Corrective Action Plans

Finding 397059 (2021-006)

Material Weakness 2021

Open Cities Health Center, Inc. and Affiliate

MN

Eligibility Special Tests & Provisions Subrecipient Monitoring

Finding 2021-006 Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Material Weakness Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 U.S. Department of Human Services Condition: Supporting documents could not be located for four of...

Finding 2021-006 Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Material Weakness Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 U.S. Department of Human Services Condition: Supporting documents could not be located for four of the thirty patients selected for testing. As such, we were unable to determine eligibility. Action Planned in Response to the Finding: Effective immediately, the revenue cycle team will implement and monitor procedures to ensure that all supporting documents are kept for determining sliding fee discounts and patient eligibility. Official Responsible for Ensuring the CAP: Becky Howard Planned Completion Date: June 30th, 2024

View Audit 306434

Finding 397056 (2021-005)

Material Weakness 2021

Open Cities Health Center, Inc. and Affiliate

MN

Questioned Costs Allowable Costs / Cost Principles Eligibility

Finding 2021-005 Compliance Requirement: Allowable Cost/Cost Principles Material Weakness Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 U.S. Department of Human Services Condition: A walkthrough of fourteen individuals was performed to agree personnel files a...

Finding 2021-005 Compliance Requirement: Allowable Cost/Cost Principles Material Weakness Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 U.S. Department of Human Services Condition: A walkthrough of fourteen individuals was performed to agree personnel files and to payroll. Of the fourteen files reviewed, seven had no approved current pay rate documented, and the salary or hourly rate paid was not the rate contained in the file. Action Planned in Response to the Finding: Effective immediately, the human resources team will begin using of a checklist within each file as an additional procedure to ensure that each file contains all necessary documents and that the file has been updated for current rates of pay. Official Responsible for Ensuring the CAP: Becky Howard Planned Completion Date: June 30th, 2024

View Audit 306434 Questioned Costs: $1

Finding 396650 (2021-001)

Material Weakness 2021

Three Rivers Health System, Inc. and Subsidiaries

MI

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Finding Number: 2021-001 Condition: The Organization's controls in place for reporting submission did not identify that guidelines were not followed related to the reporting of expenses. Planned Corrective Action: The Organization accepts the finding and has implemented additional layers of review r...

Finding Number: 2021-001 Condition: The Organization's controls in place for reporting submission did not identify that guidelines were not followed related to the reporting of expenses. Planned Corrective Action: The Organization accepts the finding and has implemented additional layers of review regarding expense submission to ensure the reports are submitted within the established guidelines. The submission was prepared by prior management that is no longer at the organization during a period of transition from the acquisition by Beacon. Subsequent reporting was performed for TRH by Beacon management after this initial submission and subsequent audits were performed with all findings resolved. As stated above, the Organization had sufficient additional expenditures and lost revenue from the COVID-19 pandemic and there are no resulting PRF recognition issues. Contact person responsible for corrective action: Harley McCoige, Controller Anticipated Completion Date: N/A - Completed

View Audit 306248 Questioned Costs: $1

Finding 396486 (2021-002)

Significant Deficiency 2021

The County of Lebanon, Pennsylvania

PA

Internal Control / Segregation of Duties Material Weakness Reporting

Segregation of Duties over Reporting: The Department was in need of additional accounting personnel and as of December 2023 a new employee was hired so adequate oversight will be corrected going forward.

View Audit 306097

Finding 396244 (2021-007)

Material Weakness 2021

California Fire Safe Council, Inc.

CA

Reporting Material Weakness § 200.302 § 200.328 § 200.329

Finding 2021-007 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Joel Rusco, Chief Financial and Administrative Officer Jessica Martinez, Program Director Jacy Hyde, Executive Director Contact Person: Joel Rusco, Chief F...

Finding 2021-007 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Joel Rusco, Chief Financial and Administrative Officer Jessica Martinez, Program Director Jacy Hyde, Executive Director Contact Person: Joel Rusco, Chief Financial and Administrative Officer Jessica Martinez, Program Director Corrective Action Plan: • Clark Nuber has reviewed the current closing and reporting policies and procedures. Clark Nuber’s proposed updates and revisions will be reviewed and approved by CFSC Management and thereafter implemented by CFSC staff. • CFSC will be considering an automated AP and approval processes through Bill.com or another similar provider to determine whether a provider of this nature will assist in more timely expenditure recognition workflows. • CFSC will update its fiscal reporting policies and procedures to direct that all reports are reviewed by both the grant manager and finance manager to ensure all known expenses are included and that the Schedule of Expenditures of Federal Awards is properly prepared in accordance with the Uniform Guidance. • CFSC will be doing a full review of policies and procedures to ensure they are compliant with GAAP and Uniform Guidance requirements. • The Board of Directors has approved hiring three additional Financial Staff to improve capacity for reporting. Anticipated Completion Date: CFSC will establish and implement the enhanced policies and procedures by the end of Q2 of 2024. CFSC aims to fully onboard additional Finance Staff in Q2 of 2024.

View Audit 305892

Finding 396243 (2021-006)

Material Weakness 2021

California Fire Safe Council, Inc.

CA

Subrecipient Monitoring Reporting Material Weakness § 200.328 § 200.329

Finding 2021-006 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jessica Martinez, Program Director Joel Rusco, Chief Financial and Administrative Officer Jacy Hyde, Executive Director Contact Person: Joel Rusco, Chief F...

Finding 2021-006 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jessica Martinez, Program Director Joel Rusco, Chief Financial and Administrative Officer Jacy Hyde, Executive Director Contact Person: Joel Rusco, Chief Financial and Administrative Officer Jessica Martinez, Program Director Corrective Action Plan: • CFSC retained Clark Nuber to review current reporting policy and procedures. Clark Nuber’s recommendations will be reviewed and approved by CFSC management and thereafter implemented by all CFSC staff. • CFSC will implement the updated policy, procedures, and tracking mechanisms to ensure all grant progress reports are submitted to managers prior to the due date for review, approval, and timely submission to the funding agency. • CFSC is conducting a full review of policies and procedures to ensure they are compliant with GAAP and Uniform guidance requirements. Anticipated Completion Date: CFSC will establish and implement the new policies and procedures by the end of Q2 2024.

View Audit 305892

Finding 396045 (2021-004)

Material Weakness 2021

Orutsararmiut Native Council

AK

Special Tests & Provisions Material Weakness Internal Control / Segregation of Duties

Federal Agency: US Department of the Interior Federal Program: BIA Compact Assistance Listing Number: 15.022 Award Number: GT-OSGT043-16 Award Year: 2021 Type of Finding: Material Weakness in internal control over compliance and material noncompliance. Name of Contact: Brian Henry, Executive Dire...

Federal Agency: US Department of the Interior Federal Program: BIA Compact Assistance Listing Number: 15.022 Award Number: GT-OSGT043-16 Award Year: 2021 Type of Finding: Material Weakness in internal control over compliance and material noncompliance. Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Due to miscommunication and turnover of accounting personnel, a misunderstanding arose regarding the collateralization of the Council’s general checking account to which federal awards are deposited. The financial institution utilizes a repurchase agreement by which the daily remaining collected balance in the checking account is invested by the bank, acting as agent of the Council. Securities purchased are exclusively obligations of the U.S. government and/or its agencies, or municipal bonds rated A or better. Proposed Completion Date: This finding is presently resolved.

View Audit 305670

Finding 396042 (2021-003)

Material Weakness 2021

Orutsararmiut Native Council

AK

Material Weakness Reporting Internal Control / Segregation of Duties § 200.512

Federal Agencies: US Department of Treasury and Department of the Interior Federal Programs: CARES Act (CARES), ARPA, ERA and BIA Compact, respectively Assistance Listing Numbers: 21.019, 21.027, 21.023 and 15.022, respectively Award Numbers: None, None, ERA0672, GT-OSGT043-16, respectively Award Y...

Federal Agencies: US Department of Treasury and Department of the Interior Federal Programs: CARES Act (CARES), ARPA, ERA and BIA Compact, respectively Assistance Listing Numbers: 21.019, 21.027, 21.023 and 15.022, respectively Award Numbers: None, None, ERA0672, GT-OSGT043-16, respectively Award Years: 2021 (CARES), 2021 (ARPA), 2021 (ERA) and 2021 (BIA Compact), respectively Type of Finding: Material weakness in internal control over compliance and material noncompliance. Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Due to turnover in the finance department, there have been unplanned delays in preparing for and scheduling the annual audit. All efforts are focused on the timely completion of the year-end closing and scheduling of the audit in advance of the nine-month deadline. Proposed Completion Date: December 31, 2024

View Audit 305670

Finding 395081 (2021-002)

Material Weakness 2021

Houston Housing Authority

TX

HUD Housing Programs Eligibility Material Weakness

The Houston Housing Authority agrees with this finding. The Houston Housing Authority has undertaken a program to review all voucher files for the purpose of getting all delinquent recertifications completed. During this process, if other required documents are identified, steps are taken to complet...

The Houston Housing Authority agrees with this finding. The Houston Housing Authority has undertaken a program to review all voucher files for the purpose of getting all delinquent recertifications completed. During this process, if other required documents are identified, steps are taken to complete the missing documentation and make sure that the files are complete. This review is still ongoing with expected completion in the first half of 2024. Where needed staff will be provided the necessary training to make sure that all HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having competent, well-trained staff working in the HCVP as well as other departments within the agency.

View Audit 305009

Finding 395080 (2021-001)

Material Weakness 2021

Houston Housing Authority

TX

Internal Control / Segregation of Duties HUD Housing Programs Material Weakness

The recommendation of the auditor was for the Houston Housing Authority to review its existing internal control procedures to ensure that data is properly recorded in the books and records to prevent misstatements from occurring in the future. l he Houston Housing Authority agrees with this finding ...

The recommendation of the auditor was for the Houston Housing Authority to review its existing internal control procedures to ensure that data is properly recorded in the books and records to prevent misstatements from occurring in the future. l he Houston Housing Authority agrees with this finding and related recommendations. During the audit, as these issues arose, notes were taken, evaluation of what had happened was made so that we could make the necessary adjustments to our procedures to prevent the continuation of these issues. In addition, we hired a firm to come in and undertake a review of the finance department. The purpose of this review was to review our existing staffing levels, workloads, experience, etc., for purposes of proposing a reorganization of the finance department to address any deficiencies. We have reviewed the recommendations from this consultant and are in the process of implementing many of the recommended changes. As we continue to work on getting all past due audits completed we are working very diligently to address the issues within the finance department that gave rise to this finding. We fully expect the finding to be present for the 2022 audit as many of the departmental improvements and changes were not made prior to 2023 so would not have been in practice during 2022. Our audit delinquencies commenced with the 2019 audit being delayed in part due to the COVID pandemic. We also determined in the completion of the 2019 audit that it was in the best interest of HHA to terminate our relationship with the prior auditor and procure a new audit firm. The completion of the 2021 audit will be our second audit wrapped up with the new audit firm. We are confident that the changes we have made and will continue to make will ensure that future prepared by the Houston Housing Authority will be in better condition than those for the 2021 audit. existing internal control procedures to ensure that data is properly recorded in the books and records to prevent misstatements from occurring in the future.

View Audit 305009

Finding 395061 (2021-005)

Material Weakness 2021

Housing Authority of Cass County

ND

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

Contact Person Derek Johnson, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and monitoring of program activity. Planned Completion Date for CAP December 31, 2022.

View Audit 304992 Questioned Costs: $1

Finding 394595 (2021-002)

Significant Deficiency 2021

The County of Lebanon, Pennsylvania

PA

Internal Control / Segregation of Duties Material Weakness Reporting

Segregation of Duties over Reporting: The Department was in need of additional accounting personnel and as of December 2023 a new employee was hired so adequate oversight will be corrected going forward.

View Audit 304491

Finding 394528 (2021-105)

Material Weakness 2021

Pancare of Florida, INC

FL

Cash Management Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Use of Budgeted Versus Actual Costs for Reimbursements Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Corrective Action Planned: The Organization has hired a n...

Use of Budgeted Versus Actual Costs for Reimbursements Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented

View Audit 304417

Finding 394526 (2021-101)

Material Weakness 2021

Pancare of Florida, INC

FL

Subrecipient Monitoring Special Tests & Provisions Matching / Level of Effort / Earmarking § 200.303

Lack of Internal Controls Over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identi...

Lack of Internal Controls Over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization’s policies for the sliding fee scale were recently updated during fiscal year 2022, by management, based on findings during the monitoring by HRSA performed in 2022, but management will consider discussing potential improvements to their policy with the grantor to potentially update it to allow for certain exceptions. The Organization will also consider discussing the agreement with the local school district in more detail with the grantor to either structure their policies to allow for these visits to have different requirements or to see if the grantor would be willing to provide a waiver with regards to theses visits not being technically in compliance with other regular clinic visits. The planned corrective action for this finding is currently in the process of development, approval, and implementation. The Organization expects to have the corrective action implemented by July 1, 2024. The Organization will continue to engage the consulting services of the professional certified accounting firm to assist in this process through completion. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: July 1, 2024

View Audit 304417

Finding 393788 (2021-005)

Material Weakness 2021

Housing Authority of the City of Pueblo

CO

Special Tests & Provisions Allowable Costs / Cost Principles HUD Housing Programs

U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing – 2021 Special Tests and Provisions: Project-Based Budgeting and Accounting Material Weakness in Internal Control over Compliance Finding Summary: During testing, we identified several errors in how expenses we...

U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing – 2021 Special Tests and Provisions: Project-Based Budgeting and Accounting Material Weakness in Internal Control over Compliance Finding Summary: During testing, we identified several errors in how expenses were being charged and or allocated to the projects. In addition, there was insufficient documentation supporting how allocation methods were determined and there were no reviews of the allocation calculations by another individual. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: We agree that in 2021 expenses were not consistently allocated to our Public Housing Projects. However, we have now implemented consistent allocation methods so that expenses charged to our Public Housing projects will be reasonable and proper. We also review those allocation methods an a regular basis and change them as necessary. Anticipated Completion Date: January 2023

View Audit 303983

Finding 393787 (2021-004)

Material Weakness 2021

Housing Authority of the City of Pueblo

CO

Eligibility Material Weakness Internal Control / Segregation of Duties

U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing – 2021 Eligibility Material Weakness in Internal Control over Compliance Finding Summary: Testing indicated that there was an error in a tenant’s rent calculation that was not detected by the Authority’s intern...

U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing – 2021 Eligibility Material Weakness in Internal Control over Compliance Finding Summary: Testing indicated that there was an error in a tenant’s rent calculation that was not detected by the Authority’s internal controls. In addition, there was no review of the rent calculation by another individual. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: We have implemented a process to ensure eligibility requirements are being followed and that another person reviews the rent calculations once they are determined. Anticipated Completion Date: January 2023

View Audit 303983

Finding 393781 (2021-003)

Material Weakness 2021

Housing Authority of the City of Pueblo

CO

HUD Housing Programs Material Weakness Internal Control / Segregation of Duties

U.S. Department of Housing and Urban Development – CFDA #14.871 Section 8 Housing Choice Vouchers Special Test and Provisions – HQS Enforcement Material Weakness in Internal Control over Compliance and Material Instance of Non-Compliance Finding Summary: There was no documentation of a life-threaten...

U.S. Department of Housing and Urban Development – CFDA #14.871 Section 8 Housing Choice Vouchers Special Test and Provisions – HQS Enforcement Material Weakness in Internal Control over Compliance and Material Instance of Non-Compliance Finding Summary: There was no documentation of a life-threatening issue being resolved within 24 hours. There were 60 failed inspection reports tested and 13 instances where a life-threatening issue was identified and HACP did not have documentation that the issue was resolved within 24 hours as required. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: We have procedures in place that require follow up inspections and believe these issues were corrected, but the documentation was not obtained. The Housing Authority has implemented a process that requires proper documentation to be completed, after a failed inspection, to show that proper action was taken to correct the issue within the prescribed timeframe. Anticipate Completion Date: January 2023

View Audit 303983

Finding 393763 (2021-002)

Material Weakness 2021

Gateway Community Health Centers, Inc.

NC

Cash Management Material Weakness Internal Control / Segregation of Duties

Management Response: The current policy will be reviewed for changes necessary to ensure compliance with Section 330(k)(3)(E), (F), and (G) of the PHS Act; and 42 CFR 51c.303(e), (f), and (g) and 42 CFR 56.303(e), (f), and (g). We concur that we did not write off the receivables from the subsidiary ...

Management Response: The current policy will be reviewed for changes necessary to ensure compliance with Section 330(k)(3)(E), (F), and (G) of the PHS Act; and 42 CFR 51c.303(e), (f), and (g) and 42 CFR 56.303(e), (f), and (g). We concur that we did not write off the receivables from the subsidiary ledger monthly, which will be reviewed as to the efficiency of monthly write-off, with any necessary changes. We did make a bad debt allowance for those write-offs in a timely manner, thus meeting the essence of our policy #PS-06 entitled Billing, Collection and Debt Write-off.

View Audit 303939

Finding 393712 (2021-001)

Material Weakness 2021

Community Development Partnership

MA

Material Weakness

The Net Suite accounting software is set up to separate transactions for its Rural Development (RD) project (Fred Bell Way) and to produce a separate statement of financial position and a general ledger. However, at the point of conversion to the Net Suite software in March 2021 and for several mon...

The Net Suite accounting software is set up to separate transactions for its Rural Development (RD) project (Fred Bell Way) and to produce a separate statement of financial position and a general ledger. However, at the point of conversion to the Net Suite software in March 2021 and for several months thereafter this functionality was not being utilized correctly. and as such, there are historical transactions which must be corrected to separate all of the transactions for the RD project (Fred Bell Way). We are working with Net Suite consultants to assist us in getting these corrections processed.Anticipated Completion Date April 15, 2024.Responsible Contact Person-Kathleen Boyce, CFAO.

View Audit 303856

Finding 393537 (2021-003)

Material Weakness 2021

Tucson Audubon Society

AZ

Material Weakness Reporting Internal Control / Segregation of Duties

National Park Service Conservation, Protection, outreach, and Education – Assistance Listing No. 15.954 Recommendation: We recommend management review its current processes and procedures to ensure reports are submitted timely, reviewed, and ensure evidence is retained to support the compilation, r...

National Park Service Conservation, Protection, outreach, and Education – Assistance Listing No. 15.954 Recommendation: We recommend management review its current processes and procedures to ensure reports are submitted timely, reviewed, and ensure evidence is retained to support the compilation, review, and submission of the reports and ensure compliance with UG. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As of the fall of fiscal year 2023, all Federal Reporting has been brought up to date. TAS now tracks all reporting due dates and requirements in a spreadsheet that is managed by our Program point person in conjunction with the finance staff to ensure both Project Performance Reports and Financial Reports are submitted by the federal due dates. Name(s) of the contact person(s) responsible for corrective action: Kim Lopez, Director of Finance & Operations, Erin Zylstra, Quantitative Ecologist Planned completion date for corrective action plan: COMPLETED

View Audit 303685

Finding 392608 (2021-008)

Material Weakness 2021

Fairbanks Rescue Mission, Inc.

AK

Questioned Costs Subrecipient Monitoring Material Weakness

Federal Award Finding: 2021-008 Material Weakness in Internal Control over Compliance and Nompliance - Reporting Requirements. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with extensiv...

Federal Award Finding: 2021-008 Material Weakness in Internal Control over Compliance and Nompliance - Reporting Requirements. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with extensive banking and accounting experience to create a higher level of scrutiny and oversite of the Missions finances. We contracted a professional accounting/bookkeeping firm {Midnight Sun Bookkeeping Services) and empowered them to establish procedures and practices consistent with GAAP {Generally Accepted Accounting Principles) as well as track and participate in day to day activities of Accounting; thereby, assuring accuracy of financial data and assuring compliance. We have formalized check writing, money handling, and credit card control procedures. Switched to an online time tracking system for employees and digitized all employee documents. Created an online filing system for all grant expenses Proposed Completion Date: January 01, 2024

View Audit 302911 Questioned Costs: $1

Finding 392607 (2021-007)

Material Weakness 2021

Fairbanks Rescue Mission, Inc.

AK

Questioned Costs HUD Housing Programs Subrecipient Monitoring

Federal Award Finding: 2021-007 Material Weakness in Internal Control over Compliance and Noncompliance - Eligibility Requirement. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with exte...

Federal Award Finding: 2021-007 Material Weakness in Internal Control over Compliance and Noncompliance - Eligibility Requirement. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with extensive banking and accounting experience to create a higher level of scrutiny and oversite of the Missions finances. We contracted a professional accounting/bookkeeping firm {Midnight Sun Bookkeeping Services) and empowered them to establish procedures and practices consistent with GAAP {Generally Accepted Accounting Principles) as well as track and participate in day to day activities of Accounting; thereby, assuring accuracy of financial data and assuring compliance. We have formalized check writing, money handling, and credit card control procedures. Switched to an online time tracking system for employees and digitized all employee documents. Created an online filing system for all grant expenses Proposed Completion Date: January 01, 2024

View Audit 302911 Questioned Costs: $1

Finding 392605 (2021-005)

Material Weakness 2021

Fairbanks Rescue Mission, Inc.

AK

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

Financial Statement and Federal Award Finding: 2021-005 Material Weakness in Internal Control over Financial Reporting and Compliance and Noncompliance -Allowable Costs/Cost Principles. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's...

Financial Statement and Federal Award Finding: 2021-005 Material Weakness in Internal Control over Financial Reporting and Compliance and Noncompliance -Allowable Costs/Cost Principles. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with extensive banking and accounting experience to create a higher level of scrutiny and oversite of the Missions finances. We contracted a professional accounting/bookkeeping firm (Midnight Sun Bookkeeping Services) and empowered them to establish procedures and practices consistent with GAAP (Generally Accepted Accounting Principles) as well as track and participate in day to day activities of Accounting; thereby, assuring accuracy of financial data and assuring compliance. We have formalized check writing, money handling, and credit card control procedures. Switched to an online time tracking system for employees and digitized all employee documents. Created an online filing system for all grant expenses Proposed Completion Date: January 01, 2024

View Audit 302911 Questioned Costs: $1

Finding 392596 (2021-002)

Material Weakness 2021

Self Regional Healthcare and Affiliates

SC

Reporting Allowable Costs / Cost Principles Material Weakness

Contact Person: Timothy Evans Managements Response: The issue involved not keeping manual purchase order requests that contained original approvals for a period of greater than two years. At the time of the audit the original manual purchase requisition requests had not been saved or scanned. ...

Contact Person: Timothy Evans Managements Response: The issue involved not keeping manual purchase order requests that contained original approvals for a period of greater than two years. At the time of the audit the original manual purchase requisition requests had not been saved or scanned. When we recognized this deficiency, we immediately changed our processes so that all original requests for purchase orders that have the authorizing signatures are saved for a period of 5 years. Completion Date: January 2024.

View Audit 302889

Finding 392586 (2021-004)

Material Weakness 2021

The Jackson County Health Care Authority

AL

Questioned Costs Allowable Costs / Cost Principles Eligibility

Finding 2021-004- Material Weakness and Material Noncompliance over Allowable Cost and Reporting Contact Person: Andrew Wenning Managements Response: During a review of expenses related to the COVID pandemic, the audit identified payroll and non-payroll expenses that management first thought eligibl...

Finding 2021-004- Material Weakness and Material Noncompliance over Allowable Cost and Reporting Contact Person: Andrew Wenning Managements Response: During a review of expenses related to the COVID pandemic, the audit identified payroll and non-payroll expenses that management first thought eligible but on further review, (and subsequent to the submission to the portal) determined were unallowable per the Coronavirus Relief Fund grant terms and conditions. Management has put into place a policy for an individual in the accounting department to review all COVID expenses on a monthly basis going forward. In addition, management will further investigate the total likely questioned cost in order to determine the complete known questioned cost in the period 1 payroll and non-payroll expenditure population by June 30, 2024. For payroll expenses, the policy includes that a review and approval of the expenditures will be performed by an individual in accounting to ensure that the hours and wages calculated meet the terms and conditions of the CRF. If any non-eligible payroll expenses are identified during the review process, they will be removed. For all other expenses, we will obtain and retain approved copies of all invoices or other documentation to support expenses and review for eligibility. If any non-eligible expenses are identified during the review process, they will be removed. Completion Date: April 5, 2024

View Audit 302859 Questioned Costs: $1

Corrective Action Plans

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