Corrective Action Plans

Finding 387006 (2022-004)

Material Weakness 2022

Workforce Development Board Work4wv Region 1, Inc.

WV

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.303 § 200.309

2022-004 Period of Performance U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement internal controls and policies to ensure that supporting documentation is maintained for all transactions, and that a member of management who...

2022-004 Period of Performance U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement internal controls and policies to ensure that supporting documentation is maintained for all transactions, and that a member of management who is knowledgeable of the period of performance is reviewing and approving all transactions prior to payment. Action Taken: For each accounting procedure, internal controls have been put in place. The Board’s payroll processing goes through three levels of approval before it is processed. The expenditures process goes through three levels of approval before the bill is paid. The Board is verifying that each report or process is approved by at least three levels of approval and within a timely manner. Expenditure checks are issued every two weeks. The approval of these checks is also approved by an officer of the Board of Directors. Any out of the ordinary practices have both the approval of the Executive Director and an officer of the Board of Directors. With the past issues of this Board, the Board added an internal control for the sake of period of performance, for reports that are submitted to Workforce WV. In addition, these reports will be reviewed and approved by one of the managers of the Board within the time the report is due.

View Audit 299381 Questioned Costs: $1

Finding 387005 (2022-003)

Material Weakness 2022

Workforce Development Board Work4wv Region 1, Inc.

WV

Matching / Level of Effort / Earmarking § 200.303

2022-003 Earmarking U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement controls and procedures to ensure that all requirements for earmarking within the Uniform Guidance are properly followed. Action Taken: The Board will c...

2022-003 Earmarking U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement controls and procedures to ensure that all requirements for earmarking within the Uniform Guidance are properly followed. Action Taken: The Board will create a spreadsheet that shows the earmarking percentage for each category. The Board will review various reports for each funding stream at month end and record the actual earmarking percentage for each month. With this information, the Board will discuss these percentages at the monthly manager’s meeting, budget meeting and Board of Directors meeting. If a plan of action is needed, a plan of action will be developed. Also, Workforce WV has a software system that takes the expenditures reported for each funding stream, for each month, called the MACC report in which each Region completes a report that will verify which percentages are not in compliance.

View Audit 299381

Finding 387004 (2022-002)

Material Weakness 2022

Workforce Development Board Work4wv Region 1, Inc.

WV

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.403

2022-002 Activities Allowed or Unallowed U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all charges to federal programs are adequately reviewed and approved prior to payment, and that a...

2022-002 Activities Allowed or Unallowed U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all charges to federal programs are adequately reviewed and approved prior to payment, and that adequate supporting documentation for all federal program charges is maintained. Action Taken: The Board is taking adequate action to review and approve all charges to the federal programs. The Board’s steps have been reviewed with Workforce WV and has been approved our procedures. Supporting documentation is kept both in physical and electronic forms. Each check the Board distributes has an approved purchase order attached, (if applicable), invoice, or if it is a monthly recurring charge, statement or bill attached and once the bill is entered into our system and the bill is paid, the check has the Executive Director’s initials and date showing it is approved in our accounting system. Also, if the expenditures are questionable, we will receive approval before submission of the bill from our liaison in the Workforce WV office.

View Audit 299381 Questioned Costs: $1

Finding 386603 (2022-002)

Significant Deficiency 2022

Barrio Logan College Institute

CA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

Finding 2022-002 – Reporting – Significant Deficiency in Internal Controls Over Compliance Recommendation We recommend that the Organization set a timeline for closing the books, preparing audit schedules and conducting the audit so the audit can be completed timely. Management should ensure that ...

Finding 2022-002 – Reporting – Significant Deficiency in Internal Controls Over Compliance Recommendation We recommend that the Organization set a timeline for closing the books, preparing audit schedules and conducting the audit so the audit can be completed timely. Management should ensure that all involved in the audit process have adequate capacity, are aware of the deadlines and commit to them. Action to be Taken Barrio Logan College Institute agrees with the finding. We are committed to getting the single audit completed on time. A plan for August 31, 2023 audit has been developed and will begin in February 2024 and is expected to be completed before the deadline in 45 CFR 75.501.

View Audit 298911

Finding 386438 (2022-004)

Significant Deficiency 2022

Elkhart and St. Joseph Counties Head Start Consortium

IN

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.303

Finding 2022-004 – Head Start Cluster – Reporting Contact Person Responsible for Corrective Action: Brenda Overton Contact Phone Number: 574.393.5866 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all required federal reports h...

Finding 2022-004 – Head Start Cluster – Reporting Contact Person Responsible for Corrective Action: Brenda Overton Contact Phone Number: 574.393.5866 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all required federal reports have a documented, formal review of the reports before they are submitted to ensure the information submitted is accurate Anticipated Completion Date: April 2024

View Audit 298779

Finding 386434 (2022-002)

Material Weakness 2022

Elkhart and St. Joseph Counties Head Start Consortium

IN

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

Finding 2022-002 – Head Start Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Brenda Overton Contact Phone Number: 574.393.5866 Views of Responsible Official: We concur with the finding. Description of Corrective Act...

Finding 2022-002 – Head Start Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Brenda Overton Contact Phone Number: 574.393.5866 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all vouchers are reviewed by a secondary individual, all supporting backup is maintained for each claim, and all payroll amounts agree to approved contracts. Anticipated Completion Date: April 2024

View Audit 298779 Questioned Costs: $1

Finding 385644 (2022-007)

Material Weakness 2022

Greenfield Exempted Village School District

OH

Matching / Level of Effort / Earmarking Subrecipient Monitoring Cash Management

In this audit period the requirement for paying the prevailing wage was new and we have taken steps to ensure compliance. Even though both contractors paid prevailing wages, it was not in the written contracts.

View Audit 298366

Finding 384940 (2022-001)

Significant Deficiency 2022

Central College

IA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

Central College respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Forge Financial and Management Consulting, Inc. 1245 Jordan Creek Parkway West Des Moines, IA 50266 Audit period" 7/1/2021-6/30/2022 The...

Central College respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Forge Financial and Management Consulting, Inc. 1245 Jordan Creek Parkway West Des Moines, IA 50266 Audit period" 7/1/2021-6/30/2022 The findings for the June 30, 2022 schedule of findings are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Finding 2022-001 - Late Disbursement of PLUS Loan Funds Recommendation: We recommend the College evaulate its procedures for disbursing SFA funds and implement changes to verify correct documentation is obtained. Views of Responsible Officials and Planned Corrective Actions: College will begin to utilize functionality within Colleague ERP to track new PLUS loan applications. New applications will be entered into Colleague by financial aid and visable to the business office. The new applications will be reviewed and credit balances will be issued to the parent or student as outlined in the application. This process will be completed weekly by the business office to ensure that all credit balances are distributed in the required timeframe. Anticipated Completion Date: January 26, 2024. If the Department of Education has questions regarding this plan, please call Karen Tumlinson, Vice President for Finance and Administration at (641) 628-5276.

View Audit 297980

Finding 384783 (2022-003)

Significant Deficiency 2022

Arizona Health Care Association, Inc.

AZ

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Significant Deficiency § 200.303 § 200.430

Coronavirus State and Local Fiscal Recovery Funds _ Assistance Listing No. 21.027 Recommendation: We recommend that the Association adopt a formal policy for tracking employee time and effort supporting grant expenses. Additionally, management should summarize the actual time employees spend on gran...

Coronavirus State and Local Fiscal Recovery Funds _ Assistance Listing No. 21.027 Recommendation: We recommend that the Association adopt a formal policy for tracking employee time and effort supporting grant expenses. Additionally, management should summarize the actual time employees spend on grant award programs and adjust the budgeted cost allocations to reflect the actual time spent. A second person knowledgeable of grant award requirements should review the time and effort summaries for proper completion and recording. This will help ensure that internal contols over compliance are established and will help ensure that cost charged to grant award programs are supported and allowable. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Staff now complete a Time and Effort Certification form from the State of Arzona for each pay period to reflect time spent on each grant. Name(s) of the contact person(s) responsible for corrective action: Frank Caruso, Director of Finance and Operations. Planned completion date for corrective action plan: Already corrected, January 2023.

View Audit 297894

Finding 384590 (2022-003)

Significant Deficiency 2022

Family Service Association of Howard County

IN

Equipment & Real Property Management Procurement, Suspension & Debarment Significant Deficiency § 200.303 § 200.313

Significant Deficiency in Internal Control Over Compliance and Noncompliance – F. Equipment and Real Property Management Recommendation: The Auditor recommends FSA implement procedures to ensure equipment and real property purchased with federal funding is appropriately capitalized and tracked. Pl...

Significant Deficiency in Internal Control Over Compliance and Noncompliance – F. Equipment and Real Property Management Recommendation: The Auditor recommends FSA implement procedures to ensure equipment and real property purchased with federal funding is appropriately capitalized and tracked. Planned Corrective Actions: Family Service Association of Howard County Inc. (FSA) will implement procedures to ensure equipment and real property purchased with federal funding is appropriately capitalized and tracked beginning April 2024.

View Audit 297675

Finding 384385 (2022-017)

Significant Deficiency 2022

The City of Frederick, Maryland

MD

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking

Moving forward, email correspondence used in the approval process shall be maintained by Weinberg Center management in the same manner as physical invoices or timesheets.

View Audit 297486

Finding 384374 (2022-006)

Significant Deficiency 2022

The City of Frederick, Maryland

MD

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Significant Deficiency

Staff allocations are reviewed regularly to ensure they are based on work assignments. We are now tracking changes to allocations for historical reference.

View Audit 297486

Finding 384187 (2022-008)

Significant Deficiency 2022

College Unbound

RI

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

Finding number: 2022-008 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.268 Award year: 2022 Corrective Action Plan: College Unbound has implemented the process of monthly reconciliation for Pell and Direct Loans. This process beg...

Finding number: 2022-008 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.268 Award year: 2022 Corrective Action Plan: College Unbound has implemented the process of monthly reconciliation for Pell and Direct Loans. This process began in Spring 2023. The issues identified in this finding were resolved by the school in advance of the audit, although we agree that it was not in a timely manner. Timeline for Implementation of Corrective Action Plan: Completed Contact Person: Diana Perdomo, CFO

View Audit 297283

Finding 384185 (2022-007)

Material Weakness 2022

College Unbound

RI

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Finding number: 2022-007 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 and 84.268 Award year: 2022 Corrective Action Plan: College Unbound hired an experienced Registrar in late spring 2022. They have implemented the process ...

Finding number: 2022-007 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 and 84.268 Award year: 2022 Corrective Action Plan: College Unbound hired an experienced Registrar in late spring 2022. They have implemented the process of monthly reporting to the Clearinghouse, including reviewing reports for accuracy. Timeline for Implementation of Corrective Action Plan: Completed Contact Person: Diana Perdomo, CFO

View Audit 297283

Finding 384183 (2022-005)

Significant Deficiency 2022

College Unbound

RI

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

Finding number: 2022-005 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.268 Award year: 2022 Corrective Action Plan: College Unbound previously contracted with a third party to process T4 funds, including a review of this process....

Finding number: 2022-005 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.268 Award year: 2022 Corrective Action Plan: College Unbound previously contracted with a third party to process T4 funds, including a review of this process. We have brought it in house as of FY24. Timeline for Implementation of Corrective Action Plan: Ongoing. Started 8/22/23, fully implemented by the end of FY24. Contact Person: Diana Perdomo, CFO

View Audit 297283

Finding 384181 (2022-004)

Significant Deficiency 2022

College Unbound

RI

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

Finding number: 2022-004 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 and 84.268 Award year: 2022 Corrective Action Plan: College Unbound hired two new positions, a Controller and a Bursar, who both started on 10/2/23 (the r...

Finding number: 2022-004 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 and 84.268 Award year: 2022 Corrective Action Plan: College Unbound hired two new positions, a Controller and a Bursar, who both started on 10/2/23 (the role was previously filled by a single temporary employee). Part of the Bursar’s scope of work is to work with Financial Aid to ensure that ledgers are correct. Reconciliation reports are also reviewed monthly to ensure accuracy and resolve discrepancies timely. Timeline for Implementation of Corrective Action Plan: Ongoing. Fully implemented by the end of FY24. Contact Person: Diana Perdomo, CFO

View Audit 297283

Finding 384177 (2022-002)

Significant Deficiency 2022

College Unbound

RI

Student Financial Aid Eligibility Matching / Level of Effort / Earmarking

Finding number: 2022-002 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.268 Award year: 2022 Corrective Action Plan: College Unbound previously contracted with a third party to process T4 funds for FY20 through FY23. As of 8/22/23...

Finding number: 2022-002 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.268 Award year: 2022 Corrective Action Plan: College Unbound previously contracted with a third party to process T4 funds for FY20 through FY23. As of 8/22/23 (the start of FY24), we have a new software and a new process to review Entrance Counseling and Master Promissory Note completion before transmitting direct loans. Timeline for Implementation of Corrective Action Plan: Ongoing. Started 8/22/23, fully implemented by the end of FY24. Contact Person: Diana Perdomo, CFO

View Audit 297283

Finding 383958 (2022-001)

Significant Deficiency 2022

Beth Israel Lahey Health, Inc.

MA

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Cash Management

Management Response and Corrective Action Plan Finding 2022-001 Federal Agency: United States Department of Health and Human Services Program Name: Provider Relief Fund (PRF) Assistance Listing Number: 93.498 Responsible Individual: Katherine Bacher, VP of System Services Accounting and Finance Co...

Management Response and Corrective Action Plan Finding 2022-001 Federal Agency: United States Department of Health and Human Services Program Name: Provider Relief Fund (PRF) Assistance Listing Number: 93.498 Responsible Individual: Katherine Bacher, VP of System Services Accounting and Finance Contact Information: Katherine.bacher@bilh.org; 617-278-7059 There was an error in PRF Reporting period 2 and 3 due to a misapplication of utilizing the same quarterly budget amount for both Quarter 3 and Quarter 4, resulting in an understatement of lost revenue. Management agrees with the recommendation and moving forward, there will be at least two reviews of the PRF filing prior to submission to better ensure complete and accurate information is submitted to HRSA. Corrective Action Plan: BILH will develop dual signoff of all submissions: • Director of Revenue and Reimbursement will compile and review the initial draft • VP of Revenue and Reimbursement will review the initial draft for completeness and accuracy • VP of System Services Accounting and Finance will final review for completeness and accuracy Expected Completion Date: September 30, 2024 Status of Completion: Not Started

View Audit 296974

Finding 383901 (2022-002)

Significant Deficiency 2022

City of Woodland

CA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.500

The City recently went through an implementation of a new financial software, which includes a checklist and has allowed for development of some documentation and assignment of roles and responsibilities. Along with filling vacant staff positions, the Finance Department will work to develop and enh...

The City recently went through an implementation of a new financial software, which includes a checklist and has allowed for development of some documentation and assignment of roles and responsibilities. Along with filling vacant staff positions, the Finance Department will work to develop and enhance documentation specific to financial reporting procedures.

View Audit 296908

Finding 383857 (2022-007)

Material Weakness 2022

Community Partners

CA

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.329

Community Partners acknowledges that while performance reports were maintained for internal Community Partners grants, prior practice did not ensure that performance reports for fiscally sponsored programs were maintained by Community Partners. Current management will ensure that Community Partners ...

Community Partners acknowledges that while performance reports were maintained for internal Community Partners grants, prior practice did not ensure that performance reports for fiscally sponsored programs were maintained by Community Partners. Current management will ensure that Community Partners maintains records to illustrate all required reporting is completed per funder requirements. The person responsible for the corrective action detailed above will be Joyce Williams, Chief Financial and Operations Officer, (213) 346‐3202. We anticipate corrective action will be completed by June 30, 2024.

View Audit 296891

Finding 383854 (2022-004)

Material Weakness 2022

Community Partners

CA

Questioned Costs Material Weakness Period of Performance § 200.334 § 200.403

Community Partners acknowledges that documentation to support expenditures was not consistently kept across all federal grants. Current leadership has addressed this issue by implementing documentation standards across all federal grants. Furthermore, through the implementation of NetSuite, expendit...

Community Partners acknowledges that documentation to support expenditures was not consistently kept across all federal grants. Current leadership has addressed this issue by implementing documentation standards across all federal grants. Furthermore, through the implementation of NetSuite, expenditures will be fully supported and approved by staff before posting. The person responsible for the corrective action detailed above will be Joyce Williams, Chief Financial and Operations Officer, (213) 346‐3202. We anticipate corrective action will be completed by June 30, 2024.

View Audit 296891 Questioned Costs: $1

Finding 383733 (2022-004)

Significant Deficiency 2022

Ford County, Kansas

KS

Subrecipient Monitoring Cash Management Significant Deficiency § 200.305

The County does not have a complete set of written cash management policies and procedures as required by the Uniform Guidance. The lack of written procedures did not result in any material noncompliance, fraud or abuse with respect to the major program. Recommendation: Management should determine...

The County does not have a complete set of written cash management policies and procedures as required by the Uniform Guidance. The lack of written procedures did not result in any material noncompliance, fraud or abuse with respect to the major program. Recommendation: Management should determine the scope of written policies needed for compliance with all federal programs and develop policies and procedures to comply with the Uniform Guidance. Grantee Response: Management agrees with the finding and recommendation. The County’s existing policies are currently under review by management and staff to determine what updates/changes are necessary in order to meet the Uniform Guidance requirements. Once any updates/changes are drafted, the policy will be presented to the Governing Body for review and approval.

View Audit 296750

Finding 383641 (2022-003)

Material Weakness 2022

Daviess Community Hospital

IN

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

Daviess Community Hospital will prepare a revised lost revenue calculation that can be provided to HRSA if necessary.

View Audit 296676

Finding 382877 (2022-005)

Significant Deficiency 2022

Rio Grande Hospital

CO

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Cluster Finding Summary: During our testing, we noted a lack of documentation of a secondary review on the RD442-2 forms submitted to the USDA. Responsible Individual...

Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Cluster Finding Summary: During our testing, we noted a lack of documentation of a secondary review on the RD442-2 forms submitted to the USDA. Responsible Individuals: Greg Porter, CFO & Arlene Harms, CEO Corrective Action Plan: Management will ensure that the RD442-2 forms submitted to the USDA have a documented secondary review. Anticipated Completion Date 3/12/2024

View Audit 296454

Finding 382656 (2022-007)

Material Weakness 2022

County of Delta

MI

Allowable Costs / Cost Principles Cash Management Procurement, Suspension & Debarment § 200.303

2022-007: Material Weakness and Noncompliance – Written Policies Required by the Uniform Guidance Statement of Condition/Criteria: Delta County does not have written policies and procedures to implement the requirements of 2 CFR section 200 for the administration of federal awards specific to the Ai...

2022-007: Material Weakness and Noncompliance – Written Policies Required by the Uniform Guidance Statement of Condition/Criteria: Delta County does not have written policies and procedures to implement the requirements of 2 CFR section 200 for the administration of federal awards specific to the Airport or for federal awards in general. 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal controls over the federal awards that provide assurance that the entity is managing the federal awards in compliance with federal statutes, regulations, and the conditions of the federal award. Planned Corrective Action: County management will develop written policies and procedures for grants and will formalize responsibilities between Airport management, Michigan Department of Transportation and other consultants. Contact person responsible for corrective action: Ashleigh Young, County Controller/Administrator Anticipated Completion Date: March 2024

View Audit 296246

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