Corrective Action Plans

Finding 1159784 (2021-009)

Material Weakness 2021

NY

Matching / Level of Effort / Earmarking § 200.306

PAX will implement a dedicated cost center in the books and records specifically for tracking these expenses. This will allow for better transparency and accountability in reporting. Additionally, PAX will reconcile against this cost center to ensure that the expenses reported to the grantor and bud...

PAX will implement a dedicated cost center in the books and records specifically for tracking these expenses. This will allow for better transparency and accountability in reporting. Additionally, PAX will reconcile against this cost center to ensure that the expenses reported to the grantor and budgetary allocations align with the actual expenditures. Dije Kucana, Comptroller, effective immediately

View Audit 370334

Finding 1155786 (2021-005)

Material Weakness 2021

Medstar, Inc.

MI

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Condition: The Organization was unable to provide supporting documentation to substantiate the allowability and accuracy of the expenses and lost revenue submitted in the portal. Planned Corrective Action: Company is an emergency services (ambulance, first responder, and was instrumental in the admi...

Condition: The Organization was unable to provide supporting documentation to substantiate the allowability and accuracy of the expenses and lost revenue submitted in the portal. Planned Corrective Action: Company is an emergency services (ambulance, first responder, and was instrumental in the administration of the monoclonal antibodies) - healthcare company and was during the pandemic. Company was able to provide general ledger information by personnel classification in aggregate monthly with percentages related to the Covid pandemic, Company changed payroll companies in June, 2022 from Trion to DM Payroll -where we were unable to access the payroll registers by personnel name. Medstar has full access to payroll registers through DM Payroll. Contact person responsible for corrective action: Lalainia Budyznowski Anticipated Completion Date: 06/30/2022 - Completed

View Audit 368173 Questioned Costs: $1

Finding 575384 (2021-008)

Material Weakness 2021

National Center for the Advancement of Stem

PA

Cash Management Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303 § 200.305

Agency: Person Responsible for Corrective Action: Name Title: Anticipated Completion Date Response to Finding: 2021-008 CASH MANAGEMENT National Center for the Advancement of STEM Education, Inc. (nCASE) : Nancy Priselac Executive Director : December 8, 2023 Management concurs with audit recomm...

Agency: Person Responsible for Corrective Action: Name Title: Anticipated Completion Date Response to Finding: 2021-008 CASH MANAGEMENT National Center for the Advancement of STEM Education, Inc. (nCASE) : Nancy Priselac Executive Director : December 8, 2023 Management concurs with audit recommendation. Correction Action to be Taken: nCASE has put written procedures in place to compile the SF425. The procedures also detail the approval process by management for the final review of the SF425. nCASE is working with a consultant to ensure that the numbers in the SF425 match the data output from our accounting software and is replicable. This has been implemented internally and performed by nCASE. nCASE has taken corrective measures in our accounting software by detailing the audit log and recording all changes with supporting documentation. There is final weekly review and approval of the changes. DoD has reviewed the matters covered in the audit report thoroughly, and the grant was closed out without any repayment of funds to DoD. Upon subsequent review and reconciliation, amounts were not overcharged.

View Audit 365412

Finding 575382 (2021-006)

Material Weakness 2021

National Center for the Advancement of Stem

PA

Questioned Costs Special Tests & Provisions Matching / Level of Effort / Earmarking § 200.303 § 200.308

Agency: National Center for the Advancement of STEM Education, Inc. (nCASE) Person Responsible for Corrective Action: Name: Nancy Priselac Title: Executive Director Anticipated Completion Date: December 8, 2023 Response to Finding: Management concurs with audit recommendation. Correction Action to b...

Agency: National Center for the Advancement of STEM Education, Inc. (nCASE) Person Responsible for Corrective Action: Name: Nancy Priselac Title: Executive Director Anticipated Completion Date: December 8, 2023 Response to Finding: Management concurs with audit recommendation. Correction Action to be Taken: Management has established policies and procedures that define how personnel are to record involvement in project activities. These records are used to document time and labor for specific projects and in combination with time‐ keeping documentation will reflect this data in payroll documentation. DoD has reviewed the matters covered in the audit report thoroughly, and the grant was closed out without any repayment of funds to DoD. Upon subsequent review and reconciliation, amounts were not overcharged.

View Audit 365412 Questioned Costs: $1

Finding 575380 (2021-004)

Material Weakness 2021

National Center for the Advancement of Stem

PA

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

Agency: National Center for the Advancement of STEM Education, Inc. (nCASE) Person Responsible for Corrective Action: Name: Nancy Priselac Title: Executive Director Anticipated Completion Date: December 8, 2023 Response to Finding: Management concurs with audit recommendation. Correction Action to b...

Agency: National Center for the Advancement of STEM Education, Inc. (nCASE) Person Responsible for Corrective Action: Name: Nancy Priselac Title: Executive Director Anticipated Completion Date: December 8, 2023 Response to Finding: Management concurs with audit recommendation. Correction Action to be Taken: nCASE will invoice for the indirect amount proportional only to the direct amount invoiced and only after the direct amount has been invoiced. Policy and procedure have been updated to reflect how this is invoiced. DoD has reviewed the matters covered in the audit report thoroughly, and the grant was closed out without any repayment of funds to DoD. Upon subsequent review and reconciliation, amounts were not overcharged.

View Audit 365412 Questioned Costs: $1

Finding 574658 (2021-011)

Material Weakness 2021

Virgin Islands Port Authority

VI

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.303

The Authority will continue to make progress in meeting required review processes and submission timelines. For the reports where the necessity of submission is in question, the Authority will consult with its federal partner to obtain a determination.

View Audit 364929

Finding 574653 (2021-009)

Material Weakness 2021

Virgin Islands Port Authority

VI

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.303

The Director of Engineering will sign reports submitted to the FAA as validation that the items have been reviewed. The Senior Compliance Officer serves as the record-keeper for documents filed between VIPA, the FAA, and other institutions, ensuring that VIPA submits the required filings and maintai...

The Director of Engineering will sign reports submitted to the FAA as validation that the items have been reviewed. The Senior Compliance Officer serves as the record-keeper for documents filed between VIPA, the FAA, and other institutions, ensuring that VIPA submits the required filings and maintains a working spreadsheet of items sent. Additionally, a tickler system has been implemented in accounting to serve as a reminder to submit financial reports to Engineering or the grantor.

View Audit 364929

Finding 574651 (2021-006)

Material Weakness 2021

Virgin Islands Port Authority

VI

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

The Authority will ensure that when a federal report is prepared by Director, it will be reviewed by another Director or member of the management team.

View Audit 364929

Finding 573470 (2021-003)

Significant Deficiency 2021

Development Bank of American Samoa

AS

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

Finding No.: 2021-003 Segregation of Duties Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: HOME Investment Partnerships Program Assistance Listing Number: 14.239 Name of Contact Persons: Faaeteete Sio and Ruth Matagi Corrective Action: Due to ...

Finding No.: 2021-003 Segregation of Duties Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: HOME Investment Partnerships Program Assistance Listing Number: 14.239 Name of Contact Persons: Faaeteete Sio and Ruth Matagi Corrective Action: Due to the COVID-19 pandemic, DBAS had to work a staggered schedule for the staff to include vulnerable employees who are 60+ year olds (management) to work remotely from home. Two of the signors fall under this category. DBAS will ensure and enforce proper segregation of duties will be followed. Loan approval and check signer controls will be reviewed and revised to ensure segregation of duties concerns are mitigated moving forward. This situation has since been addressed and corrected with the return of staff to the office.

View Audit 364205

Finding 571922 (2021-006)

None 2021

Choctaw County

OK

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.403

We will implement policies and procedures to ensure compliance with applicable grant requirements.

View Audit 362988 Questioned Costs: $1

Finding 571921 (2021-005)

Material Weakness 2021

Choctaw County

OK

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

We will implement control procedures to ensure compliance with requirements.

View Audit 362988

Finding 570042 (2021-004)

Material Weakness 2021

Local Redevelopment Authority of the Lands and Facilities of Naval Station Roosevelt Roads

PR

Procurement, Suspension & Debarment Reporting Matching / Level of Effort / Earmarking § 200.512

2021-004 Late Single Audit Submissions Category: Material weakness in Internal Control and Material Noncompliance Condition: The Authority has not timely submitted the Single Audit Reporting Packages for the years ended June 30, 2021, and 2022. Management’s Response: Starting in FY 2024-2025, the Fi...

2021-004 Late Single Audit Submissions Category: Material weakness in Internal Control and Material Noncompliance Condition: The Authority has not timely submitted the Single Audit Reporting Packages for the years ended June 30, 2021, and 2022. Management’s Response: Starting in FY 2024-2025, the Finance Department will maintain detailed records of all payments made, deposits received, and the reimbursement and transfer processes. This approach ensures that all reports are completed in a timely manner. To strengthen internal control over accounts, disbursements, and fund entries, the LRA’s Finance Department will hire additional personnel. These new team members are responsible for updating and managing accounting records. Together, they have established a strict timeline for completing important tasks to ensure a clear and concise flow of funds. The workloads will be divided among the team, with specific responsibilities assigned for Accounts Receivable, Accounts Payable, Bank Reconciliation, and Bookkeeping. Some responsibilities are interlinked, allowing team members to support one another in the event of absence or the need for assistance and providing documents to the external audits for the Single Audits. Person in charge: Juan C. Rodriguez Rivera Accounting Official 787-705-7188 Juan.rodriguez@lra.pr.gov Implementation Date: FY 2024-2025

View Audit 361347

Finding 570041 (2021-003)

Material Weakness 2021

Local Redevelopment Authority of the Lands and Facilities of Naval Station Roosevelt Roads

PR

Reporting Procurement, Suspension & Debarment Period of Performance

2021-003 Performance and Financial Reports Submissions Category: Material weakness in Internal Control and Material Noncompliance Condition: The Authority did not comply with the submission due dates of the Performance Reports and Federal Financial Reports established by the OEA in their Notice of A...

2021-003 Performance and Financial Reports Submissions Category: Material weakness in Internal Control and Material Noncompliance Condition: The Authority did not comply with the submission due dates of the Performance Reports and Federal Financial Reports established by the OEA in their Notice of Award granted on June 6, 2020. In addition, from five reports examined to test compliance with due dates, the submission date could not be verified in four instances, including the Federal Financial Report. Management’s Response: Starting in FY 2024-2025, the Finance Department will maintain detailed records of all payments made, as well as the reimbursement and transfer processes. The LRA’s Finance Department will hire additional personnel to strengthen the internal control of its accounts, disbursements, and fund entries. The new team members will be task with updating and managing accounting records. Together, they have will develop a strict timeline for completing important tasks to ensure a concise and transparent flow of funds. Workloads will be divided, with specific responsibilities assigned to individual team members, including Accounts Receivable, Accounts Payable, Bank Reconciliation, and Bookkeeping. Some responsibilities are interconnected, allowing team members to support each other in case of absence or when assistance is needed. Person in charge: Juan C. Rodriguez Rivera Accounting Official 787-705-7188 Juan.rodriguez@lra.pr.gov Implementation Date: FY 2024-2025

View Audit 361347

Finding 570040 (2021-002)

Significant Deficiency 2021

Local Redevelopment Authority of the Lands and Facilities of Naval Station Roosevelt Roads

PR

Internal Control / Segregation of Duties Cash Management Significant Deficiency

2021-002 Reserve Account Category: Significant Deficiency in Internal Control and Noncompliance Condition: The Authority has a deposit deficiency of $40,416 in the Reserve Account. The balance of the debt service reserve as of June 30, 2021, shall be $90,936. Management’s Response: Starting in FY 20...

2021-002 Reserve Account Category: Significant Deficiency in Internal Control and Noncompliance Condition: The Authority has a deposit deficiency of $40,416 in the Reserve Account. The balance of the debt service reserve as of June 30, 2021, shall be $90,936. Management’s Response: Starting in FY 2024-2025, the Finance Department will initiate the necessary transfers to the Reserve Account to rectify the deposit deficiency. Additionally, we will establish a plan for regular monitoring of the account to prevent future deficiencies. To ensure ongoing compliance and to identify any potential issues early, we will schedule more frequent internal audits. Person in charge: Juan C. Rodriguez Rivera Accounting Official 787-705-7188 Juan.rodriguez@lra.pr.gov Implementation Date: FY 2024-2025

View Audit 361347

Finding 565787 (2021-013)

Material Weakness 2021

Rogers County

OK

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.403

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with work with all elected officials and with the ...

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with work with all elected officials and with the state and local partners in each federal award to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements. These policies and procedures will be designed to identify requirements for recipients and sub-recipients of grants, ensure accurate equipment and real property management, procurement, recipient and subrecipient monitoring and reporting. Further, policies will ensure a proper understanding of all grant requirements and compliance of the same.

View Audit 359478 Questioned Costs: $1

Finding 565131 (2021-004)

Significant Deficiency 2021

Falmouth-Pendleton County Airport Board

OH

Equipment & Real Property Management Matching / Level of Effort / Earmarking Special Tests & Provisions

Finding Reference Number: 2021-004 Description of Finding: Lack of Internal Control Over Compliance – Unfamiliarity with Federal Compliance Requirements Statement of Concurrence or Nonconcurrence: The Board of the Falmouth Pendleton County Airport agrees with the audit finding. Corrective ...

Finding Reference Number: 2021-004 Description of Finding: Lack of Internal Control Over Compliance – Unfamiliarity with Federal Compliance Requirements Statement of Concurrence or Nonconcurrence: The Board of the Falmouth Pendleton County Airport agrees with the audit finding. Corrective Action: In future years, when receiving federal funds, management will contact the appropriate Federal agency and inquire about Uniform Guidance compliance requirements for federal funds. Name of Contact Person: Dan Bell, Board Chairman, k62airport@gmail.com (859) 816-8879 Projected Completion Date: On or before June 30, 2025

View Audit 359062

Finding 565128 (2021-001)

Material Weakness 2021

Falmouth-Pendleton County Airport Board

OH

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

Finding Reference Number: 2021-001 Description of Finding: Lack of Internal Control Over Financial Reporting – No Accounting System Used Statement of Concurrence or Nonconcurrence: The Board of the Falmouth Pendleton County Airport agrees with the audit finding. Corrective Action: The Boa...

Finding Reference Number: 2021-001 Description of Finding: Lack of Internal Control Over Financial Reporting – No Accounting System Used Statement of Concurrence or Nonconcurrence: The Board of the Falmouth Pendleton County Airport agrees with the audit finding. Corrective Action: The Board has contracted with a local Accountant to begin entering all Board financial records into Quick Books online. Name of Contact Person: Dan Bell, Board Chairman, k62airport@gmail.com (859) 816-8879 Projected Completion Date: On or before June 30, 2025

View Audit 359062

Finding 560020 (2021-001)

Material Weakness 2021

Stark State College

OH

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.414 § 200.502 § 200.510

Management feels that the SEFA wasprepared in accordance with guidance that was available at the time. We will continue to evaluate all federal programs’ expenditures and include on the SEFA as necessary. All federal expenditures will continue to be reconciled to College ledgers.

View Audit 355948

Finding 556181 (2021-007)

Material Weakness 2021

Island Health, Inc.

MA

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

Item 2021.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this...

Item 2021.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance. • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant’s period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail. • Review these procedures annually to ensure ongoing compliance with the grant’s period of performance.

View Audit 354872

Finding 555674 (2021-007)

Material Weakness 2021

Island Health, Inc.

MA

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

Item 2021.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this...

Item 2021.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance. • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant’s period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail. • Review these procedures annually to ensure ongoing compliance with the grant’s period of performance.

View Audit 354288

Finding 554491 (2021-012)

Material Weakness 2021

Washington County

OK

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

No corrective action taken.

View Audit 353149

Finding 553802 (2021-002)

None 2021

Niagara Area Management Corporation

NY

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking

Niagara Area Management Corporation has hired a new Chief Financial Officer and Director of Finance. NAMC has also engaged a new public accounting firm. It is NAMC policy to submit the annual audited financial statements and the data collection form to the Federal Audit Clearinghouse within 9 months...

Niagara Area Management Corporation has hired a new Chief Financial Officer and Director of Finance. NAMC has also engaged a new public accounting firm. It is NAMC policy to submit the annual audited financial statements and the data collection form to the Federal Audit Clearinghouse within 9 months after year-end.

View Audit 352433

Finding 553726 (2021-004)

Significant Deficiency 2021

Falmouth-Pendleton County Airport Board

OH

Equipment & Real Property Management Matching / Level of Effort / Earmarking Special Tests & Provisions

Finding Reference Number: 2021-004 Description of Finding: Lack of Internal Control Over Compliance – Unfamiliarity with Federal Compliance Requirements Statement of Concurrence or Nonconcurrence: The Board of the Falmouth Pendleton County Airport agrees with the audit finding. Corrective ...

Finding Reference Number: 2021-004 Description of Finding: Lack of Internal Control Over Compliance – Unfamiliarity with Federal Compliance Requirements Statement of Concurrence or Nonconcurrence: The Board of the Falmouth Pendleton County Airport agrees with the audit finding. Corrective Action: In future years, when receiving federal funds, management will contact the appropriate Federal agency and inquire about Uniform Guidance compliance requirements for federal funds. Name of Contact Person: Dan Bell, Board Chairman, k62airport@gmail.com (859) 816-8879 Projected Completion Date: On or before June 30, 2025

View Audit 352320

Finding 553723 (2021-001)

Material Weakness 2021

Falmouth-Pendleton County Airport Board

OH

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

Finding Reference Number: 2021-001 Description of Finding: Lack of Internal Control Over Financial Reporting – No Accounting System Used Statement of Concurrence or Nonconcurrence: The Board of the Falmouth Pendleton County Airport agrees with the audit finding. Corrective Action: The Boa...

Finding Reference Number: 2021-001 Description of Finding: Lack of Internal Control Over Financial Reporting – No Accounting System Used Statement of Concurrence or Nonconcurrence: The Board of the Falmouth Pendleton County Airport agrees with the audit finding. Corrective Action: The Board has contracted with a local Accountant to begin entering all Board financial records into Quick Books online. Name of Contact Person: Dan Bell, Board Chairman, k62airport@gmail.com (859) 816-8879 Projected Completion Date: On or before June 30, 2025

View Audit 352320

Finding 530128 (2021-002)

Material Weakness 2021

Astria Health

WA

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

Finding Number 2021-002: Reporting - Material Weakness in Internal Control Over Compliance and Instance of Material Noncompliance. Program: U.S. Department of Helath and Human Services - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution. Response and Corrective Action Plan: Mana...

Finding Number 2021-002: Reporting - Material Weakness in Internal Control Over Compliance and Instance of Material Noncompliance. Program: U.S. Department of Helath and Human Services - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution. Response and Corrective Action Plan: Management agress with the finding. The Organization will review and modify policies and procedures over Federal Grant Awards to ensure management implements policies and procedures to ensure there is understanding of the terms and conditions of Federal awards and that reports are prepared and reviewed by separate individuals with evidence of review documented. Anticipated Completion Date: by December 31, 2024. Responsible Person: Matthew Matthiessen, CFO.

View Audit 348226

Corrective Action Plans

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