Corrective Action Plans

Finding 394255 (2023-002)

Significant Deficiency 2023

CA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding 2023-002 Federal Agency: U.S. Department of the Treasury Program/Cluster: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Assistance Listing Number: 21.027 Pass-through: N/A Award No. and Year: N/A, 2022 Compliance Requirements: Reporting Type of Finding: Significant Defic...

Finding 2023-002 Federal Agency: U.S. Department of the Treasury Program/Cluster: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Assistance Listing Number: 21.027 Pass-through: N/A Award No. and Year: N/A, 2022 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Views of Responsible Officials and Corrective Action Plan: Management agrees. The review of the information to be submitted has been performed and documented, however, due to the report submission portal not providing an option for the authorized official to review inputted information and authorize the submission, the preparer submitted the report in accordance with the previously approved information. Our procedures have been modified to document evidence of additional review of required reports by the responsible individual prior to submission. Responsible Individual(s): Olga Tikhomirova, Director of Finance Anticipated Completion Date: September 2024

View Audit 304261

Finding 394241 (2023-001)

Significant Deficiency 2023

Peak Vista Community Health Centers, INC

CO

Eligibility Questioned Costs Subrecipient Monitoring

Condition – Peak Vista (“the Organization”) determines the sliding fee discount charged to patients based on the patient’s annual gross income and household size. We found two encounters where applications were not retained. Therefore, we could not determine if the sliding fee discount applied was i...

Condition – Peak Vista (“the Organization”) determines the sliding fee discount charged to patients based on the patient’s annual gross income and household size. We found two encounters where applications were not retained. Therefore, we could not determine if the sliding fee discount applied was in accordance with the guideline. Recommendation – We recommend that the Organization's procedures be strengthened to ensure income is properly verified and adequately documented and retained. The Organization should strengthen processes surrounding monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. Peak Vista has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the enrollment and eligibility process, including our Enrollment, Reception, and Billing teams will be retrained on the process with emphasis on proper documentation. The Organization management plans to incorporate into our quality assurance audits the documentation for single service date discount applications and provide feedback and retraining as necessary to staff as needed. Anticipated Date of Completion – In progress. Action Taken – We have reviewed the recommendation and have developed a plan for addressing this issue. Person Responsible for Corrective Action Plan – Ryan Spillane, Chief Financial Officer Corrective Action Plan – Ryan Spillane, Deputy Chief Financial Officer

View Audit 304236 Questioned Costs: $1

Finding 394237 (2023-001)

None 2023

Puerto Rico Fiscal Agency & Financial Advisory Authority

PR

Questioned Costs Reporting Internal Control / Segregation of Duties § 200.512

Management response: Finding accepted Management has in place all the internal controls needed to issue the Uniform Guidance report for the fiscal year ending on June 30, 2024, and subsequent years on time. Currently, management is working with the 2024 fiscal year financial statement audit and uni...

Management response: Finding accepted Management has in place all the internal controls needed to issue the Uniform Guidance report for the fiscal year ending on June 30, 2024, and subsequent years on time. Currently, management is working with the 2024 fiscal year financial statement audit and uniform guidance audit plan which take into consideration to issue those reports on or before March 31, 2025. Corrective action plan: The submission of the 2023 data collection form and reporting package will be performed on or before April 30, 2024. Contact Person: Jessica Ortiz Rivera – Title: Comptroller

View Audit 304216

Finding 394236 (2023-001)

Significant Deficiency 2023

Laurentian Hall Associates, Inc. Dba Laurentian Hall 033-35197

PA

Questioned Costs Subrecipient Monitoring HUD Housing Programs

Name of auditee: Laurentian Hall Associates, Inc. HUD auditee identification number: 033-35197 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2023 CAP prepared by Name: Dana Wall Position: Director of Accounting Telephone number: 412-578-7872 C...

Name of auditee: Laurentian Hall Associates, Inc. HUD auditee identification number: 033-35197 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2023 CAP prepared by Name: Dana Wall Position: Director of Accounting Telephone number: 412-578-7872 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2023-001: As of December 31, 2023, the Corporation has not made the required payment of 50% of available surplus cash from the prior fiscal period. Comments on the Finding and Each Recommendation: The delinquent payment should be made to HUD and future required payments should be made within the time period defined in the Use Agreement and Mortgage Restructuring Agreement. Action(s) taken or planned on the finding: Agree. Management agrees with the recommendation and made the delinquent mortgage payment of $18,268 on February 14, 2024.

View Audit 304215 Questioned Costs: $1

Finding 394226 (2023-001)

None 2023

Silver Lake Housing, Inc.

TX

Questioned Costs Cash Management HUD Housing Programs

Condition: The tenant security deposit cash account was insufficient to cover the tenant security deposit liability. Response: The Project is experiencing escalation of operating costs and management is going to request a Budget Based Rent increase for the property. Management believes that it wi...

Condition: The tenant security deposit cash account was insufficient to cover the tenant security deposit liability. Response: The Project is experiencing escalation of operating costs and management is going to request a Budget Based Rent increase for the property. Management believes that it will then be able to fund the shortfall in the security deposit cash account.

View Audit 304188

Finding 393960 (2023-005)

Significant Deficiency 2023

School District of Fort Atkinson

WI

Questioned Costs

Plan: The District will have a dual review process so this mistake does not happen again.

View Audit 304135

Finding 393959 (2023-004)

Significant Deficiency 2023

School District of Fort Atkinson

WI

Questioned Costs Cash Management

Plan: The District will have a dual review process so this mistake does not happen again.

View Audit 304135 Questioned Costs: $1

Finding 393958 (2023-003)

Significant Deficiency 2023

School District of Fort Atkinson

WI

Questioned Costs

Plan: The business manager will review numbers entered by other staff members. The assistant to the business manager will review the information entered by the business manager.

View Audit 304135

Finding 393957 (2023-002)

Significant Deficiency 2023

School District of Fort Atkinson

WI

Questioned Costs Cash Management

Plan: The District receives notices from our Medicaid consultants reminding us multiple times before the deadline comes. If the district has not submitted by the second notice, we will schedule a meeting to dedicate time to submitting on time.

View Audit 304135

Finding 393952 (2023-001)

Significant Deficiency 2023

School District of Fort Atkinson

WI

Questioned Costs Cash Management Reporting

Plan: The District will keep physical copies of reports and claims submitted. As students switched categories (free, reduced, and paid), the electronic system failed to keep that in account, leading to discrepancies.

View Audit 304135 Questioned Costs: $1

Finding 393950 (2023-002)

Significant Deficiency 2023

Columbia Gorge Community College

OR

Allowable Costs / Cost Principles Questioned Costs Eligibility

2023-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles – Significant Deficiency in Internal Controls over Compliance Federal Agency Name: Department of Education Federal Assistance Listing Number: 84.425E Federal Program Name: Higher Education Emergency Relief Funds (HEERF) S...

2023-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles – Significant Deficiency in Internal Controls over Compliance Federal Agency Name: Department of Education Federal Assistance Listing Number: 84.425E Federal Program Name: Higher Education Emergency Relief Funds (HEERF) Student Aid Portion Finding Summary: The College did not have consistent controls in place to formerly approve a plan for distribution of funds that was documented and circulated to the College. The lack of a documented plan for distribution of funds to students increases the risk that funds were inappropriately disbursed to students at the wrong amounts. In addition, it increases the risk that the disbursements were not equitable across the student population. Responsible Individuals: Dr. Lorelle Davies, Chief Financial Officer Michael N. Espinoza, Vice President of Student Services Corrective Action Plan: HEERF procedures and processes were adopted and provided to the auditors during the audit process. Three independent outreach efforts were implemented to contact, support, and release funding to students. Limited staffing and a sense of urgency in emergency disbursements contribute less than perfect execution. Documentation was provided for all sample disbursements with a few instances of missing documentation. The Rubric for disbursement through Student Services based on a Pell and enrollment need evaluation was not available to auditors. The college can reproduce criteria to support disbursement. All HEERF funding was distributed to students that met eligibility requirements withing the June 30, 2023, disbursement deadline. Ongoing efforts include the following:  The college will continue to archive and document all disbursement records.  Continued implementation of processes and procedures for all aid disbursement to prevent future instances. Anticipated Completion Date: Completed June 30, 2023

View Audit 304126

Finding 393949 (2023-003)

Significant Deficiency 2023

Columbia Gorge Community College

OR

Questioned Costs Reporting Significant Deficiency § 200.328 § 200.329

2023-003 – Reporting – Significant Deficiency in Internal Controls over Compliance Federal Agency Name: Department of Education Federal Assistance Listing Number: 84.425E, 84.425F Federal Program Name: Higher Education Emergency Relief Funds (HEERF) Student Aid Portion, Higher Education Emergency Re...

2023-003 – Reporting – Significant Deficiency in Internal Controls over Compliance Federal Agency Name: Department of Education Federal Assistance Listing Number: 84.425E, 84.425F Federal Program Name: Higher Education Emergency Relief Funds (HEERF) Student Aid Portion, Higher Education Emergency Relief Funds (HEERF) Institutional Portion Finding Summary: A sample of 4 special reports from the population of 4 special reports was selected. For the three quarterly reports selected, the College could not provide support that the reports were published timely. In addition, the College could not provide consistent institutional records for the data included in the three quarterly reports or annual reports. Three of the four quarterly reports were corrected based on the audit procedures performed, the College did not properly identify these as “corrected” upon posting to the College website. Responsible Individuals: Dr. Lorelle Davies, Chief Financial Officer 105 Courtney Judah, Executive Director of Institutional Effectiveness Corrective Action Plan: The college will continue to apply a detailed reporting process for timely collection and reporting of grants. Reporting to include the following:  Accurate and regular collection of data needed to report outcomes and service populations.  Cross verify data with Institutional Effectiveness and Institutional Research.  Post in accordance with grant requirements including documentation to record posting and submission dates. Anticipated Completion Date: Completed April 30, 2024

View Audit 304126

Finding 393941 (2023-008)

Material Weakness 2023

Columbia Gorge Community College

OR

Questioned Costs Student Financial Aid Procurement, Suspension & Debarment

2023-008 – Eligibility – Material Weakness in Internal Controls over Compliance and Material Noncompliance Student Financial Assistance Cluster U.S Department of Education Federal Assistance Listing Number: 84.063, 84.268, 84.007, 84.033, 84.379 Federal Program Name: Federal Pell Grant Program, Fede...

2023-008 – Eligibility – Material Weakness in Internal Controls over Compliance and Material Noncompliance Student Financial Assistance Cluster U.S Department of Education Federal Assistance Listing Number: 84.063, 84.268, 84.007, 84.033, 84.379 Federal Program Name: Federal Pell Grant Program, Federal Direct Student Loans, Federal Supplemental Educational Opportunity Grants, Federal Work-Study Program Finding Summary: The College did not have adequate controls in place to ensure the appropriate and reasonable amounts were included in each eligible cost of attendance category for its students, that awards were properly calculated, refunds were disbursed timely and student records were accurate. The auditors were not able to conclude that the College is in compliance with eligibility requirements in the OMB compliance supplement. Repeat finding: No Responsible Individuals: Michael N. Espinoza, Vice President of Student Services Views of responsible officials and planned corrective actions: The college entered into a third-party contract to manage financial aid packaging and awarding. Calculation and reporting completed by prior Financial Director submitted national average as the college calculations instead of college service area specific calculations. The college worked with the third-party provider to ensure policies and processes adopted in July 2023 to ensure cost of attendance (COA) reporting and calculations are complete and accurate going forward. Corrective Action: The College will review their policies, procedures and controls to ensure that annually a cost of attendance schedule is approved, and that the approved schedule is used in packaging student financial aid. Rationale for adjustments made to the budgeted cost of attendance for individual students should be documented and support maintained. The College will review all processes and procedures related to eligibility to ensure controls are well documented and to properly adhere to requirements for eligibility of Title IV aid. Anticipated Completion Date: to be completed by June 30, 2024

View Audit 304126 Questioned Costs: $1

Finding 393938 (2023-005)

Material Weakness 2023

Columbia Gorge Community College

OR

Student Financial Aid Questioned Costs Special Tests & Provisions

2023-005 – Special Tests and Provisions – Return of Title IV Funds (R2T4) – Material Weakness in Internal Controls over Compliance and Material Noncompliance Student Financial Assistance Cluster Department of Education Finding Summary: This occurred because of lack of controls and processes in place...

2023-005 – Special Tests and Provisions – Return of Title IV Funds (R2T4) – Material Weakness in Internal Controls over Compliance and Material Noncompliance Student Financial Assistance Cluster Department of Education Finding Summary: This occurred because of lack of controls and processes in place to ensure supporting documentation is maintained for student’s withdrawal dates, and a lack of understanding of compliance requirements. This resulted in a failure to properly identify students requiring calculation for return of funds to the federal government, or eligibility for post withdrawal disbursement. As a result, the auditors were unable to determine if the College is remitting unearned funds to the federal government, or offering eligible students post withdrawal disbursements if available to them. Responsible Individuals: Michael N. Espinoza, Vice President of Student Services Corrective Action Plan: The college entered into a third-party contract to manage financial aid packaging and awarding. Integration and processes for the R2T4 calculation with the third-party processer was not completed correctly. New integrations, policies, and processes to be adopted in fiscal year 2023-24.  Develop and implement ongoing tracking and reporting for all financial aid reporting.  Financial Aid and Student Accounts work to regularly review and action student account files.  Continue to work with third-party service to review and promptly return Title IV funding in compliance with federal rulings. Anticipated Completion Date: to be completed by June 30, 2024

View Audit 304126 Questioned Costs: $1

Finding 393932 (2023-001)

Material Weakness 2023

Willcox Unified School District No. 13

AZ

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding Number: 2023‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425U Contact Person: Kevin Davis, Superintendent & Business Manager Anticipated Completion Date: July 15, 2024 Planned Corrective Action: This finding related to federal grants,...

Finding Number: 2023‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425U Contact Person: Kevin Davis, Superintendent & Business Manager Anticipated Completion Date: July 15, 2024 Planned Corrective Action: This finding related to federal grants, specifically ESSER Funds was due to changing requirements in the program, the newness of the ESSER grants, and lack of training for our grants manager as they are also new to the position. Additional grants training will be conducted for this individual and be completed by July 15, 2024. As our ESSER grants have been expended and completion reports finalized by Grants Management, with no issues or errors found, this should not be an issue in the future.

View Audit 304097

Finding 393924 (2023-001)

Significant Deficiency 2023

Terra State Community College

OH

Questioned Costs Subrecipient Monitoring § 200.329

The College omitted lost revenue and reported incorrect expenses on quarterly grant reports (9/22 and 3/23 reports). The College will revise procedures to ensure amounts reported on quarterly reports are correct.

View Audit 304082

Finding 393880 (2023-010)

Material Weakness 2023

YWCA West Central Michigan

MI

Cash Management Period of Performance Questioned Costs § 200.305

The YWCA will implement the following changes in its accounting procedures. 1. The Staff Accountant will review the period each expenditure is related to and record the invoice to the appropriate period when entering it into accounts payable. The month and year will be noted on the invoice. 2. The C...

The YWCA will implement the following changes in its accounting procedures. 1. The Staff Accountant will review the period each expenditure is related to and record the invoice to the appropriate period when entering it into accounts payable. The month and year will be noted on the invoice. 2. The CFO will review the month and year noted by the Staff Accountant prior to entry into accounts payable.

View Audit 304072 Questioned Costs: $1

Finding 393879 (2023-009)

Significant Deficiency 2023

YWCA West Central Michigan

MI

Cash Management Questioned Costs Significant Deficiency § 200.305

The YWCA will implement the following changes in its accounting procedures. Each month, an aged open accounts payable report will be produced as part of the month end closing. Invoices that are past due will be paid in the following batch of payments (which are typically run weekly). If it is deter...

The YWCA will implement the following changes in its accounting procedures. Each month, an aged open accounts payable report will be produced as part of the month end closing. Invoices that are past due will be paid in the following batch of payments (which are typically run weekly). If it is determined that the invoice is not being paid for a valid reason, it will be removed from accounts payable at that time.

View Audit 304072 Questioned Costs: $1

Finding 393864 (2023-006)

Material Weakness 2023

YWCA West Central Michigan

MI

Period of Performance Questioned Costs Allowable Costs / Cost Principles

The YWCA will implement the following changes in its accounting procedures: 1. The Staff Accountant will review the period each expenditure is related to and record the invoice to the appropriate period when entering it into accounts payable. The month and year will be noted on the invoice. 2. The C...

The YWCA will implement the following changes in its accounting procedures: 1. The Staff Accountant will review the period each expenditure is related to and record the invoice to the appropriate period when entering it into accounts payable. The month and year will be noted on the invoice. 2. The CFO will review the month and year noted by the Staff Accountant prior to entry into accounts payable.

View Audit 304072 Questioned Costs: $1

Finding 393863 (2023-005)

Significant Deficiency 2023

YWCA West Central Michigan

MI

Questioned Costs Special Tests & Provisions Significant Deficiency

The YWCA will implement the following changes in its accounting procedures: 1. For each client in the HEAL program, where the YWCA pays rent for the client, a rent reasonableness form will be completed by the HEAL program staff and approved by the HEAL Program Director and Sr. Director. The form wil...

The YWCA will implement the following changes in its accounting procedures: 1. For each client in the HEAL program, where the YWCA pays rent for the client, a rent reasonableness form will be completed by the HEAL program staff and approved by the HEAL Program Director and Sr. Director. The form will be saved in the client’s file within the Bizstream client management program. The rent reasonableness form will also be submitted to the finance department prior to, or along with a request for the client’s first rent payment.

View Audit 304072

Finding 393860 (2023-001)

Significant Deficiency 2023

Cecilian Housing Corporation

PA

Questioned Costs Subrecipient Monitoring

Comments on the Finding and Each Recommendation: At December 31, 2023 and throughout 2023, the security deposit cash account did not equal or exceed the security deposit liability. Management deposited $1,513 into the security deposit cash account on March 18, 2024. Action(s) taken or planned on th...

Comments on the Finding and Each Recommendation: At December 31, 2023 and throughout 2023, the security deposit cash account did not equal or exceed the security deposit liability. Management deposited $1,513 into the security deposit cash account on March 18, 2024. Action(s) taken or planned on the finding: Management concurs with the finding and will continue to monitor on a going forward basis.

View Audit 304066 Questioned Costs: $1

Finding 393847 (2023-001)

None 2023

Town of Union Local Development Corporation

NY

Questioned Costs Subrecipient Monitoring

Reference: 2023-001 Subrecipient Monitoring Criteria Code of Federal Regulations §200.332 lists the requirements that must be clearly identified to subrecipients. Corrective Action Plan The Corporation acknowledges and is aware of this finding. The Chief Executive Officer, Joseph Moody, is the respo...

Reference: 2023-001 Subrecipient Monitoring Criteria Code of Federal Regulations §200.332 lists the requirements that must be clearly identified to subrecipients. Corrective Action Plan The Corporation acknowledges and is aware of this finding. The Chief Executive Officer, Joseph Moody, is the responsible party for the financial statements. The award notifications shall be revised to include language to be in compliance with Code of Federal Regulations §200.332. The Corporation is currently working on the revisions and the anticipated completion date is March 31, 2024.

View Audit 304046

Finding 393802 (2023-003)

None 2023

Hood River County

OR

Questioned Costs Procurement, Suspension & Debarment § 200.214

Hood River County has developed procedures to ensure the suspended and debarred listing is checked prior to awarding contracts to outside parties. In addition, the County is maintaining documentation of a second check being performed before the vendor can be entered into the payment system. We expec...

Hood River County has developed procedures to ensure the suspended and debarred listing is checked prior to awarding contracts to outside parties. In addition, the County is maintaining documentation of a second check being performed before the vendor can be entered into the payment system. We expect this to be running without exception by 12/31/2024.

View Audit 303987 Questioned Costs: $1

Finding 393800 (2023-002)

Material Weakness 2023

Hood River County

OR

Questioned Costs Procurement, Suspension & Debarment § 200.320

Management understands that the U.S. government requires recipients of federal grants, such as Hood River County, to adhere to specific terms and conditions. The overarching requirement Hood River county must follow is the Office of Management and Budget's Uniform Adminstrative Requirements, Cost Pr...

Management understands that the U.S. government requires recipients of federal grants, such as Hood River County, to adhere to specific terms and conditions. The overarching requirement Hood River county must follow is the Office of Management and Budget's Uniform Adminstrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, 2 CFR part 200, referred to as Uniform Guidance. Hood River County is training personnel to be mindful of following this guidance when making purchases. Through monthly meetings of the Grants Committee which attempts to centralize the County's grant work. The County is also in the process of hiring a Grants Manager to bring a higher level of education and experience overall. Hood River County is already taking these steps to inform and educate personnel at the time of this audit report.

View Audit 303987 Questioned Costs: $1

Finding 393771 (2023-002)

Material Weakness 2023

City of Satellite Beach

FL

Questioned Costs Procurement, Suspension & Debarment § 200.320

2023-002 Procurement Recommendation: Competitive quotes should be obtained and retained as a specified in the City’s procurement policies and Uniform Guidance. Non-competitive procurement (for sole source vendors) should be documented and approved prior to incurring expenses. The City should update ...

2023-002 Procurement Recommendation: Competitive quotes should be obtained and retained as a specified in the City’s procurement policies and Uniform Guidance. Non-competitive procurement (for sole source vendors) should be documented and approved prior to incurring expenses. The City should update and expand procurement polices to document competitive procurement practices for procurement less than the bid threshold. Management Response: Staff have already implemented a procurement procedure to attach all the quotes received from vendors to the purchase order. In the future when reviewing, staff will be able to see all the vendors that provided a quote and see the lowest quote was used to procure the item(s). Staff will be updating the procurement policy during the current fiscal year to expand the policy on procurement less than the bid threshold. Responsible Parties: Brittany Retherford, Assistant City Manager, Nick Walsh, Comptroller, and Mindy Brown, Assistant Comptroller Anticipated Completion Date: September 30, 2024

View Audit 303974 Questioned Costs: $1

Corrective Action Plans

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