Planned Completion Date for CAP FY2023

View Audit 23038

Finding 16323 (2022-004)

Material Weakness 2022

West Holt Memorial Hospital

NE

Special Tests & Provisions Questioned Costs Cash Management § 200.327 § 200.328

Criteria: The Hospital must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Hospital is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CF...

Criteria: The Hospital must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Hospital is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with program requirements. Terms and conditions of the federal award require the Hospital to maintain a reserve fund at specified balance levels. Condition: During 2022, the accounts that represented the reserve fund had a balance below that required by the loan resolution agreements and required deposits were not being made to restore the balances to required levels. Planned Corrective Action: Management agrees with the finding and will deposit required amounts into the reserve fund. Planned Completion Date: Ongoing Person Responsible: Jeremy Bauer, CEO

View Audit 22832

Finding 16320 (2022-005)

Material Weakness 2022

Town of Sullivan Sanitary District No. 1

WI

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

2022-005 Federal Procedure Manual Condition: Internal controls over federal grants should be in place to provide reasonable assurance that misstatement in the schedule of expenditures of federal awards would be prevented or detected. Criteria: Non-federal entities who receive federal or state gra...

2022-005 Federal Procedure Manual Condition: Internal controls over federal grants should be in place to provide reasonable assurance that misstatement in the schedule of expenditures of federal awards would be prevented or detected. Criteria: Non-federal entities who receive federal or state grants or have grant programs should have documented policies and procedures in place over grants and grant expenditures. Cause: The District does not have documented policies and procedures in place over grants and grant expenditures. Effect: Without documented policies and procedures, the internal control over federal grants is low, and the risk of misstatement in the schedule of expenditures of federal and state awards is high. Auditor's Recommendation: We recommend that the District works on written policies and procedures over grants and grant expenditures. Management Response: The District will work with their auditor to develop and adopt written grant procedures that are in accordance with the Uniform Guidance. Contact Person: Dawn Bauer Anticipated Completion: December 31, 2023

View Audit 22335

Finding 16319 (2022-004)

Material Weakness 2022

Town of Sullivan Sanitary District No. 1

WI

Internal Control / Segregation of Duties Reporting

2022-004 Drafting Schedule of Expenditures of Federal Awards and Related Notes Condition: Like other entities of similar size, the District requires the assistance of the auditor to prepare the schedule of expenditures of federal awards in accordance with the Uniform Guidance. Criteria: Internal co...

2022-004 Drafting Schedule of Expenditures of Federal Awards and Related Notes Condition: Like other entities of similar size, the District requires the assistance of the auditor to prepare the schedule of expenditures of federal awards in accordance with the Uniform Guidance. Criteria: Internal controls over preparation of the schedule of expenditures of federal awards should be in place to provide reasonable assurance that a misstatement in the schedule of expenditures of federal awards would be prevented or detected. Cause: Management relies on the auditor to assist with the preparation of the schedule of expenditures of federal awards. Effect: The District's system of internal control may not prevent, detect, or correct misstatements in the schedule of expenditures of federal awards. Auditor's Recommendation: The auditor will continue to work with the District, providing information and training when necessary, to make the District?s personnel more knowledgeable about its responsibility for the schedule of expenditures of federal awards. Management Response: The control deficiency has been discussed with the District?s Board and they acknowledge their responsibility for the schedule of expenditures of federal awards. The District accepts responsibility for the schedule of expenditures of federal awards. Due to the technical nature of preparing the schedule of expenditures of federal awards, and due to limited resources, the District does not anticipate the need for this assistance to change in the foreseeable future. Contact Person: Dawn Bauer Anticipated Completion: Not Applicable

View Audit 22335

Finding 16316 (2022-002)

Significant Deficiency 2022

Chisholm School District I-42

OK

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

Reference Number: 22-02 Name of Award ? Project Number (794, 628, 770) (Federal Findings) Condition/Finding: The District's final expenditure reports with the Oklahoma State Department of Education and Oklahoma Cost Accounting System (OCAS), did not match the actual allowable expense for their p...

Reference Number: 22-02 Name of Award ? Project Number (794, 628, 770) (Federal Findings) Condition/Finding: The District's final expenditure reports with the Oklahoma State Department of Education and Oklahoma Cost Accounting System (OCAS), did not match the actual allowable expense for their program. Three programs (794, 628, 770) had OCAS coding errors when final reports were submitted to the Oklahoma State Department of Education. Corrective steps that have already been implemented and/or the steps that will be implemented: All OCAS data, both receiving and expenditures, will be correct and accurate. All OCAS data involving Federal Programs will be reported correctly and accurately to the Oklahoma State Department of Education. Completion Date: Immediately The plan for monitoring adherence to the corrective action plan: All Chisholm Public Schools central office personnel involved with purchase orders, and OCAS data, will seek professional development and training to improve professionally. Additionally, all Chisholm Public Schools central office personnel will work collaboratively to ensure that all OCAS data is correct and accurate on an ongoing basis. Finally, all finalized OCAS data will be completely accurate when submitting to the Oklahoma State Department of Education. If warranted, reasons why the district does not consider a Corrective Action necessary. Superintendent's Signature Date

View Audit 21640

Corrective Action Plans

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