Corrective Action Plans

Finding 479602 (2023-001)

Material Weakness 2023

VT

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Material Weakness § 200.318 § 200.327

CORRECTIVE ACTION PLAN {Concerning Finding 2023-001-RF3-407-3.0) Contact Person Responsible for Corrective Action: Judy L. Hayward Corrective Action: The Royalton Fire District 1 will take the following actions to address finding 2023-01. We will prepare and adopt a Federal Procurement Policy. Antic...

CORRECTIVE ACTION PLAN {Concerning Finding 2023-001-RF3-407-3.0) Contact Person Responsible for Corrective Action: Judy L. Hayward Corrective Action: The Royalton Fire District 1 will take the following actions to address finding 2023-01. We will prepare and adopt a Federal Procurement Policy. Anticipated Completion Date: June 30, 2024.

View Audit 316182

Finding 479582 (2023-001)

Material Weakness 2023

Care Alliance Health Center

CT

Special Tests & Provisions Subrecipient Monitoring Eligibility

To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2023 The findings from the October 31, 202...

To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2023 The findings from the October 31, 2023, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Federal Award Findings: Finding 2023.001 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken We will invest the time and resources into improving all areas related to the Sliding Fee Scale. We will implement the following steps to our process to ensure all federal guidelines and requirements are met. 1. Documented Process: Design and implement an internal control process to ensure sliding fee discounts are accurately calculated based on family size and income. 2. Documented Procedures: Establish clear procedures and guidelines for front desk staff to follow when determining discounts, including appropriate documentation requirements, eligibility criteria, and fee structure. These procedures will be aligned with our written policy to ensure consistency and accuracy in discount calculations. 3. Training and Education: Provide training to front desk staff members responsible for determining eligibility and applying sliding fee discounts to ensure they understand the process. 4. Regular Reviews: Implement regular reviews and monthly audits to verify that all discounts are properly supported and documented. Quarterly reviews will be conducted to verify compliance, identify areas for improvement, and evaluate the effectiveness of the sliding scale fee program to ensure it meets our patients' needs and complies with all federal guidelines. Responsible Parties: 1. The Controller and revenue cycle staff will develop the written procedure. 2. The Clinical Support Supervisor and revenue cycle staff will overseE3 the training. 3. The Revenue Cycle Manager_will monitor adherence to the procedure, conduct regular monthly audits, and report results to the Controller. 4. The Controller will conduct quarterly documentation reviews of the internal audit results. Timeline: 1. Procedure draft completion: Completed 2. Review and approval by senior management: July 24, 2024 3. Initial staff training session: July 25, 2024 4. Follow-up training sessions: As needed 5. Monthly compliance audits: Starting September 1, 2024

View Audit 316128

Finding 479546 (2023-001)

Material Weakness 2023

Dayton's Bluff Neighborhood Housing Service, Inc.

MN

Reporting Subrecipient Monitoring Material Weakness

Dayton’s Bluff Neighborhood Housing Service and Subsidiary submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: January 1,...

Dayton’s Bluff Neighborhood Housing Service and Subsidiary submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: January 1, 2023 – December 31, 2023 The findings from the December 31, 2023 schedule of findings, questioned costs and recommendations. FINDINGS - FINANCIAL STATEMENT AUDIT Finding 2023-001 - Auditor Preparation of the Financial Statements Material Weakness Finding Summary: The Organization does not have an internal control system designed to provide for the preparation of the complete consolidated financial statements, including the accompanying footnotes, as required by GAAP. We were also requested to draft the financial statements and accompanying notes to the financial statements. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of financial statements and accompanying notes. We requested that our auditors Lethert, Skwira, Schultz & Co. LLP, prepare the financial statements and the accompanying notes to the financial statements as a part of their annual audit. We have designated a member of management to review the drafted financial statements and accompanying notes. Responsible Individuals: Jim Erchul, Executive Director, 651-774-6995 Anticipated Completion Date: Ongoing

View Audit 316095

Finding 479530 (2023-002)

Material Weakness 2023

Worker Education & Resource Center INC

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness

The Organization had a significant turnover in both Fiscal Manager Consultant and Executive Director during the year being audited. The Fiscal Manager Consultant was replaced by the Director of Finance in the later part of the fiscal year 2022-2023. This required the new Director of Finance to creat...

The Organization had a significant turnover in both Fiscal Manager Consultant and Executive Director during the year being audited. The Fiscal Manager Consultant was replaced by the Director of Finance in the later part of the fiscal year 2022-2023. This required the new Director of Finance to create and implement as many internal controls that were needed, that were not implemented, and/or recommended by our current CPA firm who had been previously auditing prior years. Additionally, our Director of Finance has engaged the Board of Directors in taking a more active role in the financial statement overview that was not previously recommended to them by our CPA firm.

View Audit 316070

Finding 479513 (2023-003)

Material Weakness 2023

Christian Community Health Center

IL

Material Weakness Internal Control / Segregation of Duties

Finding Number: 2023-003 Sliding Scale Assessment Planned Corrective Action: CCHC has created a workflow for staff as a guide in processing the sliding fee scale. This workflow is approved by the Head Nurse Supervisor and signed. Please see attached workflow sheet. CCHC will verify with Athena EHR...

Finding Number: 2023-003 Sliding Scale Assessment Planned Corrective Action: CCHC has created a workflow for staff as a guide in processing the sliding fee scale. This workflow is approved by the Head Nurse Supervisor and signed. Please see attached workflow sheet. CCHC will verify with Athena EHR system to make sure that the most up to date poverty guidelines are in the system that is being used to calculate sliding fee discounts. Person Responsible for Corrective Action Plan: Pasue Mahan, Chief Clinic Officer Anticipated Date of Completion: 07/01/2024

View Audit 316037

Finding 479440 (2023-001)

Material Weakness 2023

County of Accomack, Virginia

VA

Subrecipient Monitoring Material Weakness Reporting

Corrective Action Plan for Finding FA-2023-001: Lack of Timely Reporting, Reporting, Education Stabilization Funds (ESF) #84.425C, 84.425D, and 84.425U (Material Weakness and Nonmaterial Compliance) A master calendar is now being kept of required reports and their due date to ensure timely reportin...

Corrective Action Plan for Finding FA-2023-001: Lack of Timely Reporting, Reporting, Education Stabilization Funds (ESF) #84.425C, 84.425D, and 84.425U (Material Weakness and Nonmaterial Compliance) A master calendar is now being kept of required reports and their due date to ensure timely reporting. Responsible Official: Dr. Rhonda Hall, Accomack County Public Schools Superintendent, rhonda.hall@ accomack.k12.va.us (757-787-5759); Estimated completion date is not later than the June 30, 2024.

View Audit 315971

Finding 479373 (2023-001)

Material Weakness 2023

Spyglass Ridge

OR

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

Views of Responsible Officials and Planned Corrective Actions We agree with this finding. NWCH was successful in adding needed staff in 2023, but was unable to hire a degreed accountant or controller, or to contract with an accounting firm for oversight of the accounting function. Bookkeeper trainin...

Views of Responsible Officials and Planned Corrective Actions We agree with this finding. NWCH was successful in adding needed staff in 2023, but was unable to hire a degreed accountant or controller, or to contract with an accounting firm for oversight of the accounting function. Bookkeeper training was provided from Shelter Resources Financial Manager in February 2023. NWCH is researching CPA firms in order to contract a qualified controller with expertise in real estate holdings relevant to NWCH. NWCH has been actively searching for a qualified CPA to hire or contract with since 2021, however, due to capacity constraints and overwhelmed CPA firms, NWCH has been unsuccessful. Efforts to hire experienced accounting personnel continues.

View Audit 315878

Finding 479347 (2023-002)

Material Weakness 2023

Brazos Valley Community Action Programs

TX

Allowable Costs / Cost Principles Material Weakness Matching / Level of Effort / Earmarking

CORRECTIVE ACTION PLANNED: We agree with the finding and have begun the process of enacting additional internal controls over the documentation of approval for pay rates. Beginning in August 2023, the Head Start program was administered with management, accounting, and payroll functions independent ...

CORRECTIVE ACTION PLANNED: We agree with the finding and have begun the process of enacting additional internal controls over the documentation of approval for pay rates. Beginning in August 2023, the Head Start program was administered with management, accounting, and payroll functions independent of other Agency programs. These key personnel report directly to the Board of Directors, which will direct staff to thoroughly document the approval of current pay rates for all active employees. The Agency will also enact additional controls to regularly review these records to ensure that, in the future, all required approvals and reviews are evidenced with written documentation. PERSON RESPONSIBLE FOR CORRECTION ACTION: James McCullough, Board President ANTICIPATED COMPLETION DATE: September 30, 2024

View Audit 315839

Finding 479327 (2023-009)

Material Weakness 2023

Colorado Legal Services, INC

CO

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.403

COIVD-19: Coronavirus State and Local Fiscal Recovery – Assistance Listing No. 21.027 Recommendation: We recommend that the Organization consider updating its salaries, wages, and employee benefit cost allocation methodology and process to reduce the frequency of manual adjustments based on review ...

COIVD-19: Coronavirus State and Local Fiscal Recovery – Assistance Listing No. 21.027 Recommendation: We recommend that the Organization consider updating its salaries, wages, and employee benefit cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual time records and expense data and maximize the use of automated allocations based on employees’ time and effort records, effective compensation during work periods, and that are calculated in a consistent manner. We also recommend that the Organization maintain contemporaneous documentation supporting all cost allocations. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization is updating the segregation of duties in order to improve the preparation, review and sign steps of the process. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025

View Audit 315826 Questioned Costs: $1

Finding 479314 (2023-008)

Material Weakness 2023

Colorado Legal Services, INC

CO

Matching / Level of Effort / Earmarking Material Weakness Reporting

Aging Cluster – Special Programs for the Aging, Title III, Part B – Assistance Listing No. 93.004 Recommendation: We recommend that the Organization implement a control process to ensure that it meets its matching requirements within the grant period. Explanation of disagreement with audit finding...

Aging Cluster – Special Programs for the Aging, Title III, Part B – Assistance Listing No. 93.004 Recommendation: We recommend that the Organization implement a control process to ensure that it meets its matching requirements within the grant period. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization is updating the segregation of duties in order to improve the preparation, review and sign steps of the process. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025

View Audit 315826

Finding 479298 (2023-007)

Material Weakness 2023

Colorado Legal Services, INC

CO

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

Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization update its derivative income allocation method, policy and procedures to reflect the method described in the federal regulations. Explanation of disagreement with audit finding: ...

Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization update its derivative income allocation method, policy and procedures to reflect the method described in the federal regulations. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization will reach out to LSC to understand if our current method is acceptable. If not, the Organization will implement corrections to comply with applicable standards. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025

View Audit 315826

Finding 479297 (2023-006)

Material Weakness 2023

Colorado Legal Services, INC

CO

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization consider updating its salaries, wages, and employee benefit cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual tim...

Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization consider updating its salaries, wages, and employee benefit cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual time records and expense data and maximize the use of automated allocations based on employees’ time and effort records, effective compensation during work periods, and that are calculated in a consistent manner. We also recommend that the Organization maintain contemporaneous documentation supporting all cost allocations. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization will review this finding and current methodology and propose corrections as part of a broader review of its technologies. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025

View Audit 315826 Questioned Costs: $1

Finding 479294 (2023-003)

Material Weakness 2023

Colorado Legal Services, INC

CO

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.430

Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization consider updating its salaries and wages cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual time records and expen...

Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization consider updating its salaries and wages cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual time records and expense data and maximize the use of automated allocations based on employees’ time and effort records. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization will review this finding and current methodology and propose corrections as part of a broader review of its technologies. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025

View Audit 315826 Questioned Costs: $1

Finding 479212 (2023-001)

Material Weakness 2023

Lake Erie College of Osteopathic Medicine

PA

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Finding 2023-001 Condition The College did not notify the National Student Loan Data System (NSLDS) in a timely manner for 24 students with status changes in our sample of 25 students. The sample was not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The College has ...

Finding 2023-001 Condition The College did not notify the National Student Loan Data System (NSLDS) in a timely manner for 24 students with status changes in our sample of 25 students. The sample was not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The College has updated its policies and procedures to ensure notifications to the National Student Loan Data System are performed timely. In addition, all members of the responsible team will undergo formalized training to ensure their knowledge and proficiency regarding all applicable rules and regulations are kept up to date. Name(s) of Contact Person(s) Responsible for Corrective Action: Jeremy Sivillo, Institutional Registrar Kevin A. Thomas, D.O., Assistant Dean of Institutional Enrollment Management Anticipated Completion Date: Policies and procedure update implementation has been completed. Training for existing staff is to be completed by April 30, 2024. Training material development for new employees will be completed by May 31, 2024

View Audit 315742

Finding 479180 (2023-002)

Material Weakness 2023

Brazos Valley Council of Governments

TX

HUD Housing Programs Material Weakness Reporting

Planned Corrective Action: While we agree that the submission dates lagged the scheduled dates, we do not agree that this condition rises to the level of a material weakness in internal controls over reporting. BVCOG submitted their audited financial statements for fiscal year 2022 through the Feder...

Planned Corrective Action: While we agree that the submission dates lagged the scheduled dates, we do not agree that this condition rises to the level of a material weakness in internal controls over reporting. BVCOG submitted their audited financial statements for fiscal year 2022 through the Federal Audit Clearinghouse (FAC) on June 30, 2023, which is prior to June 30, 2023. BVCOG awaits receipt of their audited financial fiscal year 2023 in order to submit them to the FAC. The audited fiscal year 2022 financial statements were submitted separately to HUD on November 22, 2023. HUD approved our submission without notice of delay. Unaudited financial statements for the fiscal year ending 2023 were submitted and accepted by HUD, with no point score deduction penalties or requests for corrective action. The timing of HUD’s Real Estate Assessment Center (REAC) report submission depends on acceptance of the previous unaudited or audited financial statements. The REAC submissions require that each year’s unaudited submission be approved by HUD before the audited submission can be submitted; further, both submissions for a year must be accepted by HUD before the next year’s submissions can be completed. Due to various factors including the COVID-19 pandemic and Winter Storm Uri in 2021, the Fiscal Year 2020 unaudited submission process completed April 2022. Subsequent staff turnover delayed the submission of the audited 2020 submission until August 2023. Once that submission was approved by HUD, the 2021 and 2022 submissions were completed by the end of November 2023. BVCOG realizes its REAC submission procedures rely on institutional knowledge and addressed this risk by engaging an outside CPA firm with personnel knowledgeable of the REAC system. This arrangement ensures additional cross-training opportunities in the future for current finance staff such that, if a key staff person leaves, there will be others in the department who know and understand the procedures necessary for compliance with HUD deadlines. Contact Person Responsible for Corrective Action: Janet Dudding, MBA, CPA, CGFO, Director of Finance Anticipated Completion Date: July 2024

View Audit 315724

Finding 479164 (2023-002)

Material Weakness 2023

Housing Authority of Aitkin County

NE

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

Moving forward, a supervisory review of the move in files will be performed by a different staff member for the Authority than the staff member who initially determined eligibility. This will ensure that the Authority continues compliance with eligibility requirements.

View Audit 315674

Finding 479163 (2023-001)

Material Weakness 2023

Housing Authority of Aitkin County

NE

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

It was discovered that our financial institution was pledging securities based on book value and not on market value which led to the deposits not being fully collateralized according to HUD requirements and State Statutes. The Authority will review the collateral reports at least quarterly to dete...

It was discovered that our financial institution was pledging securities based on book value and not on market value which led to the deposits not being fully collateralized according to HUD requirements and State Statutes. The Authority will review the collateral reports at least quarterly to determine that pledging requirements are adequate to ensure compliance in the future.

View Audit 315674

Finding 479153 (2023-001)

Material Weakness 2023

The Warren Center, Inc,

TX

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

Finding 2023-001: Allowable costs – material weakness in internal controls over compliance and compliance finding. Management Response All submissions of 􀆟mesheets and payroll reimbursed by grants will require review by the Controller or the COO, in the Controller’s absence, to ensure that expenditu...

Finding 2023-001: Allowable costs – material weakness in internal controls over compliance and compliance finding. Management Response All submissions of 􀆟mesheets and payroll reimbursed by grants will require review by the Controller or the COO, in the Controller’s absence, to ensure that expenditures charged to the grants agree to the original 􀆟mesheets or payroll prior to submission or charging to a specific grant

View Audit 315643

Finding 479056 (2023-003)

Material Weakness 2023

Evergreen Youth & Family Services, Inc.

MN

Subrecipient Monitoring Material Weakness Reporting

Transitional Living for homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to monitor program income and ensure that the funds are being properly used before requesting additional federal funds. This could include regular reporti...

Transitional Living for homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to monitor program income and ensure that the funds are being properly used before requesting additional federal funds. This could include regular reporting on the use of program income and conducting periodic reviews to ensure compliance with program requirements. Additionally, the Organization should review its policies and procedures to ensure they are in compliance with program requirements and make any necessary updates. Finally, the Organization should ensure that all staff members responsible for monitoring program income are properly trained and have a clear understanding of program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During each Payment Management System Draw process, the Finance Director will verify the draw amounts and run a program income and expense report to verify that the amount of miscellaneous expenses for the Transitional Living Program are more than the program income received. A copy of the income and expense statement will be saved in each draw file with the other verification documents. A column for verification initials of this process was added to the ACF Grant Balances Spreadsheet used for recording the draw amounts and dates of the draws. Name(s) of the contact person(s) responsible for corrective action: Julia Montebello, Finance Director Planned completion date for corrective action plan: 4/26/2024

View Audit 315565

Finding 479055 (2023-002)

Material Weakness 2023

Evergreen Youth & Family Services, Inc.

MN

Eligibility Material Weakness Internal Control / Segregation of Duties

Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that proper documentation and support for eligibility is obtained and reviewed by a qualified individual. Explanation of disagreement with audit...

Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that proper documentation and support for eligibility is obtained and reviewed by a qualified individual. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Program Director will conduct Weekly Document Reviews for new and ongoing clients and will also verify eligibility as staff submit weekly request forms for clients to receive services. Weekly Review Schedule: • The Program Director will conduct a review of all documentation once a week. Verification Process: • During the review, the Program Director will verify that all required documents for eligibility is being completed accurately, processed, and documented. Documentation of Review: • The results of this review will be documented on each client’s initial intake form and in Apricot. • The Program Director will sign the intake form to indicate verification and completion of the review and will also document this in Apricot. • By adhering to this procedure, we ensure that all documentation is thoroughly checked and validated on a consistent basis, maintaining the integrity and accuracy of our eligibility process. Name(s) of the contact person(s) responsible for corrective action: Elena Guerra, EYS Program Director. Planned completion date for corrective action plan: ongoing

View Audit 315565

Finding 479030 (2023-003)

Material Weakness 2023

West Central Nebraska Joint Housing Authority

NE

Internal Control / Segregation of Duties Special Tests & Provisions Eligibility

Finding 2023-003: We agree with the finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the inte...

Finding 2023-003: We agree with the finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the internal control deficiencies noted. The Board had reviewed the issue and determined that there are no additional procedures which can be reasonably done to eliminate the deficiencies and accepts them.

View Audit 315549

Finding 479023 (2023-001)

Material Weakness 2023

Catholic Social Services

NE

Internal Control / Segregation of Duties Material Weakness Reporting

Catholic Social Services' management will improve its system of internal controls to correctly identify and present a complete and accurate schedule of expenditures of federal awards.

View Audit 315529

Finding 478998 (2023-001)

Material Weakness 2023

Arapahoe County, Colorado

CO

Reporting Subrecipient Monitoring Material Weakness § 200.303

Community Development Block Grant and COVID-19 Community Development Block Grant – Material Weakness Condition: During testing of the Federal Funding Accountability and Transparency Act (FFATA) reports, it was noted that no FFATA reporting had been completed during the year ended December 31, 2023. ...

Community Development Block Grant and COVID-19 Community Development Block Grant – Material Weakness Condition: During testing of the Federal Funding Accountability and Transparency Act (FFATA) reports, it was noted that no FFATA reporting had been completed during the year ended December 31, 2023. Recommendation: We recommend that the County continue with the process being implemented during the fiscal year 2024, which includes completing submission of the reports and tracking the timely submission of the FFATA reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: With significant turnover of tenured leadership and employees within the Community Resources Department, Arapahoe County Community Resources took proactive measures in 2023 for review of the Community Development Housing and Homeless Services (CDHHS) programs (CDBG and HOME Investment) by recognized consultants within the field. Community Resources has contracted with two consultants, to assist in a full review and re-development of policies and procedures (Civitas) for the CDBG and HOME programs as well as a full review of all case files (Affordable Housing Consultants). Included with this response are the contracts with both Civitas and Affordable Housing Consultants for verification purposes. The County anticipates their work to be completed and an implementation of updated policies and procedures for these programs by fall of 2024. In response to the direct finding of no FFATA reporting during the year ending December 31st, 2023, Arapahoe County has ensured the entry of all sampled contracts. Demonstration of the report submissions have been submitted for verification purposes. It is important to note that all sub-agreements included the necessary FFATA information for the review period, but Community Resources failed to ensure that this information was entered into the FFATA Subaward Reporting System (FSRS). To ensure internal controls are in place for the FFATA’s timely and accurate submissions for all future subawards, Arapahoe County’s Community Resources Department has created the following internal controls and governance: 1. Creation of the FFATA Reporting Form which will be completed and submitted along with all future subaward agreements and includes all necessary information for complete and accurate submittal into FSRS. 2. Creation of the FFATA Subrecipient Reporting Work Instructions which detail the process, to include roles and responsibilities, for the completion and entry of the FFATA. 3. Update to our Grant Administration Policy which includes the requirement to complete and enter the FFATA in our grant administration oversight and track timely submission of the reports. Name of the contact persons responsible for corrective action: Katherine Smith Planned completion date for corrective action plan: September 30, 2024

View Audit 315527

Finding 478996 (2023-037)

Material Weakness 2023

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

DEPARTMENT OF PUBLIC HEALTH 2023-037 Block Grants for Prevention and Treatment of Substance Abuse, COVID-19 - Block Grants for Prevention and Treatment of Substance Abuse - Assistance Listing No. 93.959 Action taken in response to the finding: All subrecipient FFATA information will be batch upload...

DEPARTMENT OF PUBLIC HEALTH 2023-037 Block Grants for Prevention and Treatment of Substance Abuse, COVID-19 - Block Grants for Prevention and Treatment of Substance Abuse - Assistance Listing No. 93.959 Action taken in response to the finding: All subrecipient FFATA information will be batch uploaded to FSRS within 30 days of execution of subcontracts. The majority of BSAS subrecipient contracts are executed as of July 1. A batch upload of data will be completed each year in that period. All outlying contracts not executed on June 30 will have their FFATA data uploaded to FSRS within 30 days of contract execution throughout the year. These uploads will be conducted by the BSAS Grants coordinator. Once successfully uploaded the Grants coordinator will receive a FFATA submission receipt from FSRS for each FFATA submission. They will share this with their supervisor and the Fiscal Director for confirmation. These records will be kept on file in the BSAS Grant Teams file for future reference. Our internal Fiscal Compliance Auditor will review batches of these submission quarterly to ensure compliance. Name of the contact person responsible for corrective action: Shannon McEneaney-Farron, BSAS Fiscal Director Planned completion date for corrective action plan: July 31, 2024 If the Department of Health and Human Services has questions regarding this plan, please call David Godin at 617-721-6200.

View Audit 315520

Finding 478992 (2023-033)

Material Weakness 2023

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

DEPARTMENT OF PUBLIC HEALTH 2023-033 Opioid – STR - Assistance Listing No. 93.788 Action taken in response to the finding: All subrecipient FFATA information will be batch uploaded to FSRS within 30 days of execution of subcontracts. The majority of BSAS subrecipient contracts are executed as of Ju...

DEPARTMENT OF PUBLIC HEALTH 2023-033 Opioid – STR - Assistance Listing No. 93.788 Action taken in response to the finding: All subrecipient FFATA information will be batch uploaded to FSRS within 30 days of execution of subcontracts. The majority of BSAS subrecipient contracts are executed as of July 1. A batch upload of data will be completed each month over the grant period so that all outlying contracts not executed on June 30 will have their FFATA data uploaded to FSRS within 30 days of contract execution throughout the year. These uploads will be conducted by the BSAS Grants coordinator. Once successfully uploaded the Grants coordinator will receive a FFATA submission receipt from FSRS for each FFATA submission. They will share this with their supervisor and the Fiscal Director for confirmation. These records will be kept on file in the BSAS Grant Teams file for future reference. Our internal Fiscal Compliance Auditor will review batches of these submission quarterly to ensure compliance. Name of the contact person responsible for corrective action: Shannon McEneaney-Farron, BSAS Fiscal Director Planned completion date for corrective action plan: Ongoing. This process will commence as of July 1, 2024.

View Audit 315520

Corrective Action Plans

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