Corrective Action Plans

Finding 401085 (2022-005)

Material Weakness 2022

IL

Questioned Costs Procurement, Suspension & Debarment § 200.214

Suspension and Debarment – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare verify that vendors are not suspended or debarred prior to signing contracts or create an approved vendor list. Explanation of disagreement with audit finding: There is no disagreem...

Suspension and Debarment – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare verify that vendors are not suspended or debarred prior to signing contracts or create an approved vendor list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. Create procedure to verify vendors are not suspended or debarred: in progress a. Develop steps in the vendor diligence and procurement process to verify that the vendor is not suspended or debarred. b. Identify role or job that will handle responsibility for following procedure. c. Formalize the process into a written procedure and add to the procurement or other relevant policy. d. Conduct periodic audits to assess adherence to the procedure and train as necessary to ensure compliance.

View Audit 309100 Questioned Costs: $1

Finding 401079 (2022-004)

Material Weakness 2022

Promise Healthcare Nfp

IL

Questioned Costs Special Tests & Provisions Significant Deficiency

Procurement – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare revise its procurement policy to be consistent with the requirements of the Uniform Guidance and follow the stated procedures. Explanation of disagreement with audit finding: There is no disagre...

Procurement – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare revise its procurement policy to be consistent with the requirements of the Uniform Guidance and follow the stated procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. Review Current Procurement Policy: in progress a. Conduct a comprehensive review of Promise Healthcare’s existing procurement policy. b. Identify and revise and discrepancies or non-compliance with the requirements of the Uniform Guidance. c. Integrate industry best practices into revised policy to enhance compliance and efficiency 2. Training and Education: to start a. Provide training sessions for staff authorized to purchase along with relevant personnel on the revised procurement policy and procedures and raise awareness of the requirements of the Uniform Guidance and implications of non-compliance. b. Establish training on documentation standards for procurement activities including requisitions, solicitations, evaluations and contract awards. c. Establish training and procedure for retention of procurement-related documentation 3. Internal Controls and oversight: to start a. Implement mechanisms for monitoring and oversight to ensure compliance with the procurement policy. b. Conduct periodic internal audits to assess adherence to procurement procedures and identify areas for improvement or corrective action

View Audit 309100 Questioned Costs: $1

Finding 400566 (2022-006)

Material Weakness 2022

Pembroke Hill School

NH

Questioned Costs School Nutrition Programs Internal Control / Segregation of Duties § 200.303

Audit Finding Reference: 2021-006 Cross Training of Staff and Review of Responsibilities Management’s View and Planned Corrective Action: Management does not agree with this deficiency. We do agree that Management is actively working on some changes as improvements are made each year to improve effi...

Audit Finding Reference: 2021-006 Cross Training of Staff and Review of Responsibilities Management’s View and Planned Corrective Action: Management does not agree with this deficiency. We do agree that Management is actively working on some changes as improvements are made each year to improve efficiency. Each position in the Business Office other than HR has been crossed trained with one-to-two other team members. Cross training throughout the business office was implemented in 2016 and has continued to exist. Each position has the ability to have someone step in case of emergency, elongated vacations and when/if someone resigns or is terminated. The positions are not covered in entirety, but the important items that must be dealt with can be and are accomplished. Examples are as such: Accounts Payable is covered by our Special Ed Bookkeeper, and other staff have the ability to review manifest once generated. Payroll has been covered by the Assistant Business Administrator when vacations or vacancies have existed, Grants can be covered by the Business Administrator when vacations or vacancies have existed. The Assistant Business Administrator is covered by the Business Administrator during vacations and vacancies. Each position continues to do their own assigned job duties and takes on the other tasks as necessary. The work may not get completed in the same timely fashion as if the actual staff member holding the position was there because they are also completing their own tasks, but the work does get accomplished. When there are multiple turnovers and/illness occurring at the sometime it makes it challenging even when cross training exists. Every year the Business Administrator reviews workloads and reassesses if changes should occur to help create efficiencies and create equivalent workload between all staff members. While some positions have more deadlines than others it can appear that their plates are larger than others, but frequently tasks are divided out throughout the team to help alleviate this. These discussions are brought forth to COLT, the Senior Leadership team at the SAU, and restructuring is finalized at that time. Name of Contact Person and Completion Date: Name 1 Amber Wheeler Name 2 Danielle Rossetti Anticipated Completion Date – Already occurs

View Audit 308621 Questioned Costs: $1

Finding 400454 (2022-005)

Significant Deficiency 2022

Douglas County Board of Commissioners

GA

Questioned Costs Procurement, Suspension & Debarment § 200.318

Corrective Action Plan: We have taken proactive measures within the Purchasing Department to enhance training and awareness among our staff. Additionally, the Grant division has been reinforcing the importance of adhering to Federal grant guidelines regarding procurement. We will continue to monitor...

Corrective Action Plan: We have taken proactive measures within the Purchasing Department to enhance training and awareness among our staff. Additionally, the Grant division has been reinforcing the importance of adhering to Federal grant guidelines regarding procurement. We will continue to monitor and improve our processes to ensure compliance with established guidelines. Anticipated Completion Date: December 2024

View Audit 308475 Questioned Costs: $1

Finding 400453 (2022-007)

Significant Deficiency 2022

Reach Community Development, Inc.

OR

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Finding No. 2022-007 - Community Development Block Grants/Entitlement Grants Federal Assistance Listing Number #14.218 Statement of Condition: Owner paid one vendor invoice, of eight tested, that was not listed on the CDBG Address List as reported to Portland Housing Bureau (“PHB”) and charged ...

Finding No. 2022-007 - Community Development Block Grants/Entitlement Grants Federal Assistance Listing Number #14.218 Statement of Condition: Owner paid one vendor invoice, of eight tested, that was not listed on the CDBG Address List as reported to Portland Housing Bureau (“PHB”) and charged through to and was reimbursed by PHB under their CDBG Grant. Corrective Action: Since the time of this we have made some changes to have the appropriate funding code on each client’s folder/information so that it is easy to see where to charge when making a purchase and the CBP manager is reaching out to PHB on resolution to this instance.

View Audit 308469 Questioned Costs: $1

Finding 400451 (2022-005)

Significant Deficiency 2022

Reach Community Development, Inc.

OR

Questioned Costs HUD Housing Programs Special Tests & Provisions

Finding No. 2022-005 - Low Income Housing Preservation and Resident Homeownership Act of 1990) Federal Assistance Listing Number #99.999 Statement of Condition: The owner was unable to provide the Management Entity Profile HUD 9832 documentation for one of two properties tested and approved Mana...

Finding No. 2022-005 - Low Income Housing Preservation and Resident Homeownership Act of 1990) Federal Assistance Listing Number #99.999 Statement of Condition: The owner was unable to provide the Management Entity Profile HUD 9832 documentation for one of two properties tested and approved Management Agent's Certification HUD 9839-B for one of two properties tested. Corrective Action: REACH has contacted HUD office to request missing copies of HUD approved Management entity profile and certifications.

View Audit 308469 Questioned Costs: $1

Finding 399998 (2022-008)

Material Weakness 2022

Lincoln-King Adams-Young Academy

MI

Questioned Costs Eligibility

The Academy has put in place a Title I Coordinator to work with the Human Resources Department to ensure that the assigned staff meets the teacher’s eligibility standards for Title I.

View Audit 308166 Questioned Costs: $1

Finding 399997 (2022-007)

Material Weakness 2022

Lincoln-King Adams-Young Academy

MI

Questioned Costs Allowable Costs / Cost Principles Reporting

The Academy has put in place additional staff to monitor time and effort support, personal activity reporting, and certification processes around the Title I program.

View Audit 308166 Questioned Costs: $1

Finding 399958 (2022-003)

None 2022

Breakthrough Charter School

AL

Questioned Costs Procurement, Suspension & Debarment § 200.320

2) Finding 2022-03 - The School failed to obtain price quotations from multiple sources for a purchase that exceeded $10,000. a. Implementation of plan of action - Management will review its procurement policies to ensure that the School complies with 2 CFR 200.320 of the Uniform Guidance. b. Implem...

2) Finding 2022-03 - The School failed to obtain price quotations from multiple sources for a purchase that exceeded $10,000. a. Implementation of plan of action - Management will review its procurement policies to ensure that the School complies with 2 CFR 200.320 of the Uniform Guidance. b. Implementation date - Anticipated completion June 30, 2024. c. Persons responsible for the implementation - The Board of Directors and Head of School.

View Audit 308126 Questioned Costs: $1

Finding 399951 (2022-004)

Significant Deficiency 2022

The International Institute of Akron, Inc.

OH

Questioned Costs Allowable Costs / Cost Principles Cash Management

Management has reaffirmed their commitment to following and enforcing current policies.

View Audit 308108 Questioned Costs: $1

Finding 398984 (2022-005)

Material Weakness 2022

Coastal Harvest

WA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Corrective Action: Coastal Harvest will begin tracking all inventory on hand by source, including receipts, distributions, waste/loss, and any other adjustments, and will perform periodic reconciliations of amounts recorded in the inventory system and amounts recognized in the general ledger to ensu...

Corrective Action: Coastal Harvest will begin tracking all inventory on hand by source, including receipts, distributions, waste/loss, and any other adjustments, and will perform periodic reconciliations of amounts recorded in the inventory system and amounts recognized in the general ledger to ensure accurate USDA food commodities inventory recordkeeping compliance. Further, Coastal Harvest will include specific inventory policies and procedure in the manual discussed in the corrective action for finding 2022-001. Anticipated Completion Date: June 30, 2024

View Audit 307582 Questioned Costs: $1

Finding 398586 (2022-010)

Significant Deficiency 2022

Creek County

OK

Questioned Costs Reporting Internal Control / Segregation of Duties

Creek County has corrected this matter and the correct paid date will be applied on th efirst quarter reporting for FY2024

View Audit 307326 Questioned Costs: $1

Finding 397881 (2022-006)

Significant Deficiency 2022

Keystone College

PA

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking

College will put controls in place between Registrar and Financial Aid to ensure enrollment status of students

View Audit 306623 Questioned Costs: $1

Finding 397878 (2022-003)

Significant Deficiency 2022

Keystone College

PA

Questioned Costs Subrecipient Monitoring Cash Management

The College is reviewing processes in place with third party financial aid servicer and internal policies to implement controls over compliance

View Audit 306623 Questioned Costs: $1

Finding 396991 (2022-007)

Significant Deficiency 2022

College of Micronesia - Fsm

FM

Questioned Costs Procurement, Suspension & Debarment § 200.319

The college will strengthen its financial reporting by implementing the following: 1) Review and improve procedure related to procurement 2) Coordination with grantor regarding grant requirements 2) Review and improve recording of transactions and financial statements presentation. Contact Person ...

The college will strengthen its financial reporting by implementing the following: 1) Review and improve procedure related to procurement 2) Coordination with grantor regarding grant requirements 2) Review and improve recording of transactions and financial statements presentation. Contact Person : Roselle B. Togonon Completion Date: June 30, 2024

View Audit 306394 Questioned Costs: $1

Finding 396983 (2022-003)

Material Weakness 2022

Cornerstone Whole Healthcare Organization, Inc.

ID

Questioned Costs Cash Management Material Weakness

Plan of Action: Drafted new procedure that will be implemented 5/15/24 and will develop a tracking system in Microsoft Forms for the Project Director or Authorizing Officer requesting and approval funds by 6/1/24. Date of implementation: 6/1/2024

View Audit 306383 Questioned Costs: $1

Finding 396725 (2022-014)

Significant Deficiency 2022

Housing Authority of the City of Fayetteville

IL

Questioned Costs Procurement, Suspension & Debarment HUD Housing Programs

Views of Responsible Officials and Planned Corrective Actions: Fayetteville Housing Authority is committed to conducting a comprehensive review of all contract files to ascertain that they contain thorough documentation of the contract, associated expenditures, and progress reports. In the future, ...

Views of Responsible Officials and Planned Corrective Actions: Fayetteville Housing Authority is committed to conducting a comprehensive review of all contract files to ascertain that they contain thorough documentation of the contract, associated expenditures, and progress reports. In the future, contract files will be maintained in strict accordance with HUD procurement policies.

View Audit 306360 Questioned Costs: $1

Finding 396724 (2022-013)

Significant Deficiency 2022

Housing Authority of the City of Fayetteville

IL

Questioned Costs Procurement, Suspension & Debarment

Views of Responsible Officials and Planned Corrective Actions: A procurement policy aligned with Federal and State regulations has been approved by the Board. The Executive Director bears the responsibility of guaranteeing the adherence to correct procurement procedures. Additionally, a Capital Nee...

Views of Responsible Officials and Planned Corrective Actions: A procurement policy aligned with Federal and State regulations has been approved by the Board. The Executive Director bears the responsibility of guaranteeing the adherence to correct procurement procedures. Additionally, a Capital Needs Assessment has been executed for Public Housing to aid in the identification of forthcoming procurement requirements and in developing the agency's five-year plan. In further commitment to maintaining procurement excellence, two Board Commissioners, the Executive Director, the Director of Finance, and the Executive Assistant have undergone comprehensive training provided by NAHRO in the field of procurement.

View Audit 306360 Questioned Costs: $1

Finding 396710 (2022-003)

Material Weakness 2022

Point of Freedom

OH

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.516

As more fully described above, additional internal control procedures and practices will be implemented effective July 1, 2024, to ensure that underlying cost documentation is adequate, reasonable, and complete in accordance with 2 CFR and other regulatory requirements. More specifically, vendor inv...

As more fully described above, additional internal control procedures and practices will be implemented effective July 1, 2024, to ensure that underlying cost documentation is adequate, reasonable, and complete in accordance with 2 CFR and other regulatory requirements. More specifically, vendor invoices and the like will be scanned and electronically saved on QBO, as incurred. On the other hand, contractors were engaged to perform certain tasks and were not constrained by hours. If the subject service required on-site intervention by the contractor with a POF client at 3 AM, then the contractor was expected to and had agreed to deliver. The contractor would report any such encounters at the subsequent weekly meetings with certain contractors present. Consistent with IRS employer guidelines, POF did not supervise contractors or dictate work habits or work schedules. Instead, POF defined what each contractor was expected to do or deliver. It was incumbent upon the contractor to determine how best to accomplish the assigned and agreed upon duties defined in their jointly signed agreement. POF’s contractors were and are professionals with state credentials, degrees, or certifications which permit them to serve other NPOs or customers as independent contractors. In many cases, their work products were summarized during the previously mentioned POF weekly meetings and transmitted to Wright State University (now the Ohio State University) where the data were aggregated independently by these contracted third parties and made available to POF’s funders. Effective July 1, 2024, copies pf these weekly report summaries will be routinely saved to provide further evidence of POF’s monitoring of contractors’ activities and adherence to contract terms.

View Audit 306345 Questioned Costs: $1

Finding 396390 (2022-007)

Material Weakness 2022

Mille Lacs County

MN

Questioned Costs Reporting Material Weakness § 200.303

Finding Number: 2022-007 Finding Title: Reporting Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Dillon Hayes, County Administrator Corrective Action Planned: Guidance and timelines for reporting on the CSLFRF ...

Finding Number: 2022-007 Finding Title: Reporting Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Dillon Hayes, County Administrator Corrective Action Planned: Guidance and timelines for reporting on the CSLFRF award have been changing constantly. Staff will take better care to follow future guidance. Additionally, all funds have been expended. Anticipated Completion Date: Completed

View Audit 305961 Questioned Costs: $1

Finding 396380 (2022-005)

Significant Deficiency 2022

State of Kosrae

FM

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding No.:2022-005 Area:- Special Tests and Provisions – Annual Performance Reviews Views of Auditee and Planned Corrective Action: We do not agree with the finding as the annual evaluation was performed by the teacher and his supervisor. We understand that individual evaluation points did not ...

Finding No.:2022-005 Area:- Special Tests and Provisions – Annual Performance Reviews Views of Auditee and Planned Corrective Action: We do not agree with the finding as the annual evaluation was performed by the teacher and his supervisor. We understand that individual evaluation points did not add up to the stated total point in the evaluation form because page 3 was blank, and the addition was incorrect. Anticipated Completion Date: Ongoing Name of Contact Person: Ms. Lona Lyndon Esau, Administrator Office of Finance, Department of Administration and Finance Email: alomalya.dofa@gmail.com

View Audit 305958 Questioned Costs: $1

Finding 396236 (2022-003)

Significant Deficiency 2022

Houston Regional Hiv/aids Resource Group, Inc.

TX

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

2022-003 Compliance and Internal Controls over Allowable and Allocable Costs (Significant Deficiency) U.S. Department of Health and Human Services 93.918- Ryan White Title C Contract No. H7CHA36798-01-03, H76HA00684-22-00, and H76HA00684-23-00 Texas Department of State Health Services State HIV Serv...

2022-003 Compliance and Internal Controls over Allowable and Allocable Costs (Significant Deficiency) U.S. Department of Health and Human Services 93.918- Ryan White Title C Contract No. H7CHA36798-01-03, H76HA00684-22-00, and H76HA00684-23-00 Texas Department of State Health Services State HIV Service Grants Contract No. 537-18-0097-00001 and HHS001022300002 Recommendation: The Resource Group should follow its policies regarding expense reimbursement grants and ensure support for costs submitted for reimbursement comply with 2 CFR Subpart E. Corrective Action: To ensure expense reimbursement and support of cost submitted by subrecipients comply with 2 CFR Subpart E, The Resource Group will annually verify the subrecipient’s cost allocation plan. To verify costs are allowable and allocable to the grant, The Finance Director will conduct fiscal monitoring of subrecipients. The fiscal monitoring will be conducted at least annually in accordance with all state and federal statues, regulations and terms and conditions. As a component of the monitoring, The Resource Group will verify costs submitted for reimbursement are allowable, reasonable, approved and accurately submitted. This includes verification of the cost allocation plan and underlying documentation of associated expenses. The Finance Director is responsible for oversight and administration of fiscal monitoring. The process will include desktop/remote verification of applicable financial policy and procedures and an onsite review. A standardized monitoring tool will be used to evaluate financial compliance. The fiscal monitoring observations will result in a monitoring report, disseminated to the subrecipient within 60 days of the onsite review. In the event the Finance Director position is vacant more than 90 days, The Resource Group will contract with an appropriate financial contractor to conduct annual monitoring as needed. In the event of extenuating circumstances and the subrecipient is not reviewed annually, The Resource Group will determine the appropriateness of all costs under the cost allocation plan through the submission of alternate supporting documentation. This will be verified prior to the close of the grant period. Progress to date 1. The Finance Director was hired in August 2023. To support the financial monitoring efforts, technical assistance was received on February 5-7, 2024, from the DSHS Fiscal Support and Oversight department. The primary objective of the visit was to discuss financial monitoring requirements as it allies to state and federal regulations, statues and terms and conditions. The standardized monitoring tool was also evaluated for compliance. 2. The Finance Director has developed a fiscal monitoring schedule for 2024. Onsite reviews started in February 2024. The testing period for subrecipient monitoring has been expanded to include a testing period from Fiscal Year 2022 and Fiscal Year 2023. Responsible Party: Finance Director, Garland Thompson; Executive Director, Tiffany Shepherd, MPH Date to be Corrected: August 2024

View Audit 305880 Questioned Costs: $1

Finding 396022 (2022-001)

Material Weakness 2022

Hoquiam School District No. 28

WA

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs, procurement, and restricted purpose requirements. Name, address, and telephone of District contact person: Keith Ounsted, Business Manager 3...

Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs, procurement, and restricted purpose requirements. Name, address, and telephone of District contact person: Keith Ounsted, Business Manager 325 West Chenault Avenue, Hoquiam, WA 98550 (360) 538-8209 Corrective action the auditee plans to take in response to the finding: The District currently has policies in place regarding procurement. In this instance the policies weren’t followed. The district will review all policies around procurement to ensure they are up to date. The District will engage in a retraining of employees that are allowed to make purchases so that all personnel understand what is required. Anticipated date to complete the corrective action: 7/31/2023

View Audit 305620 Questioned Costs: $1

Finding 395962 (2022-006)

Material Weakness 2022

City of Allentown

PA

Questioned Costs Allowable Costs / Cost Principles Cash Management

U.S. Department of Housing and Urban Development - COVID-19 - Emergency Solutions Grants Program (ALN 14.231) Recommendation: We recommend the City implement internal control procedures to ensure compliance with allowable cost requirements and that IDIS drawdowns are performed timely and accurately....

U.S. Department of Housing and Urban Development - COVID-19 - Emergency Solutions Grants Program (ALN 14.231) Recommendation: We recommend the City implement internal control procedures to ensure compliance with allowable cost requirements and that IDIS drawdowns are performed timely and accurately. Action Taken: Grant compliance administrators will review each invoice for eligibility prior to the invoice being paid. The Grants Manager will approve the eligible activities prior to the drawdown in IDIS. This will be completed by June 30, 2024.

View Audit 305597 Questioned Costs: $1

Finding 395942 (2022-004)

Material Weakness 2022

City of Allentown

PA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

U.S. Department of Housing and Urban Development (HUD) - CDBG - Entitlement Grants Cluster: COVID-19 - Community Development Block Grant/Entitlement Grants (ALN 14.218) Recommendation: We recommend the City implement internal control procedures to ensure compliance with allowable cost requirements a...

U.S. Department of Housing and Urban Development (HUD) - CDBG - Entitlement Grants Cluster: COVID-19 - Community Development Block Grant/Entitlement Grants (ALN 14.218) Recommendation: We recommend the City implement internal control procedures to ensure compliance with allowable cost requirements and that all relevant documentation is maintained. We also recommend the City establish monitoring procedures for the planning and program administrative costs requirement. Action Taken: The city will implement policies to ensure we have not gone over the 20% administrative cap. In addition, funds will not be drawn until all required documentation has been provided to the Grants Manager. This will be completed by June 30, 2024.

View Audit 305597 Questioned Costs: $1

Corrective Action Plans

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