Corrective Action Plans

Finding 501142 (2023-001)

Material Weakness 2023

TX

Internal Control / Segregation of Duties HUD Housing Programs Material Weakness

2023-001 Financial Reporting – Disclaimer of Opinion Material Weakness in Internal Control Material Noncompliance Condition: During our audit of the Authority’s financial statements, numerous adjustments were needed to properly report the financial statements in accordance with generally accep...

2023-001 Financial Reporting – Disclaimer of Opinion Material Weakness in Internal Control Material Noncompliance Condition: During our audit of the Authority’s financial statements, numerous adjustments were needed to properly report the financial statements in accordance with generally accepted accounting principles. Certain accounts had not been properly reconciled and corrective entries were not readily available. Significant audit adjustments were necessary for several audit areas and the audit was significantly delayed due to these adjustments. Given the amount of adjustments needed the auditor did not have enough time to complete the necessary audit procedures and as such have issued a disclaimer of opinion on the financial statements. Auditor’s Recommendations: The Authority should continue to develop and implement internal controls over both internal and external reporting, and the year-end close process to ensure reporting remains accurate and timely, with any unexpected financial data being investigated and corrected before it is reported. The Authority should consider additional staff training on development activities. Action Taken: The Houston Housing Authority agrees with this finding and related recommendations. During this 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. We are in the process of bringing in additional staff to expand the capacity of the Finance department. As we had fallen behind on our audits we anticipated the weaknesses noted in prior audits would continue to be present in future audits including the 2023 audit. We have been working very diligently to address the issues within the finance department that gave rise to this finding. We fully expected this finding or a similar finding to be present for the 2023 audit as many of the departmental improvements and changes were not in place during the 2023 calendar year. We have also been somewhat limited in the time available to implement changes as we have been working on clearing up the prior audit delinquencies since hiring out new outside auditors. This will be the first time in years where we will have a prior year audit available to us prior to the end of the current year. We will be able to have any 2023 audit adjustments posted to the general ledger prior to yearend 2024 so many of the reconciliation issues that have been encountered on the prior audits are not expected to be present when we move into the 2024 audit. The VP Fiscal and Business Operations as well as the Director of Finance are responsible for implementing the necessary process and procedural changes to eliminate the need for this type of finding for the 2024 audit.

View Audit 323395

Finding 501083 (2023-002)

Material Weakness 2023

Pembina County Housing Authority

ND

HUD Housing Programs Eligibility Material Weakness

Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Authority’s management company has hired a Deputy Director who completes quality control audits on all tenant files periodically. The Deputy Director holds monthly meetings with all eligibility staff workers to ensure compliance...

Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Authority’s management company has hired a Deputy Director who completes quality control audits on all tenant files periodically. The Deputy Director holds monthly meetings with all eligibility staff workers to ensure compliance with policies and procedures. Planned Completion Date for CAP Immediately.

View Audit 323357

Finding 501070 (2023-001)

Material Weakness 2023

Young Women's Christian Association of Metropoliatan St. Louis

MO

Reporting Subrecipient Monitoring Material Weakness

Management is committed to ensuring we are in compliance with all Head Start Reporting required by the Department of Health and Human Services and other regulatory bodies. Management has thoroughly reviewed all the terms and conditions of its grant awards with internal management and externally with...

Management is committed to ensuring we are in compliance with all Head Start Reporting required by the Department of Health and Human Services and other regulatory bodies. Management has thoroughly reviewed all the terms and conditions of its grant awards with internal management and externally with the Department of Health and Human Services and other regulatory bodies to ensure the proper completion of subaward reports in FSRS, the SF429 and other required reporting. The above noted issue was discovered during the course of the 2022 audit, but after the reporting deadlines for the 2023 year. Upon discovery of the requirement, Management took the above noted steps to become compliant with both 2022 and 2023. The finding repeated in 2023 solely due to the timing of the discover of the issue. Effective to date, all FSRS and applicable SF429 reports have been filed correctly and timely.

View Audit 323329

Finding 501049 (2023-003)

Significant Deficiency 2023

Forum for Cultural Engagement, Inc.

NY

Reporting Material Weakness Significant Deficiency § 200.508

Views of Responsible Officials and Action Taken: FCE agrees with the finding and has implemented a corrective action plan that requires the accounting and reporting to be performed by an outside CPA firm with expertise in accrual basis accounting, cost allocation and grant accounting concepts. Durin...

Views of Responsible Officials and Action Taken: FCE agrees with the finding and has implemented a corrective action plan that requires the accounting and reporting to be performed by an outside CPA firm with expertise in accrual basis accounting, cost allocation and grant accounting concepts. During FCE’s monthly financial review, we examine each grant/class level in QB, ensuring that expenses are properly charged to the correct grant in the correct period of performance.

View Audit 323314

Finding 501012 (2023-003)

Material Weakness 2023

Umpqua Public Transportation District

OR

Subrecipient Monitoring Cash Management Material Weakness § 200.302

Finding 2023-003 – Fiscal Management System (Material Weakness) Criteria: CFR Part 200.302.b Auditee Responsibilities includes the requirement that the financial management system of each non-Federal entity provide the following: Identification, in its accounts, of all Federal awards received and e...

Finding 2023-003 – Fiscal Management System (Material Weakness) Criteria: CFR Part 200.302.b Auditee Responsibilities includes the requirement that the financial management system of each non-Federal entity provide the following: Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. Accurate, current, and complete disclosure of the financial results of each Federal award or program. Condition: The District prepared reimbursement calculations according to an internally developed spreadsheet tool, rather than using amounts directly obtained from the general ledger and supporting documentation. The reimbursement reports were to be reviewed by the District Manager prior to submission. Approval of the reimbursement requests and supporting reports by the District Manager were often delayed. Cause: General ledger data used to prepare spreadsheets, then used to complete reimbursement requests added unnecessary complexity and potential for errors in the reimbursement and request and grant reporting process. Internal control procedures assuring timely review of reports and filing of the reimbursement requests were not designed or implemented. Effect or Potential Effect: The lack of effective internal control activities over financial reporting could allow for inadvertent errors, such as calculation errors, payments for unauthorized purposes, and result in improper financial reporting. Lack of timely filing of reimbursement requests could result in overstating accounts receivable balances and critical revenues lost due to cutoff terms of the grant award. Questioned Cost: No Context: Delays in filing reimbursement claims and internal disputes regarding grant reimbursement request procedures were evident. The weak or nonexistent controls over the reimbursement request procedures resulted in lost revenues and delayed recognition of revenue, which required adjustments to correct the financial statements. Repeat of a Prior-Year Finding: Yes, Financial Statement Findings 2022-001 Recommendation: The District should establish a more simplified and effective process for the review and approval of GAAP basis reporting and grant reimbursement requests and grant reporting. As part of this process, supporting general ledger reports and supporting data should be subject to a qualified individual to review and approval on a timely basis. Monitoring of the control procedures related to the grant accounting and reimbursement request should be performed regularly to ensure reports are filed accurately and timely. Information and communication regarding identified weaknesses and opportunities to improve the policies and procedures should occur among management and the individual performing the monitoring of the procedures. District's Response: The District’s Finance Manager and District Manager are working towards using general ledger reporting exclusively for reimbursement request reporting. General ledger activity became more timely as improvements were implemented based on prior year findings. Management acknowledges delays in that process that continued as a result, to some extent, of the use of the self-developed spreadsheet reports then used for completing grant reimbursement requests. Corrective Action Plan: The District’s Finance Manager will continue to make improvements in general ledger recording and reporting systems so that those reports can then be used without intermediary report methods to prepare reimbursement request forms. Review of the reimbursement requests will take place within data reports generated directly from the general ledger. The district will engage an individual or firm to ensure that the timing and overall processes related to grant reimbursement and reporting does not result in reporting errors or omissions. Planned Implementation Date: September 30, 2024 Responsible Person: General Manager, Umpqua Public Transit District

View Audit 323248

Finding 500933 (2023-002)

Material Weakness 2023

Wabanaki Health and Wellness

ME

Material Weakness Internal Control / Segregation of Duties

2023-002 - Material Weakness - Year End Cutoff WPHW understands this finding and recognizes the corrections that were planned for FY23 did not come to fruition due to the challenges with implementing a new financial management system. Despite these challenges, WPHW has made strides in improving our...

2023-002 - Material Weakness - Year End Cutoff WPHW understands this finding and recognizes the corrections that were planned for FY23 did not come to fruition due to the challenges with implementing a new financial management system. Despite these challenges, WPHW has made strides in improving our year-end processes and acknowledges that there is additional improvement needed. For FY23, WPHW created a year-end check list and started the review process. Unfortunately, due to staff absences and NetSuite issues, we were not able to fully implement these changes. Both situations have provided us with lessons learned for how to correctly implement changes in the future. For FY24, WPWH implemented the following process: 1) Full year-end check list is distributed and review by staff (Accounting Specialists, Accountants, and AR/AP Specialists) prior to year-end for review and training, conducted by the Director of Accounting and Accounting Manager a. Review each step with staff and provide training on the expectation for each step 2) Accounting Specialists and Accountants complete necessary year-end tasks 3) Accounting Manager reviews all completed tasks to ensure accuracy and completeness 4) Director of Accounting conducts a final review and signs off at the end of the year With this clear process in place, we anticipate this issue being fully resolved in FY24.

View Audit 323235

Finding 500932 (2023-001)

Material Weakness 2023

Wabanaki Health and Wellness

ME

Material Weakness Internal Control / Segregation of Duties

2023-001 - Material Weakness - Material Adjusting Journal Entries WPHW understands this finding and recognizes that corrections that were planned for FY23 did not come to fruition. WPHW was in the process of implementing a new financial management system, NetSuite. It was our plan to implement new ...

2023-001 - Material Weakness - Material Adjusting Journal Entries WPHW understands this finding and recognizes that corrections that were planned for FY23 did not come to fruition. WPHW was in the process of implementing a new financial management system, NetSuite. It was our plan to implement new processes that would have fully addressed prior concerns. It was our plan to have the FY23 audit completed in both NetSuite and QuickBooks. However, we encountered several issues with the implementation of the new system, which delayed prior year corrected actions. In May 2024, WPHW decide to no longer work with NetSuite, due to the number of issues with the system and the company. Since that time, we have fully committed to QuickBooks and have started engaging in systematic business process redesign of our financial system. At the time of the transition back to QuickBooks fully, we also made significant staff role changes. Our accounting department now has a Director of Accounting and two new managers, AR/AP Manager and Accounting Manager. With these new positions, we have developed the following procedures for adjusting journal entries: 1) Accounting Director, Accounting Manager or AR/AP Manager identifying need for a journal entry 2) Accounting Specialist or AR/AP Specialist pulls the supporting documentation for the required entry, creates journal entry template in Excel, and prepares journal entry packet with supporting documentation for entry into QB. 3) Accountant or Accounting Manager reviews packet and determines who can enter journal a. If reviewed by Accountant, entry is entered QuickBooks by Accounting Specialist b. If reviewed by Accounting Manager, entry is entered into QuickBooks by Accountant 4) Once journal entry is entered into QuickBooks, entry is printed from QB system and added to packet. The packet is returned to the preparer to ensure all elements were completed corrected and signed off on 5) Completed packet goes to filing and are scanned into our electronic file system All adjustments must go through three different individuals to ensure separation of duties. This process will be implemented during Q4 of FY24. The Director of Accounting will go back over all the journals completed before this date to review how each were completed and delegate additional review to the Accounting Manager and Accounting Specialist to ensure each journal entry had appropriate review and support. With this process in place, we anticipate this issue being fully resolved in FY25.

View Audit 323235

Finding 500927 (2023-001)

Material Weakness 2023

Coquille Watershed Association

OR

Material Weakness Internal Control / Segregation of Duties

Views of Responsible Officials and Planned Corrective Actions - We agree with this finding. CoqWA was successful in hiring an Executive Director in 2023, and an Office Manager in 2024 who provides bookkeeping services. Training was provided to both employees, and CoqWA will continue to schedule trai...

Views of Responsible Officials and Planned Corrective Actions - We agree with this finding. CoqWA was successful in hiring an Executive Director in 2023, and an Office Manager in 2024 who provides bookkeeping services. Training was provided to both employees, and CoqWA will continue to schedule trainings for new staff with an emphasis on accrual accounting for the Office Manager who performs the bookkeeping function.

View Audit 323230

Finding 500432 (2023-002)

Material Weakness 2023

Abused Adult Resource Center

ND

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Contact Person Michelle Erickson Corrective Action Plan The Abused Adult Resource Center’s payroll allocations for grants will be documented on timesheets and the hard copies will be filed or scanned onto a local drive kept by the Center. Completion Date Fiscal Year 2024

View Audit 323201 Questioned Costs: $1

Finding 500403 (2023-002)

Material Weakness 2023

West Virginia University Health System and Controlled Entities

WV

Internal Control / Segregation of Duties Eligibility Material Weakness

Contact Person: Melissa McCoy Management’s Response: As part of the submission of expenses into the Provider Relief Portal, Princeton Community Hospital inadvertently submitted expenses for payroll and supplies expense that were ineligible. As a result, the following corrective actions will be ta...

Contact Person: Melissa McCoy Management’s Response: As part of the submission of expenses into the Provider Relief Portal, Princeton Community Hospital inadvertently submitted expenses for payroll and supplies expense that were ineligible. As a result, the following corrective actions will be taken to prevent ineligible expenses from being submitted in the future: • Exclude all ineligible expenses from any future Provider Relief Fund Portal submissions. • Offset the ineligible costs with lost revenues and unreimbursed expenses attributable to Corona virus. Princeton Community Hospital was a new acquisition into West Virginia University Health System as of January 1, 2023 and had not fully integrated into our processes at the time that this portal submission was completed. Upon further review, Princeton Community Hospital had lost revenues that support a significant portion of the funding received for this reporting period. Those lost revenues, along with eligible expenses, fully support the funding received. Completion Date: 09/27/2024

View Audit 323168

Finding 500396 (2023-005)

Material Weakness 2023

City of Greeley

CO

Subrecipient Monitoring Material Weakness Reporting § 200.303

Finding Number: 2023-005 Condition: Related to the Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027), there was no evidence that reports were reviewed for completeness and accuracy prior to submission. Planned Corrective Action: The City hired a full-time Grants Manager in February 202...

Finding Number: 2023-005 Condition: Related to the Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027), there was no evidence that reports were reviewed for completeness and accuracy prior to submission. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establish procedures to track grants that are awarded and expended by the City. New procedures will be developed to ensure that financial and performance reports for grants will be reviewed and approved by the Grants Manager prior to submission of the reports to the awarding entities. Documentation of this review will be retained with the grant documents. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: December 31, 2024

View Audit 323158

Finding 500393 (2023-004)

Material Weakness 2023

City of Greeley

CO

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness

Finding Number: 2023-004 Condition: Related to the Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027), the City did not retain evidence that they performed the suspension and debarment check prior to entering into the contract. Planned Corrective Action: Procedures will be enhanced to e...

Finding Number: 2023-004 Condition: Related to the Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027), the City did not retain evidence that they performed the suspension and debarment check prior to entering into the contract. Planned Corrective Action: Procedures will be enhanced to ensure prior to entering into an agreement with an outside entity using federal funds, the City will perform the suspension and debarment check. Documentation of this review will be retained with the grant documents. In addition, the City will research grant management software options to further enhance grant monitoring. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: December 31, 2024

View Audit 323158

Finding 500392 (2023-003)

Material Weakness 2023

City of Greeley

CO

Subrecipient Monitoring Material Weakness Reporting § 200.303

Finding Number: 2023-003 Condition: Related to the WaterSMART grant (ALN 15.507), controls in place were not adequate to ensure expenses were reported in the proper categories on the performance reports. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establ...

Finding Number: 2023-003 Condition: Related to the WaterSMART grant (ALN 15.507), controls in place were not adequate to ensure expenses were reported in the proper categories on the performance reports. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establish procedures to track grants that are awarded and expended by the City. New procedures will be developed to ensure that financial and performance reports for grants will be reviewed by the Grants Manager prior to submission of the reports to the awarding entities. Documentation of this review will be retained with the grant documents. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: December 31, 2024

View Audit 323158

Finding 500390 (2023-001)

Material Weakness 2023

Northwest Youth Services

WA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Corrective Action Plan: • Housing service leadership staff will ensure that each unit lease served through NWYS will have on file documentation of reasonable rental rates and residential use at the time of lease signing or renewal, to ensure compliance with all grant requirements. Responsible Divi...

Corrective Action Plan: • Housing service leadership staff will ensure that each unit lease served through NWYS will have on file documentation of reasonable rental rates and residential use at the time of lease signing or renewal, to ensure compliance with all grant requirements. Responsible Division/Office and Individual: • NWYS Housing leadership staff – Luis Reyna, Andy Johnson, Rebecca Pendergraft, Addison Ausley • Finance leadership staff – Stephanie Wagner, Dianne Ersser Estimated Completion Date: 9/30/2024

View Audit 323157 Questioned Costs: $1

Finding 500385 (2023-003)

Material Weakness 2023

Jackson County, Colorado

CO

Subrecipient Monitoring Reporting Allowable Costs / Cost Principles

Material Weakness, Internal Control Over Compliance and Compliance, Allowable Costs and Activities, Reporting Personnel Responsible for Corrective Action: Samantha Martin, County Administrator Anticipated Completion Date: 12/31/2024 Corrective Action Plan: The County agrees with the auditor’s rec...

Material Weakness, Internal Control Over Compliance and Compliance, Allowable Costs and Activities, Reporting Personnel Responsible for Corrective Action: Samantha Martin, County Administrator Anticipated Completion Date: 12/31/2024 Corrective Action Plan: The County agrees with the auditor’s recommendation to improve its internal controls related to federal grant allowable costs and activities determinations and reporting requirements and will implement a process that ensures federal expenditure accounting and reports are prepared and then reviewed and approved by a separate employee prior to submission.

View Audit 323150

Finding 500342 (2023-001)

Material Weakness 2023

La Plata County Colorado

CO

Subrecipient Monitoring Internal Control / Segregation of Duties Material Weakness

Finding 2023-001 Material Weakness, Internal Control Over Compliance and Compliance, Reporting Personnel Responsible for Corrective Action: Adam Rogers Anticipated Completion Date: Already completed Corrective Action Plan: The County agrees with the auditor’s recommendation to improve its internal c...

Finding 2023-001 Material Weakness, Internal Control Over Compliance and Compliance, Reporting Personnel Responsible for Corrective Action: Adam Rogers Anticipated Completion Date: Already completed Corrective Action Plan: The County agrees with the auditor’s recommendation to improve its internal controls related to federal grant reporting requirements and has implemented a process that ensures federal expenditure accounting and reports are prepared by the Grants Analyst and then reviewed and approved by the Deputy Director of Finance or Director of Finance to provide oversight and detect and correct errors before reports are submitted.

View Audit 323102

Finding 500328 (2023-004)

Significant Deficiency 2023

Lummi Indian Business Council

WA

Equipment & Real Property Management Material Weakness Reporting § 200.313

Person responsible for corrective action plan: Anthony Madera, CFO Lummi Indian Business Council 2665 Kwina Road Bellingham, WA 98226 (360) 384-7181 Condition: Management completed a physical inventory in 2022-2023, but was not able to provide support showing management review and approval. Solut...

Person responsible for corrective action plan: Anthony Madera, CFO Lummi Indian Business Council 2665 Kwina Road Bellingham, WA 98226 (360) 384-7181 Condition: Management completed a physical inventory in 2022-2023, but was not able to provide support showing management review and approval. Solution: With the guidance and authority outlined in the Department’s internal policies and in accordance with 2 CFR, Part 200, Subpart D, Property Standards, The non-Federal entity must submit annually an inventory listing of federally-owned property in its custody to the Federal awarding agency as defined within existing governing statues, regulations, or terms and conditions of the award. Procedures for the delegated staff administering these regulatory activities will follow the minimum requirements of maintaining property records. Final review of inventory will have final reviewed by Department’s CFO of approval and will be documented annually. Corrective action plan will be in accordance with c CFR, Part 200, Subpart F, §200.511 Audit findings follow-up. The Department entered into a professional agreement with Financial Service Advisors, LLC to assess current policies to update standards of management by identifying credentials and experience of senior finance staff who will oversee these activities. Revisions to the policies will provide the Department’s government an extensive manual that will be developed into a fiscal management training. Training will include but not be limited to reviewing procurement methods, fiscal review of ledger activity, and audit responsibility on a quarterly basis and reporting to tribal council. Responsible: Anthony Madera, Chief Financial Officer, Lummi Indian Business Council Anticipated completion date: 06/30/2025

View Audit 323095

Finding 500326 (2023-003)

Significant Deficiency 2023

Lummi Indian Business Council

WA

Eligibility Material Weakness Significant Deficiency

Person responsible for corrective action plan: Anthony Madera, CFO Lummi Indian Business Council 2665 Kwina Road Bellingham, WA 98226 (360) 384-7181 Condition: 2 out of 40 samples were missing proof of insurance in the patient’s file, which is a requirement under the Department's eligibility polic...

Person responsible for corrective action plan: Anthony Madera, CFO Lummi Indian Business Council 2665 Kwina Road Bellingham, WA 98226 (360) 384-7181 Condition: 2 out of 40 samples were missing proof of insurance in the patient’s file, which is a requirement under the Department's eligibility policy. Solution: Implement a standardized process for verifying, documenting, and maintaining proof of required documents (e.g. proof of residency, insurance, etc.) in the patient's file during each visit. This will involve revising and implementing the new procedures manual to verify and document patient intake. The procedures manual will support appropriate communication from data collection to when information is uploaded into EPIC to verify if clients have insurance. Our training plan will incorporate these new methods of collecting data from the clients and outline regular internal auditing of patient files to assist the Tribal Assisters to properly verify documents and communicate with providers to assist clients in enrolling with insurance providers such as but not limited to Washington Apple Health (WAH). Corrective action plan will be in accordance with c CFR, Part 200, Subpart F, §200.511 Audit findings follow-up. Responsible: Kathryn Halverson, Health and Human Services CEO, Lummi Indian Business Council Anticipated completion date: 06/30/2025

View Audit 323095

Finding 500324 (2023-002)

Material Weakness 2023

Lummi Indian Business Council

WA

Allowable Costs / Cost Principles Material Weakness Reporting

Person responsible for corrective action plan: Anthony Madera, CFO Lummi Indian Business Council 2665 Kwina Road Bellingham, WA 98226 (360) 384-7181 Condition: During transactional testing, 11 of 16 individually important items (IIIs) were journal entries with no documented review and approval pro...

Person responsible for corrective action plan: Anthony Madera, CFO Lummi Indian Business Council 2665 Kwina Road Bellingham, WA 98226 (360) 384-7181 Condition: During transactional testing, 11 of 16 individually important items (IIIs) were journal entries with no documented review and approval process. Solution: With the guidance and authority outlined in the Department’s internal policies and in accordance with 2 CFR, Part 200, Subpart E, §200.405 Allocable costs, manual adjustments will be defined as reasonable and allocable as defined within existing governing statues, regulations, or terms and conditions of the award. Levels of delegation of staff administering these regulatory activities will utilize the appropriate credentials request cost adjustments and use prudent judgment to determine those costs are necessary and do not deviate from the Department’s established practices and policies. Final review of cost adjustment requests will be reviewed by Department’s OMB and once approved a signature of review and approval will be documented. Corrective action plan will be in accordance with c CFR, Part 200, Subpart F, §200.511 Audit findings follow-up. The Department entered into a professional agreement with Financial Service Advisors, LLC to assess current policies to update standards of management by identifying credentials and experience of senior finance staff who will oversee these activities. Revisions to the policies will provide the Department’s government an extensive manual that will be developed into a fiscal management training. Training will include but not be limited to reviewing procurement methods, fiscal review of ledger activity, and audit responsibility on a quarterly basis and reporting to tribal council. Responsible: Anthony Madera, Chief Financial Officer, Lummi Indian Business Council Anticipated completion date: 06/30/2025

View Audit 323095

Finding 500322 (2023-006)

Material Weakness 2023

Greater Columbia Accountable Community of Health

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.303

Recommendation: We recommend that the Organization implements policies and procedures to perform subrecipient monitoring and that monitoring is formally documented and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in respon...

Recommendation: We recommend that the Organization implements policies and procedures to perform subrecipient monitoring and that monitoring is formally documented and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will undertake a thorough review and subsequent update of our documented policies and procedures related to federal awards. This review aims to ascertain whether any adjustments are necessary to guarantee that subawarded federal funds are utilized exclusively for their designated purposes. We are dedicated to enhancing our internal controls to adhere to federal regulations concerning the monitoring of our subrecipients. We plan to engage a consultant to help us develop policies and procedures for subrecipient monitoring, as well as to propose an organizational framework for fiscal monitoring that will strengthen our internal controls. We anticipate having the finalized policies, procedures, and training implemented by 12/31/2024. We will develop and implement a risk assessment program for subrecipients, enabling management to monitor the outcomes and demonstrate compliance with federal requirements. Records will be maintained to show that risk assessments were performed. We are dedicated to offering annual training sessions aimed at reinforcing the single audit requirements to our subrecipients. We will establish a subrecipient monitoring/compliance workgroup to define roles and responsibilities for assessing and updating policies and procedures related to subrecipient monitoring and to strengthen internal controls. Name(s) of the contact person(s) responsible for corrective action: Jan Warren/Amber Henderson (Compliance), Haydee Hill (CFO), Sharon Brown (CEO). Planned completion date for corrective action plan: 12/31/2024

View Audit 323092

Finding 500321 (2023-005)

Material Weakness 2023

Greater Columbia Accountable Community of Health

WA

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

Recommendation: We recommend that the Organization’s procurement policy is followed and that procurement procedures are documented, reviewed and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will...

Recommendation: We recommend that the Organization’s procurement policy is followed and that procurement procedures are documented, reviewed and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will review our current policies and procedures in these areas to determine if any changes should be implemented. We will ensure staff responsible for procurement of goods and services are familiar with applicable federal and state laws and policies for awarding and executing contracts. We are deeply committed to the continuous improvement of our purchasing policies and procedures to uphold the highest standards of transparency and accountability. In this regard, procurement policy will be updated to comply with the Uniform Guidance for federal awards. Furthermore, to strengthen our oversight of sole-source contracts awarded with program and non-program funds, we will introduce stringent measures requiring thorough documentation of the vendor’s or contractor’s qualifications. Name(s) of the contact person(s) responsible for corrective action: Department Head, Jan Warren/Amber Henderson (Compliance), Haydee Hill (CFO), Sharon Brown (CEO). Planned completion date for corrective action plan: 12/31/2024

View Audit 323092

Finding 500320 (2023-004)

Material Weakness 2023

Greater Columbia Accountable Community of Health

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Cash Management § 200.305

Recommendation: We recommend that the Organization implement policies and procedures to ensure subrecipients are paid within 30 days of when the billing is received. If the request is believed to be improper, support for the delay in payment should be maintained. Explanation of disagreement with au...

Recommendation: We recommend that the Organization implement policies and procedures to ensure subrecipients are paid within 30 days of when the billing is received. If the request is believed to be improper, support for the delay in payment should be maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will review and update our policies and procedures for managing accounts payable. Furthermore, we will provide additional orientation and training sessions focused on disbursements for subrecipients involved in federal grant programs. We will improve the enforcement of policies and procedures by setting up a system to track the receipt and payment of bills. Additionally, we will implement a weekly review by the compliance team to ensure that payments are made on time and that accurate documentation is retained to support any delays in payment requests that are found to be inappropriate. Name(s) of the contact person(s) responsible for corrective action: Jan Warren/Amber Henderson (Compliance), Haydee Hill (CFO) Planned completion date for corrective action plan: 12/30/2024

View Audit 323092

Finding 500319 (2023-003)

Material Weakness 2023

Greater Columbia Accountable Community of Health

WA

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Recommendation: We recommend that the Organization implements policies and procedures to properly calculate and allocate payroll benefits. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will develop and imp...

Recommendation: We recommend that the Organization implements policies and procedures to properly calculate and allocate payroll benefits. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will develop and implement an allocation plan for payroll benefits. We will develop process and procedures where charging of payroll benefits expenses to federal grants includes the written recommendation from compliance team and written approval of the CFO/CEO prior to payroll benefits being charged to federal grants. We will consult with the grantor to discuss whether the questioned costs identified in the audit should be repaid. Name(s) of the contact person(s) responsible for corrective action: Jan Warren/Amber Henderson (Compliance), Haydee Hill (CFO), Sharon Brown (CEO) Planned completion date for corrective action plan: 12/31/2024

View Audit 323092 Questioned Costs: $1

Finding 500275 (2023-006)

Material Weakness 2023

St. Vincent General Hospital District

CO

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303

Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, ...

Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, over the past 12 months we have started to reap the reward of the hard work through operationally increasing revenue, reducing costs, and being more strategic on service lines. This will allow for us to hit the reserve amounts in 2025, while maintaining the cash flow needed for operations.

View Audit 323053

Finding 500274 (2023-005)

Material Weakness 2023

St. Vincent General Hospital District

CO

Material Weakness Reporting Matching / Level of Effort / Earmarking

This was rectified mid-way through the 2023 year, when all covenants were reviewed with the USDA and Colliers Mortgage team. As a result, these reports have now been sent timely to USDA starting at the end of 2023 and have continued since then. The annual debt reserve calculation has not been provid...

This was rectified mid-way through the 2023 year, when all covenants were reviewed with the USDA and Colliers Mortgage team. As a result, these reports have now been sent timely to USDA starting at the end of 2023 and have continued since then. The annual debt reserve calculation has not been provided as that was not brought to the hospital’s direct attention during our bi-weekly USDA meetings. However, going forward these will be added.

View Audit 323053

Corrective Action Plans

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