Corrective Action Plans

Finding 509787 (2023-004)

Material Weakness 2023

Boys & Girls Clubs of Central Georgia, Inc.

GA

HUD Housing Programs Material Weakness Internal Control / Segregation of Duties

Recommendation: The Organization should establish procedures to ensure that timesheets for all employees charging time to Federal grant programs are reviewed and approved and to ensure that all non-payroll expenditures charged to Federal grant programs are reviewed and approved. Views of Responsibl...

Recommendation: The Organization should establish procedures to ensure that timesheets for all employees charging time to Federal grant programs are reviewed and approved and to ensure that all non-payroll expenditures charged to Federal grant programs are reviewed and approved. Views of Responsible Officials: Management of BGCCG acknowledges the finding and concurs with the recommendation. Response of Responsible Officials: To continuously improve BGCCG’s Accounting and Financial Reporting, workflow, and internal controls, BGCCG has begun the process to transition the back-office accounting providers from part-time status to full-time status to sufficiently accommodate the needs of the Organization. BGCCG will employ a full-time Chief Finance & Administrative Officer (CFAO), preferably with CPA/CGMA certification, and strong analytical and financial modeling and forecasting skills as well as deep knowledge of GAAP for nonprofits. This pivotal role will provide strategic direction to ensure the financial health of the Organization while driving innovative financial solutions. The CFAO will oversee all financial and accounting operations of the Organization, including the creation and execution of sound financial policies, procedures and internal controls, budgeting, accounting, cash and debt management, audits, investments, tax compliance, and weekly Accounting and Finance reporting to the CEO and Board Finance Chair. The CFAO will report directly to the CEO. This position will be employed on or before December 31, 2024. BGCCG will also employ a full-time Finance Manager (FM) with commensurate experience that demonstrates exemplary strategic and financial acumen. The FM will be responsible for intermediate-level finance and accounting functions such as general ledger/account maintenance, timely account reconciliation, accounts payable, accounts receivables, data processing, payroll processing, and reporting to the CFAO. The FM will report directly to the CFAO. This position will be employed on or before December 31, 2024. Upon the hiring and on-boarding of the CFAO and FM, BGCCG will immediately begin the process of updating its Financial Management & Accounting Control Policies & Procedures to further strengthen BGCCG’s internal controls. Corrective Action Plan: Upon the hiring and on-boarding of the new full-time CFAO and FM, management of BGCCG will work closely with the CFAO and FM to immediately implement a process to ensure that timesheets for all employees charging time to any Federal grant programs are reviewed and approved by the employee’s immediate supervisor, FM and CFAO, and/or CEO. BGCCG management will also work closely with the CFAO and FM to immediately implement a process to ensure that all non-payroll expenditures charged to Federal grant programs are reviewed and pre-approved by the FM and CFAO, and/or CEO. Acknowledged, Phillip Bryant President & CEO

View Audit 329517

Finding 509786 (2023-003)

Material Weakness 2023

Boys & Girls Clubs of Central Georgia, Inc.

GA

HUD Housing Programs Material Weakness Internal Control / Segregation of Duties

Recommendation: The Organization should establish procedures to ensure that timesheets for all employees charging time to Federal grant programs are reviewed and approved. Views of Responsible Officials: Management of BGCCG acknowledges the finding and concurs with the recommendation. Response of R...

Recommendation: The Organization should establish procedures to ensure that timesheets for all employees charging time to Federal grant programs are reviewed and approved. Views of Responsible Officials: Management of BGCCG acknowledges the finding and concurs with the recommendation. Response of Responsible Officials: To continuously improve BGCCG’s Accounting and Financial Reporting, workflow, and internal controls, BGCCG has begun the process to transition the back-office accounting providers from part-time status to full-time status to sufficiently accommodate the needs of the Organization. BGCCG will employ a full-time Chief Finance & Administrative Officer (CFAO), preferably with CPA/CGMA certification, and strong analytical and financial modeling and forecasting skills as well as deep knowledge of GAAP for nonprofits. This pivotal role will provide strategic direction to ensure the financial health of the Organization while driving innovative financial solutions. The CFAO will oversee all financial and accounting operations of the Organization, including the creation and execution of sound financial policies, procedures and internal controls, budgeting, accounting, cash and debt management, audits, investments, tax compliance, and weekly Accounting and Finance reporting to the CEO and Board Finance Chair. The CFAO will report directly to the CEO. This position will be employed on or before December 31, 2024. BGCCG will also employ a full-time Finance Manager (FM) with commensurate experience that demonstrates exemplary strategic and financial acumen. The FM will be responsible for intermediate-level finance and accounting functions such as general ledger/account maintenance, timely account reconciliation, accounts payable, accounts receivables, data processing, payroll processing, and reporting to the CFAO. The FM will report directly to the CFAO. This position will be employed on or before December 31, 2024. Upon the hiring and on-boarding of the CFAO and FM, BGCCG will immediately begin the process of updating its Financial Management & Accounting Control Policies & Procedures to further strengthen BGCCG’s internal controls. Corrective Action Plan: Upon the hiring and on-boarding of the new full-time CFAO and FM, management of BGCCG will work closely with the CFAO and FM to immediately implement a process to ensure that timesheets for all employees charging time to any Federal grant programs are reviewed and approved by the employee’s immediate supervisor, FM and CFAO. Acknowledged, Phillip Bryant President & CEO

View Audit 329517

Finding 509784 (2023-001)

Material Weakness 2023

Boys & Girls Clubs of Central Georgia, Inc.

GA

Material Weakness Reporting Internal Control / Segregation of Duties

Recommendation: Marshall Jones recommends that the Organization receive additional assistance in improving their financial reporting processes from individuals who are familiar with GAAP. Marshall Jones also recommends that management establish policies and procedures to ensure that management level...

Recommendation: Marshall Jones recommends that the Organization receive additional assistance in improving their financial reporting processes from individuals who are familiar with GAAP. Marshall Jones also recommends that management establish policies and procedures to ensure that management level reviews of monthly and annual financial information are performed on a timely basis. Views of Responsible Officials: Management of BGCCG acknowledges the finding and concurs with the recommendation. Response of Responsible Officials: To continuously improve BGCCG’s Accounting and Financial Reporting, workflow, and internal controls, BGCCG has begun the process to transition the back-office accounting providers from part-time status to full-time status to sufficiently accommodate the needs of the Organization. BGCCG will employ a full-time Chief Finance & Administrative Officer (CFAO), preferably with CPA/CGMA certification, and strong analytical and financial modeling and forecasting skills as well as deep knowledge of GAAP for nonprofits. This pivotal role will provide strategic direction to ensure the financial health of the Organization while driving innovative financial solutions. The CFAO will oversee all financial and accounting operations of the Organization, including the creation and execution of sound financial policies, procedures and internal controls, budgeting, accounting, cash and debt management, audits, investments, tax compliance, and weekly Accounting and Finance reporting to the CEO and Board Finance Chair. The CFAO will report directly to the CEO. This position will be employed on or before December 31, 2024. BGCCG will also employ a full-time Finance Manager (FM) with commensurate experience that demonstrates exemplary strategic and financial acumen. The FM will be responsible for intermediate-level finance and accounting functions such as general ledger/account maintenance, timely account reconciliation, accounts payable, accounts receivables, data processing, payroll processing, and reporting to the CFAO. The FM will report directly to the CFAO. This position will be employed on or before December 31, 2024. Upon the hiring and on-boarding of the CFAO and FM, BGCCG will immediately begin the process of updating its Financial Management & Accounting Control Policies & Procedures to further strengthen BGCCG’s internal controls. Corrective Action Plan: Upon the hiring and on-boarding of the new full-time CFAO and FM, management of BGCCG will ensure the back-office finance and accounting providers seek and attend professional development trainings as often as possible, in addition to receiving additional assistance from the Board Finance Chair and Treasurer, and CEO to continue improving the financial reporting processes as recommended. Management of the Organization will begin to work closely with the CFAO and FM to conduct weekly, monthly, and semi-annual financial reviews to ensure operational compliance, accuracy, and timely reporting of financial matters. Acknowledged, Phillip Bryant President & CEO

View Audit 329517

Finding 509771 (2023-004)

Material Weakness 2023

People Trust

AR

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.430

CDFI ERP Program (COVID-19) – Assistance Listing No. 21.033 Recommendation: We recommend management develop procedures requiring employees to track their time and effort by grant. Another individual should periodically review and approve these time and effort records before the funding request is s...

CDFI ERP Program (COVID-19) – Assistance Listing No. 21.033 Recommendation: We recommend management develop procedures requiring employees to track their time and effort by grant. Another individual should periodically review and approve these time and effort records before the funding request is sent to the federal agency or charged to the federal award. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Each employee will track their time spent on the grant through Paychex. Timesheets will be approved by Arlo Washington, President, each payroll period. Name(s) of the contact person(s) responsible for corrective action: Arlo Washington Planned completion date for corrective action plan: January 1, 2025

View Audit 329488

Finding 509375 (2023-001)

Material Weakness 2023

Southern Workforce Board, Inc.

OK

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Material Weakness § 200.508 § 200.510 § 200.512

Due to no fault of Southern Workforce Board, Inc., and circumstances beyond the previous CAP's control, the audit report for the period ending 6/30/2023 was not completed as required. Upon notification of prior audit firm closing, Southern Workforce Board, Inc. performed an immediate procurement by ...

Due to no fault of Southern Workforce Board, Inc., and circumstances beyond the previous CAP's control, the audit report for the period ending 6/30/2023 was not completed as required. Upon notification of prior audit firm closing, Southern Workforce Board, Inc. performed an immediate procurement by soliciting a Request for Proposal to 13 audit firms. Upon completion of the procurement, Michael Green, CPA was selected to perform the 6/30/2023 audit as soon as their schedule would allow. Upon successful completions of 6/30/2023 audit report, the audit process for the period ending 6/30/2024 will proceed on time. Southern Workforce Board, Inc. will ensure in the future that the audit firm selected will be able to perform the planned audits in a timely manner in the future.

View Audit 329166

Finding 509301 (2023-003)

Material Weakness 2023

Crooksville Exempted Village School District

OH

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

Finding Number: 2023-003 Planned Corrective Action: When utilizing Prevailing Wage on future projects, in addition to contract language, the Treasurer will verify Prevailing Wage Payroll Reports prior to making any project payments. Anticipated Completion Date: 6/30/2024 Responsible Contact Person:...

Finding Number: 2023-003 Planned Corrective Action: When utilizing Prevailing Wage on future projects, in addition to contract language, the Treasurer will verify Prevailing Wage Payroll Reports prior to making any project payments. Anticipated Completion Date: 6/30/2024 Responsible Contact Person: Robert D. Ogg, Jr., CPA

View Audit 329109

Finding 509000 (2023-023)

Material Weakness 2023

City of Baltimore, Maryland

MD

Reporting Material Weakness Matching / Level of Effort / Earmarking § 200.302 § 200.303

U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensu...

U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on Federal Financial Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

View Audit 329082

Finding 508944 (2023-019)

Material Weakness 2023

City of Baltimore, Maryland

MD

Eligibility Material Weakness Reporting § 200.302 § 200.303

U.S. Department of Health and Human Services AL No. 93.778 Medical Assistance Program (Medicaid; Title XIX) Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensur...

U.S. Department of Health and Human Services AL No. 93.778 Medical Assistance Program (Medicaid; Title XIX) Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on Federal Financial Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

View Audit 329082

Finding 508525 (2023-012)

Material Weakness 2023

City of Baltimore, Maryland

MD

Subrecipient Monitoring Cash Management HUD Housing Programs § 200.303

U.S. Department of Housing and Urban Development AL No. 14.241 Housing Opportunities for Persons with AIDS Material Weakness in Internal Controls and Noncompliance over Special Tests – Housing Quality Standards Repeat Finding: Yes Auditee’s Corrective Action Plan: MOHS has experienced leadership and...

U.S. Department of Housing and Urban Development AL No. 14.241 Housing Opportunities for Persons with AIDS Material Weakness in Internal Controls and Noncompliance over Special Tests – Housing Quality Standards Repeat Finding: Yes Auditee’s Corrective Action Plan: MOHS has experienced leadership and staffing changes that have impacted its ability to maintain systematic processes necessary for service delivery and administration. One area impacted by MOHS’ transition was our inspection services. During the review period, the contracted supplier had no access to the Housing Pro system, the database used to manage inspections for MOHS’ subsidized units. MOHS has a recordkeeping process for inspections in its policies and procedures for the rental assistance program. Inspection checklists are maintained in the participant records by calendar year. Housing staff identify whether or not the inspection has been completed on the recertification checklist and sign the checklist to confirm the documentation is present in the file. MOHS has resumed its recordkeeping practices to ensure staff maintain inspection checklists in the client files for the annual recertification year. Housing staff are expected to verify during the recertification that Housing Quality Standard (HQS) inspections have been conducted for the assisted unit. MOHS completed the upgrade to the new version of the Housing Pro system in March 2024. The inspections team now has access to the housing database via the web. MOHS is working with the inspections team to ensure inspection updates are entered into the inspection module timely. MOHS has a process in place to review inspection details monthly to ensure 1) inspections for each household has been conducted and 2) all inspection detail is updated in the Housing Pro system by the inspections team each week. Contact Person: HAP Program Manager – D’Andra Pollard Completion Date: June 2024

View Audit 329082

Finding 508522 (2023-009)

Material Weakness 2023

City of Baltimore, Maryland

MD

Subrecipient Monitoring Cash Management Eligibility § 200.303

U.S. Department of Housing and Urban Development (HUD) AL No. 14.241 Housing Opportunities for Persons with AIDS Material Weakness in Internal Controls and Noncompliance over Eligibility Repeat Finding: Yes Auditee’s Corrective Action Plan: Condition #1 Response MOHS acknowledges the finding that 14...

U.S. Department of Housing and Urban Development (HUD) AL No. 14.241 Housing Opportunities for Persons with AIDS Material Weakness in Internal Controls and Noncompliance over Eligibility Repeat Finding: Yes Auditee’s Corrective Action Plan: Condition #1 Response MOHS acknowledges the finding that 14 out of 40 files did not have management review. Corrective Action: The Program Manager will conduct quality control reviews for 30% of files that have been recertified each month. The quality control review will verify all eligibility components under the program were met. Condition #2 Response MOHS acknowledges the finding that 25 out of 40 selections did not have the supporting thirdparty documentation of income. MOHS followed the HOPWA guidance outlined in the Self- Certification of Income and Credible Information on HIV Status waivers released by HUD for September 2021 and March 2023. The waiver permits HOPWA grantees and project sponsors to rely upon a family member’s self-certification of income and credible information on their HIV status. The HUD-CPD notices are referenced in Exhibits A-B of this response. The program accepted the self-certification of income until the waivers from HUD ended for COVID-19 on March 31, 2023. Corrective Action: MOHS has resumed following the process of requesting third party verification of income, assets, and medical expenses to ensure proper calculation of tenant rent. Client records are being updated with the appropriate verification of income documentation from the third-party source. Condition #3 Response MOHS acknowledges the finding 6 out of 40 selections did not have documentation of the rent reasonableness. Corrective Action: MOHS uses GoSection8, an online rent comparable website to conduct rent reasonableness. Rent reasonableness is conducted at the initial move-in and with each rent increase request. Documentation of the comparison is maintained in the client record. Contact Person: Lakeysha Williams – 410-396-4887 or Lakeysha.williams@baltimorecity.gov Completion Date: July 2024

View Audit 329082

Finding 508489 (2023-025)

Material Weakness 2023

City of Baltimore, Maryland

MD

Subrecipient Monitoring Cash Management Material Weakness § 200.303

U.S. Department of Housing and Urban Development (HUD) AL No. 14.239 HOME Investment Partnerships Program Material Weakness in Internal Controls and Noncompliance over Program Income Repeat Finding: No Auditee’s Corrective Action Plan: The Agency appreciates the comprehensive review of this program ...

U.S. Department of Housing and Urban Development (HUD) AL No. 14.239 HOME Investment Partnerships Program Material Weakness in Internal Controls and Noncompliance over Program Income Repeat Finding: No Auditee’s Corrective Action Plan: The Agency appreciates the comprehensive review of this program and concurs with this finding. The Department of Housing and Community Development (DHCD) understands that while the City of Baltimore’s Department of Finance is responsible for recording and reporting program income into the general ledger, DHCD must ensure that ensure funds are properly recorded in the accounting records. Therefore, DHCD will work with the Department of Finance to ensure that program income deposits are documented correctly, are properly reflected on the general ledger and deposited into the correct accounts. Going forward, DHCD will request the general ledger details for all program income deposits on a minimum quarterly basis to ensure its accuracy and availability. Contact Person: Eugene Greene, HOME Program Manager Completion Date: December 2024

View Audit 329082

Finding 508419 (2023-002)

Material Weakness 2023

Fremont County Association of Governments

WY

Material Weakness Reporting

ITEM 2023-002: DUPLICATE ACCOUNTING RECORDS In response to Finding 2023-002, we clarify that the duplication of accounting records originated from the implementation of an FY22 audit recommendation. The auditing firm was designated to address and reconcile these duplicate entries; however, this task...

ITEM 2023-002: DUPLICATE ACCOUNTING RECORDS In response to Finding 2023-002, we clarify that the duplication of accounting records originated from the implementation of an FY22 audit recommendation. The auditing firm was designated to address and reconcile these duplicate entries; however, this task was not completed, leading to a backlog that impacted the timely completion of the FY23 audit. We have since undertaken a comprehensive reconciliation of all duplicate entries, ensuring accurate and complete financial records moving forward. With this corrective action finalized, we are now positioned to prevent reoccurrence and maintain a streamlined, efficient accounting process. Contact person: Tim Nichols Anticipated completion date: November 29, 2024

View Audit 329047

Finding 508411 (2023-006)

Material Weakness 2023

Sanilac County Community Mental Health Authority

MI

Reporting Subrecipient Monitoring Material Weakness § 200.502 § 200.510

Condition: The Authority did not identify that they were subject to an audit under the Uniform Guidance (U.G.) and a schedule of expenditures of federal awards (SEFA) was not prepared by management. Recommendation: The Authority should review federal, state, and local grants to determine if they a...

Condition: The Authority did not identify that they were subject to an audit under the Uniform Guidance (U.G.) and a schedule of expenditures of federal awards (SEFA) was not prepared by management. Recommendation: The Authority should review federal, state, and local grants to determine if they are federally funded and, if federally funded, utilize the account number outlined in the State of Michigan chart of accounts to track federal funding. Planned Corrective Action: A schedule of federal awards will be created to track total costs covered by federal awards beginning in FY24. Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2024

View Audit 329033

Finding 508410 (2023-005)

Material Weakness 2023

Sanilac County Community Mental Health Authority

MI

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.302 § 200.303 § 200.305 § 200.318 § 200.319

Condition: As a precondition to receive federal awards, prospective recipients must have effective internal controls over the federal award. As described in 2 CFR, Part 200.303, nonfederal entities must have certain written policies and procedures surrounding the management of their federal awards. ...

Condition: As a precondition to receive federal awards, prospective recipients must have effective internal controls over the federal award. As described in 2 CFR, Part 200.303, nonfederal entities must have certain written policies and procedures surrounding the management of their federal awards. Such policies should include procedures for collecting payments of federal funds per 2 CRF 200.305, cash management (i.e., minimizing the time between draws and actual disbursing of federal awards) per 2 CFR 200.302(b)(6), allowable cost per 2 CFR 200.403, and conflict of interest per 2 CFR 200.318. Per 2 CFR 200.319(d), the non-Federal entity must have written procedures for procurement transactions. Recommendation: The Authority should adopt written policies and procedures over cash management and allowable costs required under the Uniform Guidance. Planned Corrective Action: The Authority implemented these policies during the FY 2024 (BA054 Cash Management Policy and BA059 Authorization of Purchases). Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2024

View Audit 329033

Finding 508404 (2023-002)

Material Weakness 2023

Newport Borough Water Authority

PA

Material Weakness Reporting Internal Control / Segregation of Duties

The Authority did not realize quarterly reports were required and was never asked by USDA for these. USDA was contacted and the Authority has been informed that a quarterly Balance Sheet and Profit and Loss Statement will fulfill this requirement. The past due reports will be sent to USDA this mon...

The Authority did not realize quarterly reports were required and was never asked by USDA for these. USDA was contacted and the Authority has been informed that a quarterly Balance Sheet and Profit and Loss Statement will fulfill this requirement. The past due reports will be sent to USDA this month and going forward, quarterly reports will be forwarded to USDA within 30 days of the end of each quarter.

View Audit 329026

Finding 508034 (2023-005)

Material Weakness 2023

Fredonia-Moccasin Unified School District No. 6

AZ

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

2023-005 ACTIVITIES ALLOWED OR UNALLOWED AND ALLOWABLE COSTS / COST PRINCIPALS Program: Education Stabilization Fund – ESSER II and ESSER III Federal Assistance Listing Number: 84.425 Federal Agency: U.S. Department of Education Pass-Through Agency: Arizona Department of Education Grantor Number: 21...

2023-005 ACTIVITIES ALLOWED OR UNALLOWED AND ALLOWABLE COSTS / COST PRINCIPALS Program: Education Stabilization Fund – ESSER II and ESSER III Federal Assistance Listing Number: 84.425 Federal Agency: U.S. Department of Education Pass-Through Agency: Arizona Department of Education Grantor Number: 21FESSII-111175-01A and 21FESIII-111175-01A Questioned Costs: None Type of Finding: Material weakness in internal controls Compliance Requirement: A. Activities Allowed or Unallowed; B. Allowable Costs / Cost Principals Condition/Context: For one of three payroll related journal entries tested for the Education Stabilization Fund program, the District did not have documentation supporting that the entry was reviewed and approved by an individual separate from the preparer. Corrective Action: The District will review its process for preparing and recording journal entries to include a step to have the entries reviewed and approved by someone other than the preparer. In addition, the journal entries will include supporting schedules and documentation to explain why the entry is being prepared. Planned completion date for corrective action plan: For the period ending June 30, 2024. Name of the contact person responsible for corrective action: Dorene Mudrow, Superintendent

View Audit 328565

Finding 508033 (2023-004)

Material Weakness 2023

Fredonia-Moccasin Unified School District No. 6

AZ

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

2023-004 ACTIVITIES ALLOWED OR UNALLOWED Program: Education Stabilization Fund Federal Assistance Listing Number: 84.425 Federal Agency: U.S. Department of Education Pass-Through Agency: Arizona Department of Education Grantor Number: 21FESSII-111175-01A and 21FESIII-111175-01A Questioned Costs: $13...

2023-004 ACTIVITIES ALLOWED OR UNALLOWED Program: Education Stabilization Fund Federal Assistance Listing Number: 84.425 Federal Agency: U.S. Department of Education Pass-Through Agency: Arizona Department of Education Grantor Number: 21FESSII-111175-01A and 21FESIII-111175-01A Questioned Costs: $133,105 Type of Finding: Noncompliance (Other Matter), significant deficiency in internal control Compliance Requirement: A. Activities Allowed or Unallowed Condition/Context: During our testing of expenditures, it was noted that eleven expenditures with a total of $133,105 were not included within the Education Stabilization Fund budget as approved by the Arizona Department of Education. Corrective Action: The District will ensure all expenditures are approved by the SEA before purchase. Planned completion date for corrective action plan: For the period ending June 30, 2024. Name of the contact person responsible for corrective action: Dorene Mudrow, Superintendent

View Audit 328565 Questioned Costs: $1

Finding 507898 (2023-002)

Material Weakness 2023

Community Health Center Dba Alluvion Health, Inc.

MT

Material Weakness Special Tests & Provisions

Misapplication of the Sliding Fee Scale The department responsible for gathering and recording patient income data, and applying sliding fee discounts, experienced high attrition rates due to the role being entry-level. Recognizing these challenges, the Organization is in the process of revising th...

Misapplication of the Sliding Fee Scale The department responsible for gathering and recording patient income data, and applying sliding fee discounts, experienced high attrition rates due to the role being entry-level. Recognizing these challenges, the Organization is in the process of revising the training plan for this department and establishing a quality assurance process for monitoring. Additionally, the Organization will review and revise the sliding fee policy to enhance clarity of the process for application of discounts and proof of income documentation. Responsible Parties: Mark Groeller, Compliance Director, Lisa DeMallie, Associate Vice President of Patient Experience, and Melissa Darko, Revenue Cycle Director Estimated Completion Date: December 31, 2024

View Audit 328436

Finding 505564 (2023-007)

Material Weakness 2023

Michigan City Area Schools

IN

Subrecipient Monitoring Material Weakness Reporting § 200.302 § 200.303 § 200.328 § 200.329

FINDING 2023-007 Finding Subject: COVID-19 – Education Stabilization Fund – Reporting Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls that would likely be effective in preventing, or detecting and correcting, noncompliance for the rep...

FINDING 2023-007 Finding Subject: COVID-19 – Education Stabilization Fund – Reporting Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls that would likely be effective in preventing, or detecting and correcting, noncompliance for the reporting requirement. Not all EESER reports submitted by the School Corporation during the audit period were not supported by the School Corporation's records. Contact Person Responsible for Corrective Action: Tracey Haas, Deputy Treasurer Contact Phone Number and Email Address: thaas@mcas.k12.in.us (219)873-2000 ext. 8346 Views of Responsible Officials: We concur with this finding. We are implementing a proper system of internal controls and developing policies and procedures to ensure all reports are submitted accurately. Description of Corrective Action Plan: We are implementing a proper system of internal controls and developing policies and procedures to ensure all reports are submitted accurately. Moving forward we will ensure all ledgers are attached to the reports that have been submitted. Anticipated Completion Date: The anticipated date of correction for this finding is January 1, 2025.

View Audit 328262

Finding 505441 (2023-003)

Significant Deficiency 2023

Calhoun Liberty Hospital Association INC

FL

Questioned Costs Material Weakness Reporting

Calhoun-Liberty Hospital Association, Inc., D/B/A Calhoun-Liberty Hopsital, (Hospital), respectfully submits the following corrective action plan for the year ended December 31, 2023. The finding from the December 31, 2023, Schedule of Findings and Questioned Costs is discussed below. The finding is...

Calhoun-Liberty Hospital Association, Inc., D/B/A Calhoun-Liberty Hopsital, (Hospital), respectfully submits the following corrective action plan for the year ended December 31, 2023. The finding from the December 31, 2023, Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FEDERAL AWARD PROGRAMS AUDIT FINDING Significant Deficiency - Noncompliance (2023-003) Recommendation: The Hospital should continue to improve its understanding of the reporting requirements as specified in the applicable loan document and create a process to ensure all USDA requirements are met. Planned Corrective Action: As of September 30, 2024, the Hospital will open a bank account with the Hospital's current banking relationship. This account will be a restricted account dedicated to holding the required reserve as described in the existing USDA loan documents. The required reserve balance will be recorded on the Hospital's trial balance. The reconciliation for such balance will be provided upon request. Emily Brown Chief Executive Officer

View Audit 328121 Questioned Costs: $1

Finding 505399 (2023-003)

Material Weakness 2023

Douglas County

IL

Reporting Subrecipient Monitoring Material Weakness § 200.302

Finding 2023SA-003 Insufficient Grant Monitoring Comments on the Finding and Each Recommendation: The County agrees with the finding. Action(s) Taken or Planned on the Finding: The County will work to improve grant documentation and will consider implementing a review process to ensure the grant ...

Finding 2023SA-003 Insufficient Grant Monitoring Comments on the Finding and Each Recommendation: The County agrees with the finding. Action(s) Taken or Planned on the Finding: The County will work to improve grant documentation and will consider implementing a review process to ensure the grant records agree to grant reports that are filed. Name of Contact Person: Judi Pollock, County Clerk Projected Completion Date: Unknown

View Audit 328076

Finding 505381 (2023-007)

Material Weakness 2023

Chippewa County

MN

Questioned Costs Internal Control / Segregation of Duties Cash Management § 200.303

Finding Number: 2023-007 Finding Title: Social Service Fund Reporting (DHS-2556) Program: 93.778 Medicaid Cluster Name of Contact Person Responsible for Corrective Action: Jennifer Bakkelund, Fiscal Supervisor Corrective Action Planned: After speaking with State Auditors and DHS, expenses that had b...

Finding Number: 2023-007 Finding Title: Social Service Fund Reporting (DHS-2556) Program: 93.778 Medicaid Cluster Name of Contact Person Responsible for Corrective Action: Jennifer Bakkelund, Fiscal Supervisor Corrective Action Planned: After speaking with State Auditors and DHS, expenses that had been listed as “other” are now part of services rendered. A change in process of backup reports will be done to make this move of costs in the future. Fiscal Year 2023 reports are being corrected to match this new requirement. Any reports that are past the year cut off I am working directly with DHS to correct. Anticipated Completion Date: December 31, 2024

View Audit 328062 Questioned Costs: $1

Finding 505075 (2023-005)

Material Weakness 2023

Karen Organization of Minnesota

MN

Eligibility Material Weakness Internal Control / Segregation of Duties

Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: Auditor recommends that KOM review all participant files to ensure proper documentation is retained supporting eligibility of applicants. We noted that there is currently a p...

Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: Auditor recommends that KOM review all participant files to ensure proper documentation is retained supporting eligibility of applicants. We noted that there is currently a process in place to perform an annual review of random files to ensure that only eligible participants are being served, but we recommend that a process is implemented to ensure that there is proper review and approval of all applicants prior to the individual receiving services and that this review is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will provide staff training on documentation required to support participant eligibility, including for participants referred by other organizations. Program Managers will review files for newly enrolled participants to ensure eligibility and appropriateness of the service plan. Name(s) of the contact person(s) responsible for corrective action: Alexis Walstad and Eh Tah Khu, Co-Executive Directors Planned completion date for corrective action plan: 11/30/2024

View Audit 327745

Finding 505072 (2023-004)

Material Weakness 2023

Karen Organization of Minnesota

MN

Subrecipient Monitoring Material Weakness Reporting

Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: Auditor recommends that KOM review the various subrecipient requirements with the individuals involved in this process to ensure they understand the requirements. Explanation...

Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: Auditor recommends that KOM review the various subrecipient requirements with the individuals involved in this process to ensure they understand the requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will develop a template for all subgrantee agreements including the subrecipient’s unique entity identifier, assistance listings number and title, and the amount of funds available under each Federal award at the time of disbursement. Name(s) of the contact person(s) responsible for corrective action: Alexis Walstad and Eh Tah Khu, Co-Executive Directors Planned completion date for corrective action plan: 11/30/2024

View Audit 327745

Finding 505057 (2023-003)

Material Weakness 2023

Housing Authority of Brevard County

FL

HUD Housing Programs Material Weakness Special Tests & Provisions

2023-003 Special Tests and Provisions – Selection from the Waiting List Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream Vouchers – CFDA Number 14.879 Material Weakness in Internal Control and Material Noncompliance This is a repeat finding of 2022-004 from March 31, 2022 ...

2023-003 Special Tests and Provisions – Selection from the Waiting List Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream Vouchers – CFDA Number 14.879 Material Weakness in Internal Control and Material Noncompliance This is a repeat finding of 2022-004 from March 31, 2022 Condition: 14 out of 137 new admissions were selected for testing, but testing was suspended after testing 8 files due to the number of errors. Exceptions were noted as follows: • 1 tenant file had the following errors: o The tenant signed the request for tenancy approval form after the voucher expiration date. o The Authority did not follow their administrative plan when selecting applicants for admission. As a result, the tenant was not admitted properly into the Section 8 program. • 1 tenant file error where the tenant and landlord signed the request for tenancy approval form after the voucher expiration date. • 5 tenant file errors where the Authority did not follow their administrative plan when selecting applicants for admission. As a result, the tenants were not admitted properly into the Section 8 program. • 1 tenant file error where the tenant was selected from the tenant-based mainstream waiting list. A separate waiting list was maintained for tenant based mainstream vouchers in the same county or municipality covered by the regular Section 8 waiting list (the mainstream waiting list has currently been exhausted). The Authority's administrative plan does not allow a separate waiting list for the mainstream vouchers. In addition, the separate tenant based mainstream voucher waiting list was ranked randomly by the Authority's system through a lottery ranking technique. This is not in compliance with the Authority's administrative plan, which states that the waiting list should be organized by preference point and then by date and time of application (first come first serve basis). Recommendation: The Authority should correct the deficiencies and ensure staff is aware of acceptable procedures as outlined in the Authority’s Administrative plan. In addition, the Authority should review staffing levels, skill sets and case load. Furthermore, the Authority should utilize an ongoing quality control review process to ensure proper procedures are being followed. Action Taken: We concur with the recommendation. Due to the COVID-19 pandemic and related staff absences and turnover, we were unable to provide an ongoing quality control review process and provide ongoing staff training and timely management reviews. We are focused on implementing such procedures and will review staffing levels, skill sets, and case load for each employee.

View Audit 327740

Corrective Action Plans

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