Corrective Action Plans

Finding 12114 (2022-001)

None 2022

Swedishamerican Health System Corporation

IL

Questioned Costs Reporting Internal Control / Segregation of Duties § 200.303

Corrective Action Plan For: SwedishAmerican Health System Finding number: 2022-001 Description of the finding: Amounts reported as eligible expenses in Reporting Period 2 were overstated by approximately $1,059,100. Corrective actions taken or planned: Lab expenses were erroneously duplicated d...

Corrective Action Plan For: SwedishAmerican Health System Finding number: 2022-001 Description of the finding: Amounts reported as eligible expenses in Reporting Period 2 were overstated by approximately $1,059,100. Corrective actions taken or planned: Lab expenses were erroneously duplicated due to using two sources for COVD-19 lab expenses ? 1) lab expenses internally charged to certain departments, and 2) a summary of lab expenses for all departments. This was discovered in April 2022, after Reporting Period 2 had closed on March 31, 2022. The reporting portal does not allow edits to a prior closed period; therefore, we assessed all received PRF funds against all uses of funds. Reporting Period 1 and 2 we only used expenses; however, we had lost revenue of approximately ($26,783,301) when comparing actual net revenues from April 1, 2020 to June, 30 2020, to the same period April 1, 2019 to June 30, 2019. When subtracting overstated lab expenses of $1,059,100 from Reporting Period 2, this leaves lost revenues of approximately ($25,724,223) to use in in future reporting periods. Reporting Period 3 and Reporting Period 4 we received funds of approximately $17,354,104 which is less than the remaining lost revenue of approximately ($25,724,223). Reporting Period 3 and Reporting Period 4 will only use lost revenues to justify the funds received. If we could correct reporting period 2 we would claim $1,059,100 against lost revenue and reduce the duplicated expense. However, if we receive funds for reporting periods after Reporting Period 4, we will deduct the excess expenses reported from lost revenues remaining to be claimed. Anticipated completion date: 4/18/2022 Person responsible for Corrective Action Plan: Patricia DeWane, CFO and Treasurer, (779) 696-4009 pdewane@uwhealth.org SwedishAmerican Health System, SwedishAmerican Hospital, DBA UW Health

View Audit 16158

Finding 12091 (2022-001)

Significant Deficiency 2022

Seven Hills Preparatory Academy Charter School No.4159

MN

Cash Management Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN (CAP): 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding Administration will ensure sufficient backup documentation is available. 3. Official Responsible for Ensuring CAP The Executive D...

CORRECTIVE ACTION PLAN (CAP): 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding Administration will ensure sufficient backup documentation is available. 3. Official Responsible for Ensuring CAP The Executive Director is responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP The planned completion date for the CAP is immediate. 5. Official Responsible for Ensuring CAP The Board of Education will be monitoring this CAP

View Audit 16152

Finding 11958 (2022-001)

Significant Deficiency 2022

Kent School District No. 415

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Questioned Costs

Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with requirements for time-and-effort documentation. Name, address, and telephone of District contact person: Benjamin Rarick, Associate Superintendent of Finance 12033 SE 256th...

Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with requirements for time-and-effort documentation. Name, address, and telephone of District contact person: Benjamin Rarick, Associate Superintendent of Finance 12033 SE 256th Kent, WA 98031 Corrective action the auditee plans to take in response to the finding: The Grants Administrator, under the supervision of the Director of Budget, will do interim and year-end reviews to identify any instances of positions funded by multiple federal funding sources for the purpose of assessing applicability of multi-cost objective T&E requirements and following through as appropriate. The Grants Administrator, under the supervision of the Director of Budget, and in collaboration with the program administrator, will initiate time & effort documentation in every case where there is debatable fact pattern, with the intent of adopting an “abundance of caution” approach to T&E, and will additionally seek written clarification from OSPI and/or the ESD in instances where T&E requirements are not dispositive from the relevant federal compliance supplements and guidance documents. Anticipated date to complete the corrective action: October, 2024

View Audit 15931

Finding 11949 (2022-003)

Material Weakness 2022

Hope for Prisoners, Inc.

NV

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

HFP Views of Responsible Oﬃcials - Hope for Prisoners’ CEO presently reviews and approves all RFR forms in writing prior to submission. Oversight by speciﬁc board members will be provided through a review of the submitted RFR to compare it to the monthly ﬁnancial reports already being provided.

View Audit 15910

Finding 11948 (2022-002)

Material Weakness 2022

Hope for Prisoners, Inc.

NV

Reporting Internal Control / Segregation of Duties

HFP Views of Responsible Oﬃcials - Management has since created a standard operating procedure that requires program personnel to properly complete and document quality control reviews over client ﬁles. Hope for Prisoners performs client ﬁle quality control reviews through a peer-to-peer review proc...

HFP Views of Responsible Oﬃcials - Management has since created a standard operating procedure that requires program personnel to properly complete and document quality control reviews over client ﬁles. Hope for Prisoners performs client ﬁle quality control reviews through a peer-to-peer review process performed by career coaches as well as through a review by the Organization’s Program Support Specialist. The Program Support Specialist’s main job function is the performance of quality control reviews of all client ﬁles. Both of these reviews ensure that quality control checklists are being properly completed and maintained in all client ﬁles.

View Audit 15910

Finding 11887 (2022-002)

Material Weakness 2022

Sabine Parish Police Jury

LA

Subrecipient Monitoring Internal Control / Segregation of Duties

The Sabine Parish Police Jury no longer participates in programs funded the Workforce Innovation and Opportunity (WIOA) Cluster. No further corrective action is considered necessary. William Weatherford, Secretary Treasurer is responsible for implementing and overseeing corrective action and he can ...

The Sabine Parish Police Jury no longer participates in programs funded the Workforce Innovation and Opportunity (WIOA) Cluster. No further corrective action is considered necessary. William Weatherford, Secretary Treasurer is responsible for implementing and overseeing corrective action and he can be reached at 318.256.5637.

View Audit 15780

Finding 11850 (2022-002)

Significant Deficiency 2022

Grady Memorial Hospital Corporation

GA

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

Grady’s corrective action plan: Grady Memorial Hospital Corporation will implement the control and process of completing an attestation assuring compliance with the review of the PRF data in the HRSA portal prior to submission. The review was completed online at the time of the submission but was no...

Grady’s corrective action plan: Grady Memorial Hospital Corporation will implement the control and process of completing an attestation assuring compliance with the review of the PRF data in the HRSA portal prior to submission. The review was completed online at the time of the submission but was not formally documented. This will be done and retained by Grady as support going forward

View Audit 15702

Finding 11779 (2022-002)

Material Weakness 2022

Inner City Health Center

CO

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

2022-002 Federal Program: COVID-19: FY 2020 Health Center Program Look-Alikes: Expanding Capacity for Coronavirus Testing and COVID-19: American Rescue Plan Act Funding for Look-Alikes – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization review its inter...

2022-002 Federal Program: COVID-19: FY 2020 Health Center Program Look-Alikes: Expanding Capacity for Coronavirus Testing and COVID-19: American Rescue Plan Act Funding for Look-Alikes – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization review its internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will review our procedures for ensuring that sliding fee applications are completed accurately and are properly placed in patient files. We will also research and implement safeguards to ensure that the revised procedures are being followed throughout the year, potentially including audits and additional staff training. This will be performed by Andrea Cortez, Chief Operating Officer, Karina Villagrana, Practice Manager, and Andrew Shahidi, Chief Financial Officer in the next 45 days. If during this process we determine that an update, revision, or re-write of the current Sliding Fee Policy is required, we will do so and it will be submitted to the Board of Directors for approval at the March 27, 2024 meeting.

View Audit 15612

Finding 11771 (2022-004)

Significant Deficiency 2022

Family First Health Corporation

PA

Questioned Costs Reporting Significant Deficiency

Audit Finding Reference: 2022-004 Planned Corrective Action: Procedures will be put in place to review accuracy of reporting prior to submission. Completion Date: 3/31/2024 Accounting Name of Contact Person: Jenny Englerth, President/CEO; Brent Doores, CFO

View Audit 15598

Finding 11733 (2022-003)

Material Weakness 2022

Centro De Servicio A La Juventud, Inc.

PR

Material Weakness Reporting Internal Control / Segregation of Duties

Statement of Condition: Form 990 is an annual information return required to be filed with the IRS by most organizations exempt from income tax under section 501(c)(3). The form must be completed by all filing organizations and requires reporting on the organization’s exempt and other activities, fi...

Statement of Condition: Form 990 is an annual information return required to be filed with the IRS by most organizations exempt from income tax under section 501(c)(3). The form must be completed by all filing organizations and requires reporting on the organization’s exempt and other activities, finances, governance, compliance with certain federal tax filing and requirements, and compensation paid to certain persons. Correction Action Planned for 2022-003 The internal accounting control was revised to prepare consolidated financial statements to prepare and submit the Form 990 on time on time. As of Today, CSJ filed all the Form 990 due. Responsable Person: Jean Carlos García Rosa Anticipated Completion Date On or before the end of fiscal year 2022-2023

View Audit 15533

Finding 11724 (2022-001)

Significant Deficiency 2022

Historicorps

CO

Internal Control / Segregation of Duties Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

This finding was disclosed in Fall 2023. Upon disclosure, new procedures were implemented for payroll review. Upon completion of payroll by ABC Accounting and Bookkeeping, a review is completed by a second member of the ABC Accounting and Bookkeeping team and/or the HistoriCorps Executive Director...

This finding was disclosed in Fall 2023. Upon disclosure, new procedures were implemented for payroll review. Upon completion of payroll by ABC Accounting and Bookkeeping, a review is completed by a second member of the ABC Accounting and Bookkeeping team and/or the HistoriCorps Executive Director.

View Audit 15530

Finding 11599 (2022-004)

Significant Deficiency 2022

Carroll County School District

MS

Procurement, Suspension & Debarment Allowable Costs / Cost Principles School Nutrition Programs

District will implement internal controls and procedures to ensure all expenditures are properly authorized and only paid after sufficient documentation has been received to ensure all the goods and services have been received by the school district.

View Audit 15449

Finding 11597 (2022-007)

Significant Deficiency 2022

Central Consolidated School District

NM

Internal Control / Segregation of Duties Questioned Costs

Review the students' files and update PowerSchool to make the necessary corrections as needed. Student Support Services Department provides reports with due dates to Case Managers for verification. Student Services Department reviews if changes are needed.

View Audit 15407 Questioned Costs: $1

Finding 11596 (2022-009)

Material Weakness 2022

Central Consolidated School District

NM

Equipment & Real Property Management Questioned Costs Procurement, Suspension & Debarment

The Finance Grants department along with the Federal Programs department have discovered the need to add additional approver to include Federal Programs Coordinator and/or Federal Programs Specialist in requisition process of all purchases involving federal funds. This adjustment in the approval pro...

The Finance Grants department along with the Federal Programs department have discovered the need to add additional approver to include Federal Programs Coordinator and/or Federal Programs Specialist in requisition process of all purchases involving federal funds. This adjustment in the approval process will assist in catching all needed documentation required for accurate justification and federal compliance. Grants Staff to seek training in purchasing capital assets using grant funds. In addition, verify items that cost over 5k and to make sure there is a 5k equipment form completed/signed and approved by PED and have it attached to the requisition.

View Audit 15407 Questioned Costs: $1

Finding 11520 (2022-001)

Significant Deficiency 2022

La Jolla Music Society

CA

Questioned Costs Reporting Significant Deficiency

Corrective Action Plan for La Jolla Music Society Audit Finding 2022-001 Finding No. 2022-001 – LJMS did not have policies in place to ensure the single audit was submitted timely (See Corrective Action Plan for La Jolla Music Society) Criteria – 45 CFR 75.501 requires a non-Federal entity that expe...

Corrective Action Plan for La Jolla Music Society Audit Finding 2022-001 Finding No. 2022-001 – LJMS did not have policies in place to ensure the single audit was submitted timely (See Corrective Action Plan for La Jolla Music Society) Criteria – 45 CFR 75.501 requires a non-Federal entity that expends $750,000 or more during the non_x0002_Federal entity’s fiscal year in Federal awards must have a single or program-specific audit conducted for that year. Audits must be completed and submitted within 30 days after receipt of the auditor’s report, or 9 months after the end of the audit period, whichever is earlier. Condition/Context – LJMS did not submit a single audit in a timely manner to be in compliance with the audit requirement under 45 CFR 75.501. LJMS did not meet its reporting deadline. Cause – LJMS was unable to meet the deadline due to certain delays in becoming aware of the compliance requirement. Effect – Audit was not performed and submitted in a timely manner. LJMS has not met the reporting requirements under 45 CFR 75.501. Recommendation – We recommend that LJMS obtain a single audit for each year that it meets the audit requirement of 45 CFR 75.501. Corrective Action Plan- LJMS will identify grants with federal funding and evaluate whether or not a single audit is required. When an audit is required they will plan to complete the audit within the deadline. The September 30, 2022 audit and Data Collection Form will be filed within 30 days of issuance of the report. Contact Person: Karin Burns, Director of Finance Anticipated Completion: February 28, 2024

View Audit 15360

Finding 11431 (2022-009)

Significant Deficiency 2022

St. Vincent De Paul Village, Inc.

CA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.430

Corrective Action: Management, in the immediate term, will review its oversight and controls on the manual process Grants Accounting implemented for obtaining Time & Allocation Excel Sheet and calculating payroll and benefits costs accurately onto the Request for Reimbursement (RFR). Furthermore, ma...

Corrective Action: Management, in the immediate term, will review its oversight and controls on the manual process Grants Accounting implemented for obtaining Time & Allocation Excel Sheet and calculating payroll and benefits costs accurately onto the Request for Reimbursement (RFR). Furthermore, management plans to collaborate with its Payroll Service Provider to capitalize on software upgrades, aiming to enhance the accuracy of Time & Allocation to grants and reduce errors by designing straight-through-process improvements. Name of Responsible Individual(s): Jason Brenier, CFO Anticipated Completion Date: April 2024

View Audit 15308

Finding 11293 (2022-006)

Material Weakness 2022

Practical Farmers of Iowa

IA

Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Recommendation: We recommend the Organization implement documented reviews for all reports prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Practical Famers of Iowa has hired a new Grants Finan...

Recommendation: We recommend the Organization implement documented reviews for all reports prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Practical Famers of Iowa has hired a new Grants Finance Manager in August 2023. This was a new hire and new position within PFI. With the ability of the new accounting software to build budgets, apply expenses and deposits to specific grants and monitor reporting it required a Grants Finance Manager to assist with monitoring of this information. With the additional hire of the Grants Finance Manager, proper approval processes throughout all expenditures and deposits, it allows for accurate filing to be consistent from the start. Each grant has a grant owner, Heather Brown, Grants Finance Manager, builds the approved budget that was previously approved by Executive Staff, Sally Worley, Alisha Bowers, Kasey Bunce, Sarah Carlson and Christine Zrostlik. Name(s) of the contact person(s) responsible for corrective action: Sally Worley, Executive Director, Kasey Bunce, Finance Director, Chastity Schonhorst Finance Coordinator, Alisha Bower, Senior Operations Director, Sarah Carlson, Senior Program & Member Engagement Director, and Christine Zrostlik, Marketing & Communications Director. Planned completion date for corrective action plan: This has already been implemented as of August, 2023.

View Audit 15127

Finding 11292 (2022-005)

Significant Deficiency 2022

Practical Farmers of Iowa

IA

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303

Recommendation: We recommend the Organization review their policies and procedures to ensure reimbursement requests are properly supported before submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Practical Famers of Iowa has hired a new Gran...

Recommendation: We recommend the Organization review their policies and procedures to ensure reimbursement requests are properly supported before submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Practical Famers of Iowa has hired a new Grants Finance Manager in August 2023. This was a new hire and new position within PFI. With the ability of the new accounting software to build budgets, apply expenses and deposits to specific grants and monitor reporting it required a Grants Finance Manager to assist with monitoring of this information. With the additional hire of the Grants Finance Manager, proper approval processes throughout all expenditures and deposits, it allows for accurate filing to be consistent from the start. Each grant has a grant owner, Heather Brown, Grants Finance Manager, builds the approved budget that was previously approved by Executive Staff, Sally Worley, Alisha Bowers, Kasey Bunce, Sarah Carlson and Christine Zrostlik. Name(s) of the contact person(s) responsible for corrective action: Sally Worley, Executive Director, Kasey Bunce, Finance Director, Chastity Schonhorst Finance Coordinator, Alisha Bower, Senior Operations Director, Sarah Carlson, Senior Program & Member Engagement Director, and Christine Zrostlik, Marketing & Communications Director. Planned completion date for corrective action plan: This has already been implemented as of March, 2023.

View Audit 15127 Questioned Costs: $1

Finding 11291 (2022-004)

Material Weakness 2022

Practical Farmers of Iowa

IA

Questioned Costs Cash Management Period of Performance § 200.303

Recommendation: We recommend the Organization implement a process to evaluate if expenses are eligible for reimbursement during the grant period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As mentioned above w...

Recommendation: We recommend the Organization implement a process to evaluate if expenses are eligible for reimbursement during the grant period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As mentioned above with the implementation of our new accounting software in March 2023, it allows for expenses and payments to be allocated to each grant as intended and drawn down specifically to that grant. In doing this, it allows for constant and consistent tracking for live to date tracking and allows for revenue and expenses to be reviewed and reported at any point in time. In allowing for constant tracking of this information it allows us to send out monthly and/or quarterly invoices for reimbursement from our grantors. Name(s) of the contact person(s) responsible for corrective action: Sally Worley, Executive Director, Kasey Bunce, Finance Director, Chastity Schonhorst Finance Coordinator, Alisha Bower, Senior Operations Director, Sarah Carlson, Senior Program & Member Engagement Director, and Christine Zrostlik, Marketing & Communications Director. Planned completion date for corrective action plan: This has already been implemented as of March, 2023.

View Audit 15127 Questioned Costs: $1

Finding 11260 (2022-003)

Material Weakness 2022

Pittsfield Housing Authority

RI

Questioned Costs Eligibility HUD Housing Programs

2022-003 – Eligibility Rent Calculations – ALN#14.850 – Public & Indian Housing The finding of missing income verifications for eligibility and recertification rent calculations is being addressed as part of a holistic review under the Recovery Agreement of Federal Public Housing program compliance,...

2022-003 – Eligibility Rent Calculations – ALN#14.850 – Public & Indian Housing The finding of missing income verifications for eligibility and recertification rent calculations is being addressed as part of a holistic review under the Recovery Agreement of Federal Public Housing program compliance, including an update to the Admissions and Continued Occupancy Policy (ACOP), retraining for all Public Housing staff and implementation of initial and recertification checklists as well as regular QC audits. Planned Implementation Date of Corrective Action Reminders to Staff regarding appropriate verification of all income: Completed Updates to Section 8 Administrative Plan and ACOP: 12/31/23 Retraining of staff, checklists and QC audit procedures: 6/30/24 Person(s) Responsible for Corrective Actions: Paul Dettman, PHA Consultant Tracy Pero, Section 8 Staff Leased Housing Program Manager Senior Public Housing Manager

View Audit 15062

Finding 11259 (2022-002)

Material Weakness 2022

Pittsfield Housing Authority

RI

HUD Housing Programs Questioned Costs Special Tests & Provisions

2022-002–Rent Reasonableness Determination–ALN14.871– Housing Voucher Cluster Effective 3/3/23, PHA switched from manual calculations of rent reasonableness to a web-based Rental Reasonableness software designed to meet HUD standards. Rent reasonableness determinations are now being made for all par...

2022-002–Rent Reasonableness Determination–ALN14.871– Housing Voucher Cluster Effective 3/3/23, PHA switched from manual calculations of rent reasonableness to a web-based Rental Reasonableness software designed to meet HUD standards. Rent reasonableness determinations are now being made for all participants prior to initial HAP contract execution and in conjunction with any requested rent increases. Planned Implementation Date of Corrective Action Reminders to Staff regarding appropriate verification of all income: Completed Updates to Section 8 Administrative Plan and ACOP: 12/31/23 Retraining of staff, checklists and QC audit procedures: 6/30/24 Person(s) Responsible for Corrective Actions Paul Dettman, PHA Consultant: Tracy Pero, Section 8 Staff Leased Housing Program Manager Senior Public Housing Manager

View Audit 15062 Questioned Costs: $1

Finding 11258 (2022-001)

Material Weakness 2022

Pittsfield Housing Authority

RI

HUD Housing Programs Questioned Costs Eligibility

2022-001 – Eligibility Rent Calculations –ALN#14.871 – Housing Voucher Cluster The finding of missing income verifications for eligibility and recertification rent calculations is being addressed as part of a holistic review under the Recovery Agreement of Section 8 program compliance, including an ...

2022-001 – Eligibility Rent Calculations –ALN#14.871 – Housing Voucher Cluster The finding of missing income verifications for eligibility and recertification rent calculations is being addressed as part of a holistic review under the Recovery Agreement of Section 8 program compliance, including an update to the Section 8 Administrative Plan, retraining for all Section 8 staff and implementation of initial and recertification checklists as well as regular QC audits. Planned Implementation Date of Corrective Action Reminders to Staff regarding appropriate verification of all income: Completed Updates to Section 8 Administrative Plan and ACOP: 12/31/23 Retraining of staff, checklists and QC audit procedures: 6/30/24 Person(s) Responsible for Corrective Actions: Paul Dettman, PHA Consultant Tracy Pero, Section 8 Staff Leased Housing Program Manager Senior Public Housing Manager

View Audit 15062

Finding 11225 (2022-001)

Significant Deficiency 2022

Adults and Youth United Development Association. INC

TX

Material Weakness Reporting Internal Control / Segregation of Duties

Objective: Ensure timely and accurate payment of payroll taxes to comply with legal requirements and avoid penalties.

View Audit 15012

Finding 11225 (2022-001)

Significant Deficiency 2022

Adults and Youth United Development Association. INC

TX