Corrective Action Plans

Finding 388416 (2022-001)

Material Weakness 2022

Christus Health

TX

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

Finding 2022-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: ...

Finding 2022-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: July 1, 2020 to June 30, 2022 Corrective Action Planned: Management agrees that certain expenses to the COVID department were not reviewed and approved at the order entry level in specific cases. Although evidence of review was not retained for every charge to the COVID department, we believe the appropriateness of the charge was reasonable. Additionally, based on monthly review of departmental expenses and full-time equivalent (FTE) analysis at the facility level, we believe that these expenditures are subject to the appropriate level of review to identify unexpected variances. As it relates to the COVID Activity Code, this code was created as a means to track certain COVID hours worked, but was not configured to calculate the amounts associated with those hours, resulting in the need to make reasonable estimates. Even using the base pay rate at the time the hours were incurred would not have been accurate since it would omit adjustments for shift differentials, weekend hours, and overtime. We performed internal analyses and reviewed the results of samples selected by the auditors and concluded that the risk of a material overcharge to the program was minimal. Further, we have almost $40 million of unused lost revenues after our final PRF submission for Period 5, such that any questioned costs would easily be covered by other eligible uses of PRF funds. We have reviewed our processes related to the retention of expense documentation to improve audit evidence should this program ever be awarded in future periods. Responsible party: Lee Sonne, Vice President of Finance and Controller Implementation Date: Procedures were reviewed and analysis completed along with the Period 5 portal filing in September 2023.

View Audit 300148 Questioned Costs: $1

Finding 387734 (2022-001)

Material Weakness 2022

City of Grand Rapids, Michigan

MI

Reporting Subrecipient Monitoring Material Weakness § 200.501 § 200.508 § 200.510 § 200.518

Finding Number: 2022-001 Condition: The original SEFA prepared for audit purposes did not include all federal expenditures that should have been reported under ALN 66.443. Planned Corrective Action: All programs that have both Federal and State/Local funding will be examined to ensure correct expend...

Finding Number: 2022-001 Condition: The original SEFA prepared for audit purposes did not include all federal expenditures that should have been reported under ALN 66.443. Planned Corrective Action: All programs that have both Federal and State/Local funding will be examined to ensure correct expenditure by funding source is properly recorded. Contact person responsible for corrective action: Curt A. Reppuhn, CPA Deputy Comptroller Anticipated Completion Date: Fiscal Year Ended June 30, 2023

View Audit 299804

Finding 386546 (2022-004)

Material Weakness 2022

Neuse River Council of Governments D/b/a Eastern Carolina Council

NC

Allowable Costs / Cost Principles Cash Management Material Weakness

The Council agrees with this finding. The Council has hired a new Finance Director with the appropriate skills, knowledge, and experience to oversee the Finance Department. The Finance Director has identified and corrected internal control issues.

View Audit 298859

Finding 386434 (2022-002)

Material Weakness 2022

Elkhart and St. Joseph Counties Head Start Consortium

IN

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

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

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

View Audit 298779 Questioned Costs: $1

Finding 386268 (2022-005)

Material Weakness 2022

Churches United for the Homeless

MN

Allowable Costs / Cost Principles Material Weakness

Department of Treasury Federal Financial Assistance Listing/ALN 21.027 COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Allowable Costs and Allowable Activities Material Weakness in Internal Control over Compliance Finding Summary: The Organization’s internal controls did not have adequate...

Department of Treasury Federal Financial Assistance Listing/ALN 21.027 COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Allowable Costs and Allowable Activities Material Weakness in Internal Control over Compliance Finding Summary: The Organization’s internal controls did not have adequate internal controls to ensure payroll costs and invoice allocations are properly calculated. Responsible Individuals: Robben Luhning and Susan Koesterman. Corrective Action Plan: During 2022, a new payroll system was implemented that should rectify the issue. Anticipated Completion: December 31, 2023.

View Audit 298678

Finding 386174 (2022-006)

Material Weakness 2022

Danville Redevelopment & Housing Authority

VA

Questioned Costs HUD Housing Programs Material Weakness

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs to ensure that established internal control policies related to HQS...

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs to ensure that established internal control policies related to HQS inspections are being followed on a timely basis. Amy Barts, Director of Housing, is responsible for implementing this corrective action by December 31, 2023.

View Audit 298608 Questioned Costs: $1

Finding 386171 (2022-005)

Material Weakness 2022

Danville Redevelopment & Housing Authority

VA

Questioned Costs HUD Housing Programs Eligibility

Views of responsible officials and planned corrective action: The Authority agrees with the finding and will increase oversight on the maintenance of the waiting list and process of housing applicants to better monitor adequacy with compliance requirements. Amy Barts, Director of Housing, is respons...

Views of responsible officials and planned corrective action: The Authority agrees with the finding and will increase oversight on the maintenance of the waiting list and process of housing applicants to better monitor adequacy with compliance requirements. Amy Barts, Director of Housing, is responsible for implementing this corrective action by December 31, 2023.

View Audit 298608 Questioned Costs: $1

Finding 385640 (2022-006)

Material Weakness 2022

Perry County

MS

Allowable Costs / Cost Principles Material Weakness

Corrective Action Planned: Information received from Paymode is not always clear and concise as to what payment is for. We will do our best to comply. Anticipated Completion Date: Unknown Name of Contact Person Responsible for Corrective Action: Ashly Tingle, Comptroller

View Audit 298350

Finding 384394 (2022-008)

Material Weakness 2022

City of West Fargo

ND

Material Weakness Reporting Internal Control / Segregation of Duties

Reporting Material Weakness in Internal Control Over Compliance Federal Agency Name: Department of Treasury Pass‐Through Entity: North Dakota Office of Management and Budget Assistance Listing Number: 21.027 Program Name: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Finding Summary: ...

Reporting Material Weakness in Internal Control Over Compliance Federal Agency Name: Department of Treasury Pass‐Through Entity: North Dakota Office of Management and Budget Assistance Listing Number: 21.027 Program Name: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The amounts reported as expended in the current period and cumulative expenditures for the award did not agree with the amounts supported by the City’s accounting records. Corrective Action Plan: The City will thoroughly review the Project and Expenditure Report before submission. Subsequent reporting for this award corrected the amounts previously reported. Responsible Individuals: Dustin Scott, City Administrator Anticipated Completion Date: December 31, 2023

View Audit 297513

Finding 384392 (2022-006)

Material Weakness 2022

City of West Fargo

ND

Allowable Costs / Cost Principles Material Weakness Reporting

Activities Allowed or Unallowed Material Weakness in Internal Control Over Compliance Federal Agency Name: Department of Treasury Pass‐Through Entity: North Dakota Office of Management and Budget Assistance Listing Number: 21.027 Program Name: COVID-19 – Coronavirus State and Local Fiscal Recovery F...

Activities Allowed or Unallowed Material Weakness in Internal Control Over Compliance Federal Agency Name: Department of Treasury Pass‐Through Entity: North Dakota Office of Management and Budget Assistance Listing Number: 21.027 Program Name: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Finding Summary: During the course of the engagement, it was noted that the City has no formal review process for the allocation of payroll costs to federal awards, which could result in a material misstatement of the City’s schedule of expenditures of federal awards. Corrective Action Plan: The City will review its internal control processes over compliance to ensure that payroll costs allocated to federal awards are adequately reviewed. Responsible Individuals: Dustin Scott, City Administrator Anticipated Completion Date: December 31, 2023

View Audit 297513

Finding 384383 (2022-015)

Material Weakness 2022

The City of Frederick, Maryland

MD

Questioned Costs Allowable Costs / Cost Principles Material Weakness

New financial grant accountant has been assigned to work with departments to ensure proper accounting of expenditures.

View Audit 297486 Questioned Costs: $1

Finding 384380 (2022-012)

Material Weakness 2022

The City of Frederick, Maryland

MD

Subrecipient Monitoring Material Weakness Reporting

Whe subrecipients are identified we will assign staff to update portal, monitor and control work, finances, and reporting.

View Audit 297486

Finding 384055 (2022-001)

Significant Deficiency 2022

City of Davenport

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Davenport January 1, 2022 through December 31, 2022 This schedule presents the corrective action the City is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations ...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Davenport January 1, 2022 through December 31, 2022 This schedule presents the corrective action the City is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2022-001 Finding caption: The City’s internal controls were not adequate to ensure compliance with the revenue diversion special test requirements. Name, address, and telephone of City contact person: Steve Goemmel, City Administrator City of Davenport P. O. Box 26 411 Morgan Street Davenport, WA 99122 Corrective action the auditee plans to take in response to the finding: The City’s airport fund balance was overstated due to a coding error by the Clerk/Treasurer in 2022. Every month the city pays the Washington State Department of Revenue excise tax for its utility funds, (Water/Sewer/Garbage funds) plus any revenue generated from the sale of graves at the cemetery, and leasehold tax on the airport hangar leases. The Clerk/Treasurer uses a spreadsheet template to calculate these liabilities. He inadvertently entered the calculated remittance into the airport fund rather than the garbage fund. The resulting error caused the city to overstate the expenditures in the airport fund and understated the expenditures in the garbage fund. The amount of the remittance that was paid to the Washington State Department of Revenue and the dollar amount remitted was correct and expended to the proper corresponding funds. This was also done on three small expenditures on the city’s credit card account. The expenditure amounts were paid but misassigned to the airport fund. All these expenditures were true and paid in a timely fashion. There was no misappropriation of funds. They were simply data entry mistakes to different funds numbers. No airport funds within any of our FAA grants were used to pay the Washington State Department of Revenue or other vendors. Under my direction, the Clerk/Treasurer has amended his calculation worksheet so that it does not include any expenditure to the Airport Fund. Airport Leasehold Tax is now paid to the Special Leasehold account of the Washington Department of Revenue. The City will institute a revised financial policy for credit card use so this doesn’t happen in the future. All credit card expenditures will be reviewed for accuracy in earnest. Anticipated date to complete the corrective action: June 1, 2024

View Audit 297143

Finding 383857 (2022-007)

Material Weakness 2022

Community Partners

CA

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

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

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

View Audit 296891

Finding 383854 (2022-004)

Material Weakness 2022

Community Partners

CA

Questioned Costs Material Weakness Period of Performance § 200.334 § 200.403

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

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

View Audit 296891 Questioned Costs: $1

Finding 383716 (2022-010)

Material Weakness 2022

Solen Public School District No. 3

ND

Allowable Costs / Cost Principles Material Weakness Reporting

Contact Person David Drapeaux Corrective Action Plan The district will review and update existing policies and procedures related to allowable cost principles to address deficiencies identified in this finding. The administration will ensure that staff understand the principles of allowable costs an...

Contact Person David Drapeaux Corrective Action Plan The district will review and update existing policies and procedures related to allowable cost principles to address deficiencies identified in this finding. The administration will ensure that staff understand the principles of allowable costs and compliance requirements. Completion Date On-going

View Audit 296744

Finding 383714 (2022-009)

Material Weakness 2022

Solen Public School District No. 3

ND

Material Weakness Reporting

Contact Person David Drapeaux Corrective Action Plan The district will review and update existing policies and procedures related to allowable cost principles to address deficiencies identified in this finding. The administration will ensure that staff understand the principles of allowable costs an...

Contact Person David Drapeaux Corrective Action Plan The district will review and update existing policies and procedures related to allowable cost principles to address deficiencies identified in this finding. The administration will ensure that staff understand the principles of allowable costs and compliance requirements. Completion Date On-going

View Audit 296744

Finding 383713 (2022-011)

Material Weakness 2022

Solen Public School District No. 3

ND

Material Weakness Reporting § 200.512

Contact Person David Drapeaux Corrective Action Plan The district will complete the fiscal year 2023 audit requirement on or before the March 31, 2024 deadline. Going forward the audits will be completed on time and this finding will be resolved. Completion Date March 31, 2024

View Audit 296744

Finding 383712 (2022-008)

Material Weakness 2022

Solen Public School District No. 3

ND

Material Weakness Reporting

Contact Person David Drapeaux Corrective Action Plan The district will implement measures to enhance the accuracy and verification of data reported on the Federal Impact Aid Application. The Superintendent and Business Manager will work together in the future to implement validation checks and verif...

Contact Person David Drapeaux Corrective Action Plan The district will implement measures to enhance the accuracy and verification of data reported on the Federal Impact Aid Application. The Superintendent and Business Manager will work together in the future to implement validation checks and verification processes to ensure there is accurate documentation to verify information on the application. Completion Date On-going

View Audit 296744

Finding 382876 (2022-004)

Material Weakness 2022

Rio Grande Hospital

CO

Allowable Costs / Cost Principles Eligibility Material Weakness § 200.303

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: The Organization had various invoices and employee timecards identified as COVID-19 eligible ...

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: The Organization had various invoices and employee timecards identified as COVID-19 eligible that did not follow the Organization’s review and approval process for COVID-19 funding. Responsible Individuals: Greg Porter, CFO & Arlene Harms, CEO Corrective Action Plan: Management will ensure that all invoices and employee timecards are reviewed following the Organization’s review and approval process for COVID-19 funding. Anticipated Completion Date: Ongoing

View Audit 296454

Finding 382659 (2022-008)

Material Weakness 2022

County of Delta

MI

Material Weakness Reporting Internal Control / Segregation of Duties

2022-008: Material Weakness and Noncompliance – Report Preparation and Submission Statement of Condition/Criteria: Sponsors of commercial airports are required to submit FAA Form 5100-127, Operating and Financial Summary (OMB No. 2120-0569), which captures revenues and expenditures at the airport, ...

2022-008: Material Weakness and Noncompliance – Report Preparation and Submission Statement of Condition/Criteria: Sponsors of commercial airports are required to submit FAA Form 5100-127, Operating and Financial Summary (OMB No. 2120-0569), which captures revenues and expenditures at the airport, including revenue surplus. Sponsors of commercial airports are also required to submit FAA Form 5100- 126, Financial Government Payment Report (OMB No. 2120-0569), which captures amounts paid and services provided to other units of government. The County Airport did not file FAA Form 5100-127 or FAA Form 5100-126. Planned Corrective Action: County management will develop written policies and procedures for grants to ensure all required reports are prepared and submitted. Contact person responsible for corrective action: Ashleigh Young, County Controller/Administrator Anticipated Completion Date: March 2024

View Audit 296246

Finding 382656 (2022-007)

Material Weakness 2022

County of Delta

MI

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

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

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

View Audit 296246

Finding 382361 (2022-003)

Material Weakness 2022

Touchstone Behavioral Health Dba Touchstone Health Services

AZ

Material Weakness Internal Control / Segregation of Duties

Item: 2022-003 Assistance Listing Number: 93.498 Program: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Agency: U.S. Department of Health and Human Services Award Year: Period 2 Funds – Period of Availability January 1, 2020 – December 31, 2021 Compliance...

Item: 2022-003 Assistance Listing Number: 93.498 Program: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Agency: U.S. Department of Health and Human Services Award Year: Period 2 Funds – Period of Availability January 1, 2020 – December 31, 2021 Compliance Requirement: Activities allowed or unallowed Criteria or Specific Requirement: Management is responsible for Standards for Documentation that should be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Condition: Management did not retain proper documentation of the review and approval of certain allowable expenses. Name of Contact Person: Janae Ben-Shabat, CFO Phone Number: 480-516-3116 Anticipated Completion Date: March 31, 2024 Views of Responsible Officials and Corrective Actions: Touchstone Behavioral Health d/b/a Touchstone Health Services will implement internal controls to ensure documentation is retained to support that expenses are properly reviewed and approved.

View Audit 296042

Finding 382360 (2022-002)

Material Weakness 2022

Touchstone Behavioral Health Dba Touchstone Health Services

AZ

Reporting Material Weakness Period of Performance

Item: 2022-002 Assistance Listing Number: 93.498 Program: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Agency: U.S. Department of Health and Human Services Award Year: Period 2 Funds – Period of Availability January 1, 2020 – December 31, 2021 Complianc...

Item: 2022-002 Assistance Listing Number: 93.498 Program: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Agency: U.S. Department of Health and Human Services Award Year: Period 2 Funds – Period of Availability January 1, 2020 – December 31, 2021 Compliance Requirement: Reporting Criteria or Specific Requirement: Management is responsible for reporting complete and accurate usage of Provider Relief Funds to the Health Resources & Services Administrator (“HRSA”) for each applicable period. Condition: Certain unreimbursed expenditures, totaling $479,490, reported by management as qualified expenditures for Period 2 within the HRSA Reporting Portal were improperly reported as all being incurred in Q3 of 2020 when in fact a portion of the expenses we incurred through and should have been reported in Q1 2020, Q2 2020, Q4 2020, Q1, 2021, Q2, 2021, Q3 2021 and Q4, 2021. However, we noted that all qualified expenditures were still incurred within the proper period of performance. Additionally, management did not retain proper documentation of the review and approval of the reporting submitted to HRSA. Name of Contact Person: Janae Ben-Shabat, CFO Phone Number: 480-516-3116 Anticipated Completion Date: March 31, 2024 Views of Responsible Officials and Corrective Actions: Touchstone Behavioral Health d/b/a Touchstone Health Services will implement controls to ensure the proper review and approval of federal award reporting to the federal awarding and to ensure the reporting is accurate. Additionally, management will implement a review control such that an individual outside of the preparer reviews the federal award reporting.

View Audit 296042

Finding 380867 (2022-001)

Material Weakness 2022

Silver Lake Regional School District

MA

Subrecipient Monitoring Internal Control / Segregation of Duties HUD Housing Programs

The Silver Lake Regional School District will develop and then adhere to Business Office Procedure Manual. This manual will address day-to-day implementation of the Silver Lake Regional School Committee Policies related to Finance and Operations. Once created, this manual will assist in clarifying ...

The Silver Lake Regional School District will develop and then adhere to Business Office Procedure Manual. This manual will address day-to-day implementation of the Silver Lake Regional School Committee Policies related to Finance and Operations. Once created, this manual will assist in clarifying the roles and relationship of the School Committee (as defined by law) and School Administration (as defined by policy). It will also serve to communicate how the school organization functions-who is doing what, as well as where, when, and why so that resources are allocated and tracked both efficiently and effectively. Silver Lake Regional School District administration requested additional business office staffing positions at the January 11, 2024 School Committee Meeting. This request includes additional hours for current positions and/or additional positions listed below: District Accountant, District Treasurer, Grants Management, Transportation Coordinator Silver Lake will contract for a risk assessment in the Spring of 2024 and will continue to do so at recommended intervals. Once the Business Office is adequately staffed, these additional staff will assist in addressing the issues of timely centralized reporting and compliance.

View Audit 295550

Corrective Action Plans

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