Corrective Action Plans

Finding 389897 (2023-001)

Material Weakness 2023

AZ

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

Finding Number: 2023‐001 Program Names/Assistance Listing Titles: Indian School Equalization, Administrative Cost Grants for Indian Schools, Indian Education Facilities, Operations and Maintenance Assistance Listing Numbers: 15.042, 15.046, 15.047 Contact Person: Stephanie Woody, Business Technician...

Finding Number: 2023‐001 Program Names/Assistance Listing Titles: Indian School Equalization, Administrative Cost Grants for Indian Schools, Indian Education Facilities, Operations and Maintenance Assistance Listing Numbers: 15.042, 15.046, 15.047 Contact Person: Stephanie Woody, Business Technician; Aurelia Tapaha, Business Manager/Human Resource Manager; Jeannie Lewis, Principal Anticipated Completion Date: July 2024 Planned Corrective Action: The School will review the procurement flowcharts and required documents for Business Technician. The School will obtain training for chart of accounts training for business staff along with procurement training. Business staff and administrators will keep abreast of law changes, GASB updates, and budget changes with grants received. The School will review school credit and implement a timeframe where the no use of the credit card is enforced. The School will collect all required documents to process payments. The entire balance will be paid in full amount for each month. Training on use of credit cards will be given during orientation.

View Audit 300789

Finding 389896 (2023-001)

Material Weakness 2023

Monongalia County Urban Mass Transit Authority

WV

Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.334

The party that was making sure of signatures and signatures of changes ended up in a backlog and lost time cards. If time cards are sent back for signatures a copy of the original will be kept until the signed ones come back, and follow up will be made on a timely basis.

View Audit 300786 Questioned Costs: $1

Finding 389887 (2023-001)

Material Weakness 2023

Kayenta Unified School District No.27

AZ

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness

Findings and Questioned Costs Related to Federal Awards Finding Number: 2023‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: Arlene Laughter, Business Supervisor Anticipated Completion Date: December 31, 2024 Planned Correctiv...

Findings and Questioned Costs Related to Federal Awards Finding Number: 2023‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: Arlene Laughter, Business Supervisor Anticipated Completion Date: December 31, 2024 Planned Corrective Action: The District has created an assistant manager position that will oversee all mandatory and required reports as requested by the Department of Education and Grants management. The District has also reached out to Jon Chase with Grants management to determine the required status of the report. In the future, the District will create a calendar to determine all timelines are met.

View Audit 300772

Finding 389878 (2023-002)

Material Weakness 2023

Tusculum University

TN

Student Financial Aid Subrecipient Monitoring Material Weakness

2023-002 Material Weakness: Gramm-Leach-Bliley Act (GLBA) (U.S. Department of Education, William D. Ford Direct Loan Program, ALN #84.268) Name of Contact Person Casey Reagan, Registrar, and Chris Summey, Head of our IT Department, are the Designated Employees in charge of overseeing the GLBA polic...

2023-002 Material Weakness: Gramm-Leach-Bliley Act (GLBA) (U.S. Department of Education, William D. Ford Direct Loan Program, ALN #84.268) Name of Contact Person Casey Reagan, Registrar, and Chris Summey, Head of our IT Department, are the Designated Employees in charge of overseeing the GLBA policy. Corrective Action Planned During the audit, it was noted that Tusculum did not fully address all of the requirements as described by 16 CFR 314.4. In addition, the application of the comprehensive information security program was not effectively administered by the University for the 2023 year. In fall 2023, IT, the Registrar, and the Director of Financial Aid met to discuss making sure that all of the new pieces of the GLBA policy were being implemented properly. In December of 2023, IT began the latest vulnerability scan and risk assessment to be in compliance with the risk assessment requirements of the GLBA Policy. This assessment should be completed by the end of spring 2024. The University is also working on updating its GLBA policies and procedures to align with the GLBA Policy. Anticipated Completion Date This process is currently ongoing and it is the University's goal to have ongoing GLBA policies updated and the risk assessment completed before the end of the 2023-2024 academic year.

View Audit 300763

Finding 389779 (2023-002)

Material Weakness 2023

Antioch College Corporation

OH

Procurement, Suspension & Debarment Material Weakness Matching / Level of Effort / Earmarking

Finding 2023-002 - Material Weakness - Borrowings from Endowment Fund Condition Found The College has borrowed from its endowment funds for campus renovations and to cover certain operating expenses of the College prior to and following its accreditation and approval to participate in federal studen...

Finding 2023-002 - Material Weakness - Borrowings from Endowment Fund Condition Found The College has borrowed from its endowment funds for campus renovations and to cover certain operating expenses of the College prior to and following its accreditation and approval to participate in federal student financial aid programs. As such, the fair value of assets associated with the donor-restricted endowment funds has fallen below the level that the donor or UPMIFA requires the College to retain as a fund of perpetual duration. Corrective Action Plan The College obtained guidance from legal counsel regarding the appropriateness of borrowing from the endowment fund under Ohio UPMIFA. The College has developed long-term plans for maintaining and sustaining its financial stability, including restoration of the endowment, through the following strategies outlined in the board-approved Social Enterprise and Enrollment Plan: ● Grow advancement-derived revenue ● Implement core college footprint ● Align student-derived revenue ● Activate learning hubs ● Explore potential game changers, such as the College’s recent Federal Work College designation ● Assess non-payroll cost reduction strategies ● Invest in additional capacity incrementally ● Monitor performance, evaluate results, and course-correct as needed Responsible Person for Corrective Action Plan Jane Fernandes, President

View Audit 300675

Finding 389778 (2023-001)

Material Weakness 2023

Antioch College Corporation

OH

Material Weakness Reporting Internal Control / Segregation of Duties

Finding 2023-001 - Material Weakness - Required Material Adjustments Condition Found There were insufficient internal controls over financial reporting requiring material audit adjustments during the audit to prevent the financial statements from being materially misstated. Corrective Action Plan In...

Finding 2023-001 - Material Weakness - Required Material Adjustments Condition Found There were insufficient internal controls over financial reporting requiring material audit adjustments during the audit to prevent the financial statements from being materially misstated. Corrective Action Plan In September 2024, Antioch College contracted with the firm Dean Dorton Allen Ford, PLLC to provide Accounting and Financial Outsourcing services, filling and stabilizing the controller/CFO function. With their accounting expertise, the College has restructured accounting procedures to ensure reliable internal financial reporting including an improvement in accounting systems. The College is also focusing on additional traning for finance staff , streamlining financial reporting processes, and following internal controls. Responsible Person(s) for Corrective Action Plan Jane Fernandes, President Hannah Montgomery, Director of Operations and Administration

View Audit 300675

Finding 389759 (2023-003)

Material Weakness 2023

Greenfield-Central Community School Corporation

IN

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

Finding 2023-003 –Special Education Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Nathaniel Day and Robin LeClaire Contact Phone Number: 317-462-4434 Views of Responsible Official: We concur with the finding. Descr...

Finding 2023-003 –Special Education Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Nathaniel Day and Robin LeClaire Contact Phone Number: 317-462-4434 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will complete semi-annual certifications. We will also document more fully formal secondary review of vouchers Anticipated Completion Date: Already completed for the 2023-24 audit year

View Audit 300642

Finding 389752 (2023-004)

Material Weakness 2023

County of Ventura

CA

Special Tests & Provisions Cash Management Material Weakness

Program: COVID-19 Health Center Program Cluster Assistance Listing No.: 93.224 Federal Grantor: U.S. Department of Health and Human Services Passed-through: N/A Award No. and Year: Various Compliance Requirements: Special Tests and Provisions Type of Finding: Material Weakness in Internal Control ov...

Program: COVID-19 Health Center Program Cluster Assistance Listing No.: 93.224 Federal Grantor: U.S. Department of Health and Human Services Passed-through: N/A Award No. and Year: Various Compliance Requirements: Special Tests and Provisions Type of Finding: Material Weakness in Internal Control over Compliance and Material Non-Compliance Department’s Management Response: Health Care Agency (HCA) management agrees with the recommendation to strengthen the established policies and procedures to ensure that the sliding fee discount program schedules are applied to patient charges consistent with its sliding fee discount schedule, and to ensure that County personnel strictly adheres to policies and procedures. View of Responsible Officials and Corrective Action: HCA management recognizes that the sliding fee discount schedule/discount grid established in 2020 was complex and may have contributed to errors in adjustments. A new fee schedule was developed in 2023 to establish flat fees that are more inclusive of services. The grid established in 2020 was in effect until the new grid was approved by the Board of Supervisors on March 15, 2023. Most of the encounters selected for review were encounters dated prior to the new grid’s effective date. HCA management has strengthened its sliding fee policy and procedure, approved by the Board of Supervisor on March 15, 2023. HCA management will implement the following internal control process to ensure that adjustments are consistent with the sliding fee discount program fee schedule: 1. All Medical Billing Specialists responsible for enrolling patients into the sliding fee program will be retrained on eligibility and adjustments. 2. To ensure that patients have received the correct adjustment, we will run a report of all patients under the sliding fee program with at least one encounter, year to date. All applications, proof of income, program eligibility, and adjustments will be reviewed for each patient. Corrections will be made, if applicable. 3. For the remaining of FY 22/23, a monthly report of all encounters under the sliding fee discount program will be pulled and reviewed monthly for accuracy. Corrections will be made and staff will be trained, as needed. 4. Starting in FY 23/24, a random sampling of sliding fee discount program encounters per Federally Qualified Health Center will be audited monthly to ensure accuracy and timely adjustment of encounters. Results will be trended to address any additional process improvements. COUNTY OF VENTURA, CALIFORNIA CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2023 6 Name of Responsible Persons: Lizeth Barretto, Ambulatory Care COO – Ms. Barretto will ensure that the activities listed in the Corrective Action Plan are executed until an Ambulatory Care CFO and/or Ambulatory Care Patient Revenue Manager is hired. Ambulatory Care CFO (Vacant) – Establishes sliding fee discount program policy, procedures, and fee schedules. Ambulatory Care Patient Revenue Manger (Vacant) – Responsible for the oversight of the Medical Billing Specialists responsible for sliding fee discount eligibility and adjustments. Implementation Date: April 15, 2024, Training of Medical Billing Specialists and monthly encounter review and corrections. April 22, 2024, Year to date report and internal audit August 5, 2024, Monthly sampling of encounters

View Audit 300633

Finding 389686 (2023-002)

Material Weakness 2023

Maine Mathematics and Science Alliance

ME

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

Proper filing of the documentation supporting the approvals of payments will be maintained with Standard Operating Procedures outlining the processes to ensure consistency and the ability to retrieve documents even turning times of transition. Person(s) Responsible: Gina Grange Timing for Implement...

Proper filing of the documentation supporting the approvals of payments will be maintained with Standard Operating Procedures outlining the processes to ensure consistency and the ability to retrieve documents even turning times of transition. Person(s) Responsible: Gina Grange Timing for Implementation: Complete

View Audit 300592

Finding 389665 (2023-002)

Material Weakness 2023

Bradley Angle

OR

Procurement, Suspension & Debarment Material Weakness Matching / Level of Effort / Earmarking § 200.317 § 200.318 § 200.327

2023-002 Family Violence Prevention and Services/Discretionary – Assistance Listing No. 93.592 Recommendation: Update procurement policy to be compliant with Uniform Guidance.. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response t...

2023-002 Family Violence Prevention and Services/Discretionary – Assistance Listing No. 93.592 Recommendation: Update procurement policy to be compliant with Uniform Guidance.. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Our audit identified a weakness in our policy surrounding procurement. CFR 200.318 states the non-Federal entity's documented procurement procedures must conform to the procurement standards identified in Uniform Guidance CFR sections 200.317 through 200.327. We will align our spending thresholds and policy language with that Uniform Guidance. Name(s) of the contact person(s) responsible for corrective action: Richard Seymour, Finance Director Planned completion date for corrective action plan: By May 10, 2024

View Audit 300581

Finding 389641 (2023-003)

Material Weakness 2023

Felician University

NJ

Reporting Student Financial Aid Material Weakness

Federal Pell Grant Program; Federal Direct Student Loans – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and review regulations set by the Department of Education around reporting requirements to the NSLDS to ensure the University is in co...

Federal Pell Grant Program; Federal Direct Student Loans – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and review regulations set by the Department of Education around reporting requirements to the NSLDS to ensure the University is in compliance with enrollment reporting requirements. Action taken in response to finding: Registration and Records has implemented robust controls, policies, and procedures to ensure compliance with the requirements of the student financial assistance program. Despite challenges in working with the NSC, including occasional difficulties in understanding discrepancies in reported data, we have maintained ongoing staff training, expanded NSC reporting, improved records maintenance, and enhanced auditing and retrieval processes. Additionally, we have established a collaborative relationship with the NSC to address reporting issues promptly, although we recognize there may be instances beyond our control. Name(s) of the contact person(s) responsible for corrective action: Erminda Velez- Quinones, Director of Registration and Records. Planned completion date for corrective action plan: June 30th, 2024

View Audit 300547

Finding 389577 (2023-300)

Material Weakness 2023

State of Wisconsin

WI

Questioned Costs Allowable Costs / Cost Principles Eligibility

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-300: Eligibility for the Children’s Health Insurance Program. This is the department’s Corrective Action Plan. Recommendation (2023-300): Eligibility for the Children’s Health Insurance Program We...

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-300: Eligibility for the Children’s Health Insurance Program. This is the department’s Corrective Action Plan. Recommendation (2023-300): Eligibility for the Children’s Health Insurance Program We recommend the Wisconsin Department of Health Services work with the federal government to resolve these improper payments, including the determination of the total amount of improper payments, and return these amounts to the federal government, as appropriate. Wisconsin Department of Health Services Planned Corrective Action: The Division of Medicaid Services (DMS) acknowledges that we maintained eligibility under the Children’s Health Insurance Program (CHIP) for individuals who had turned age 19, including SCHIP participants. It was our overarching policy to not terminate health care coverage upon certain changes in circumstances for Medicaid participants during the federal public health emergency (PHE). To comply with this policy, DHS made system changes at the beginning of the pandemic to maintain eligibility for all participants. After CMS provided additional information specific to SCHIP, DHS considered whether to make the necessary system changes to terminate SCHIP participants who turned 19 during the public health emergency. Because of the system limitation and DHS’s overarching goals to maintain continuous coverage, amongst other reasons, DHS decided to temporarily keep all CHIP participants enrolled until the public health emergency ended. DMS leaders met with CMS leaders on May 11, 2022, to discuss this compliance issue and related systems limitations. During that meeting, CMS indicated that they understood the system and communication challenges of having a single program that combines Medicaid and CHIP. CMS also acknowledged that the federal public health emergency was likely to end at any time, so making the required system changes would not be prudent. CMS said they would follow up with Wisconsin if they determined that further state action was needed, but they did not communicate to us after the meeting that they felt the compliance issue needed to be addressed. This confirmed the Medicaid Director’s decision to not pursue costly systems changes to support a change that might only be needed for a short period of time. After the PHE ended, DHS took proactive steps to identify aged-out CHIP participants and ensure that their eligibility was redetermined in the first two months of unwinding. In contrast to the rest of the CHIP and Medicaid population, whose renewals were distributed over a 12-month period from June 2023 through May 2024, these members’ renewals were accelerated to June and July 2023, so that their CHIP coverage would end as soon as possible after the end of the PHE. While we agree conceptually with the finding, the questioned costs identified do not consider that many (if not most) of the ineligible members would have been eligible for Medicaid as childless adults upon aging out of the CHIP program. We will discuss this likelihood with CMS and if necessary, use data available in our CARES eligibility system to assess how many of these members did retain eligibility as childless adults or in other categories of Medicaid after completing renewals in June and July. Anticipated Completion Date: March 31, 2024 Person responsible for corrective action: Jori Mundy, Director Bureau of Eligibility and Enrollment Policy, Division of Medicaid Services jori.mundy@dhs.wisconsin.gov. Rebuttal from the Wisconsin Legislative Audit Bureau - As stated in the finding, and as acknoledged by DHS, DHS maintained continous eligibility for SCHIP participants who were over age 19. This eligibility requirement continue through the public health emergency. Since CHIP and MEDICAID are separate programs, consideration of whether these participants could have been eligible for the Medicaid program would not have been part of our audit. Payments to providers for these participants were funded by SCHIP and not the medicaid program.

View Audit 300490 Questioned Costs: $1

Finding 389576 (2023-302)

Material Weakness 2023

State of Wisconsin

WI

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-302: Social Services Block Grant – FFATA Reporting. This is the department’s Corrective Action Plan.  Recommendation (2023-302): Social Services Block Grant – FFATA Reporting We recommend the Wi...

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-302: Social Services Block Grant – FFATA Reporting. This is the department’s Corrective Action Plan.  Recommendation (2023-302): Social Services Block Grant – FFATA Reporting We recommend the Wisconsin Department of Health Services: • Revise its procedures for Federal Funding Accountability and Transparency Act reporting to ensure all subawards funded by federal grants are included in reports used to identify subawards for reporting; and • Develop procedures to identify and report subawards made by the state agencies to which it has transferred federal funding. Wisconsin Department of Health Services Planned Corrective Action: DHS will update FFATA procedures to ensure all DHS federal programs are included in FFATA reporting. DHS will also develop procedures to report the subawards made by other state agencies to whom DHS has transferred federal funding. Anticipated Completion Date: August 31, 2024 Person responsible for corrective action: Vanessa Salata, Section Chief Expenditure Accounting, Bureau of Fiscal Services, Division of Enterprise Services vanessaa.salata@dhs.wisconsin.gov

View Audit 300490

Finding 389539 (2023-101)

Material Weakness 2023

State of Wisconsin

WI

Eligibility Material Weakness Reporting § 200.303

Finding 2023-101: Homeowner Assistance Fund – Service Organization Controls Auditor Recommendation: Obtain the service organization audit report for the computer system used to administer the Homeowner Assistance Fund. Planned Corrective Action: The Wisconsin Department of Administration (Depar...

Finding 2023-101: Homeowner Assistance Fund – Service Organization Controls Auditor Recommendation: Obtain the service organization audit report for the computer system used to administer the Homeowner Assistance Fund. Planned Corrective Action: The Wisconsin Department of Administration (Department) has requested and will obtain the service organization audit report for the computer system used to administer the Homeowner Assistance Fund. Anticipated Completion Date: Immediately following the issuance of the service organization audit report for the period ended May 31, 2024, which is anticipated to be received not later than September 30, 2024. Auditor Recommendation: Complete a review of the service organization audit report, assess the effectiveness of the internal controls on the computer system maintained by the service organization, and document its review. Planned Corrective Action: The Department will develop the means to inform and document its review of the service organization audit report and its assessment of the effectiveness of the internal controls on the computer system maintained by the service organization. The Department will utilize those means to evidence reviews and assessments it completed but did not document as reported to and by the auditors, and for future received service organization audit reports, including the report that will be obtained for the period ended May 31, 2024. Anticipated Completion Date: June 30, 2024, as related to the development and use of the means to evidence prior completed but undocumented reviews and assessments, and within thirty days of receipt of the service organization audit report for the period ended May 31, 2024, which is anticipated to be received not later than September 30, 2024. Auditor Recommendation: Complete a review of the complementary user entity controls at the Department of Administration that are required to be in place for it to rely on the service organization audit report, document its review, and implement user entity controls, if needed. Planned Corrective Action: The Department will develop the means to inform and document its review of the complementary user entity controls at the Department that are required to be in place for it to rely on the service organization audit report, and will implement user entity controls, if needed. The Department will utilize those means to evidence the review of complementary user entity controls it completed but did not document as reported to and by the auditors, and for complementary user entity controls contained in future service organization audit reports, including the report that will be obtained for the period ended May 31, 2024. Anticipated Completion Date: June 30, 2024, as related to the development and use of the means to document the prior completed but undocumented review, and within thirty days of receipt of the service organization audit report for the period ended May 31, 2024, which is anticipated to be received not later than September 30, 2024. Persons responsible for corrective action: David Pawlisch, Administrator Division of Energy, Housing and Community Resources david.pawlisch@wisconsin.gov

View Audit 300490

Finding 389537 (2023-102)

Material Weakness 2023

State of Wisconsin

WI

Questioned Costs Allowable Costs / Cost Principles Eligibility

Finding 2023-102: Emergency Rental Assistance Program—Documentation to Support Applicant Eligibility and Benefit Payments Auditor Recommendation: Obtain required documentation for the four applicants we identified or seek to recoup improper benefit payments it made to these applicants. Planned ...

Finding 2023-102: Emergency Rental Assistance Program—Documentation to Support Applicant Eligibility and Benefit Payments Auditor Recommendation: Obtain required documentation for the four applicants we identified or seek to recoup improper benefit payments it made to these applicants. Planned Corrective Action: The Wisconsin Department of Administration (Department) requested and received from the auditors the four applicants they identified. The Department has reviewed available documentation in its eligibility and benefit determination system and will work with the responsible community action agencies and Energy Services, Inc. (ESI) to obtain required documentation supporting the applicants’ eligibility to receive Wisconsin Emergency Rental Assistance (WERA) Program benefits. Should the Department determine that it provided WERA Program benefits to ineligible recipients, it will seek to recoup the payments made. Auditor Recommendation: Provide additional training and technical assistance to the community action agencies and Energy Services, Inc. (ESI) on the adequacy of supporting documentation that is to be obtained and entered into Home Energy (HE) Plus by the community action agencies and ESI. Planned Corrective Action: The Department will provide additional training and technical assistance to the community action agencies and ESI on the adequacy of supporting documentation obtained and entered into Home Energy (HE) Plus, its eligibility and benefit determination system, based on its monitoring of accepted documentation. Anticipated Completion Date: June 30, 2024. Persons responsible for corrective action: David Pawlisch, Administrator Division of Energy, Housing and Community Resources david.pawlisch@wisconsin.gov

View Audit 300490 Questioned Costs: $1

Finding 389519 (2023-003)

Material Weakness 2023

Johnson County, Wyoming

WY

Subrecipient Monitoring Material Weakness Reporting

Corrective Action Plan County staff will continue to increase their knowledge on proper reporting requirement including specific reporting requirement for the different types of grants received by the County and required reporting under each grant. Additionally, the County will implement review pro...

Corrective Action Plan County staff will continue to increase their knowledge on proper reporting requirement including specific reporting requirement for the different types of grants received by the County and required reporting under each grant. Additionally, the County will implement review processes to ensure reports filed are done completely and accurately. Proposed completion date: June 30, 2024.

View Audit 300480

Finding 389482 (2023-002)

Material Weakness 2023

Homeless and Hunger Coalition of Northwest Florida, Inc.

FL

Material Weakness Internal Control / Segregation of Duties

The Executive Director and one other authorized signer will be required to review all supporting documentation for State or Federal Award program expense paid with any with any type of grant funding using the updated two signature paymont request form which specifies which grant fund is being used. ...

The Executive Director and one other authorized signer will be required to review all supporting documentation for State or Federal Award program expense paid with any with any type of grant funding using the updated two signature paymont request form which specifies which grant fund is being used. Routine indirect general office expenses will require approval by the Executive Director and a second authorized signer. However, the invoice may be reviewed and initialed, omitting the payment request form. However, any funding that is used as a grant administrative cost, will require the two-signature payment request form.

View Audit 300452

Finding 389433 (2023-001)

Material Weakness 2023

Caring Health Center, Inc.

MA

Material Weakness Reporting Internal Control / Segregation of Duties

Health Resources and Services Administration Frank Kostek, Caring Health Center Inc. Vice President and CFO respectfully submits the following corrective action plan for the year ended June 30, 2023: CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: June 30, 2023 The finding fro...

Health Resources and Services Administration Frank Kostek, Caring Health Center Inc. Vice President and CFO respectfully submits the following corrective action plan for the year ended June 30, 2023: CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: June 30, 2023 The finding from the June 30, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS FEDERAL AWARD PROGRAM AUDITS Material Weakness 2023-001 - Accuracy of Reporting to the PRF Portal: U.S Department of Health and Human Services, COVID-19: Provider Relief Fund and American Rescue Plan ("ARP") Rural Distribution: Assistance Listing Number 93.498 - Reporting Recommendation We recommend that the Organization strengthen its system of internal controls to ensure that all reporting that is done and submitted is consistent with requirements and instructions as provided by regulatory agencies. Action Taken The health center reviewed the instructions for filing the Provider Relief Report and we filed the report based on our understanding of the directions. In the future we will review filing directions more carefully and seek guidance from the report source if any reporting requirement is unclear. Sincerely yours, Frank J. Kostek Vice President of Finance, Chief Financial Officer

View Audit 300377

Finding 389343 (2023-004)

Material Weakness 2023

New Castle County, Delaware

DE

Subrecipient Monitoring Material Weakness Reporting § 200.303

MATERIAL WEAKNESS 2023-004 Community Development Block Grant/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County subsequently report the subawards not reported in FSRS. We further recommend the County strengthen controls and procedures to ensure that all r...

MATERIAL WEAKNESS 2023-004 Community Development Block Grant/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County subsequently report the subawards not reported in FSRS. We further recommend the County strengthen controls and procedures to ensure that all required subawards are reported accurately and timely to FSRS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Community Services was made aware of the FFATA issue at the end of FY22. The Department developed and executed a Standard Operating Procedure (SOP) to ensure all awards over $30,000 were submitted to the FSRS system within the required time. In FY23 we entered the FY22 and FY23 sub-recipient awards in FSRS. In FY23 there were expenses for sub-recipient awards that were issued in FY20 and FY21, which was identified by CLA. The Department will modify our SOP to require all sub-recipient awards be entered regardless of the fiscal year they were awarded; this ensures accurate and up-to-date reporting. Name(s) of the contact person(s) responsible for corrective action: Mike Kapa Planned completion date for corrective action plan: June 30, 2024

View Audit 300342

Finding 389338 (2023-003)

Material Weakness 2023

Columbiana Metropolitan Housing Authority

OH

Questioned Costs HUD Housing Programs Eligibility

Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Section 8 Housing Choice Vouchers and Mainstream Vouchers programs and will implement internal control procedures that will ensure compliance with federal regulations. Melissa Bead...

Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Section 8 Housing Choice Vouchers and Mainstream Vouchers programs and will implement internal control procedures that will ensure compliance with federal regulations. Melissa Beadle, Deputy Director, will be responsible for implementing this corrective action by June 30, 2024. CMHA is aware that the HAB/MRI software does not store waitlist reports by date processed and since then, CMHA has been saving Excel files of the waitlist reports. The applicants that were selected for the audit were applicants that had preference points. All applicants with preference points were contacted at the same time to be informed that they were eligible for a voucher. The CMHA waitlists were ran by preference points and time/date of application. Once those applicants were pulled the waitlist was not saved to Excel. The preference point list was then sorted alphabetically for sign in purposes and tracking of applicant documentation. This is the list that was provided to the auditor.

View Audit 300341 Questioned Costs: $1

Finding 389337 (2023-002)

Material Weakness 2023

Columbiana Metropolitan Housing Authority

OH

Questioned Costs HUD Housing Programs Material Weakness

Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Section 8 Housing Choice Vouchers and Mainstream Vouchers programs and will implement internal control procedures that will ensure compliance with federal regulations. Michael McDo...

Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Section 8 Housing Choice Vouchers and Mainstream Vouchers programs and will implement internal control procedures that will ensure compliance with federal regulations. Michael McDougle, HCV Manager, will be responsible to implement this corrective action by June 30, 2024. CMHA has been working diligently over the past IO months to implement this corrective action with the current two CMHA employee inspectors that are following up on the life and safety 24 hour inspections and also the 30 day follow ups. When landlords have informed CMHA that they are unable to find contractors to complement the maintenance failed items, CMHA is making a note on the inspection forms and tenant file as landlords inform CM HA that they are in need of additional time. The inspection reports under this audit were completed by the contractor, Inspection Group and have since then been corrected. To date, all of the failed inspections have been reinspected and passed.

View Audit 300341 Questioned Costs: $1

Finding 389336 (2023-001)

Material Weakness 2023

Columbiana Metropolitan Housing Authority

OH

Questioned Costs HUD Housing Programs Material Weakness

Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Section 8 Housing Choice Vouchers and Mainstream Voucher programs and will implement internal control procedures that will ensure compliance with federal regulations. Michael McDou...

Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Section 8 Housing Choice Vouchers and Mainstream Voucher programs and will implement internal control procedures that will ensure compliance with federal regulations. Michael McDougle, HCV Manager, will be responsible to implement this corrective action by June 30, 2024. CMHA has been working diligently over the past IO months to correct the inspection process that was not completed by the contracted inspectors through Inspection Group. Tenants were under the impression that they were not required to have inspections if someone was sick in their household, as previously waived during the pandemic. The HCV tenants have since been informed with each month's recertification mailing that they are required under HUD regulations to have an annual inspection. CMHA has also trained and assigned two HCV staff to become inspectors and have a process in place where one employee completes the annual inspections and the other employee follows up on the reinspection as needed. If inspections are not completed by time of recertification, the HAP payment is held. To date, annual inspections have been completed by CMHA staff.

View Audit 300341 Questioned Costs: $1

Finding 389332 (2023-002)

Material Weakness 2023

The Thresholds and Affiliated Organizations

IL

Reporting Material Weakness

Condition: An award passed through IDHS was not initially classified with the correct assistance listing number on the Schedule of Expenditures of Federal Awards (SEFA) by the Agency. The incorrect ALN was identified during audit procedures and corrected by the Agency. Planned Corrective Action: Thr...

Condition: An award passed through IDHS was not initially classified with the correct assistance listing number on the Schedule of Expenditures of Federal Awards (SEFA) by the Agency. The incorrect ALN was identified during audit procedures and corrected by the Agency. Planned Corrective Action: Thresholds will have a colleague outside of the Grants team (Controller or SVP for Finance) review future SEFAs. We will pay particular attention to ensure all expenditures are shown with the correct ALN, dollar amounts, and other fields. Contact person responsible for corrective action: Al Shoreibah, Chief Financial Officer Anticipated Completion Date: April 1, 2024

View Audit 300324

Finding 389331 (2023-001)

Material Weakness 2023

The Thresholds and Affiliated Organizations

IL

Material Weakness Reporting

Condition: The Organization's controls in place for reporting submissions did not identify Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements guidelines were not followed related to the lost revenue calculations. The Period 4 reporting submission for...

Condition: The Organization's controls in place for reporting submissions did not identify Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements guidelines were not followed related to the lost revenue calculations. The Period 4 reporting submission for lost revenue did not follow the acceptable options outlined by HHS. Additionally, the Period 2 reporting submission, completed in the previous year, did not follow the acceptable options. Planned Corrective Action: Thresholds will have a second individual (Controller or SVP for Finance) review future award applications that are one-time or unusual in nature. We will pay particular attention to review the terms carefully so that Thresholds does not misunderstand things (such as the acceptable options, as in this case). Contact person responsible for corrective action: Al Shoreibah, Chief Financial Officer Anticipated Completion Date: April 1, 2024.

View Audit 300324

Finding 389300 (2023-002)

Material Weakness 2023

Rockport Housing Authority

MA

Questioned Costs HUD Housing Programs Special Tests & Provisions

RHA started using Affordable Housing to provide Rent Reasonableness reports. In addition, once the HCV program started to be managed by NHA, they use Rent O Meter to provide Rent Reasonableness Reports and NHA staff will enter those numbers into PHA web to maintain as a part of the annual renewal pr...

RHA started using Affordable Housing to provide Rent Reasonableness reports. In addition, once the HCV program started to be managed by NHA, they use Rent O Meter to provide Rent Reasonableness Reports and NHA staff will enter those numbers into PHA web to maintain as a part of the annual renewal process or when a rent increase is requested by the landlord. In addition, a checklist was developed to make sure that all items are collected as necessary and entered into the PHA web system (housing management system).

View Audit 300304 Questioned Costs: $1

Corrective Action Plans

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