Corrective Action Plans

Finding 401558 (2022-003)

Significant Deficiency 2022

Martin University

IN

Internal Control / Segregation of Duties Questioned Costs Student Financial Aid § 200.303

2022-003 Reporting – FISAP Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the applicable campus revise procedures to ensure that the record retention requirements are met and supporting documentation agrees to the FISAP, including a...

2022-003 Reporting – FISAP Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the applicable campus revise procedures to ensure that the record retention requirements are met and supporting documentation agrees to the FISAP, including a supervisory review by someone other than the preparer. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has begun to restructure all accounting and reconciliation functions. The University is implementing financial internal controls to improve the internal and external financial reporting process. Names of the contact persons responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration, and Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2024

View Audit 309593

Finding 401536 (2022-001)

Material Weakness 2022

K'ima:w Medical Center

CA

Eligibility Questioned Costs Subrecipient Monitoring

Management’s Response – To ensure that K'ima:w Medical Center has all supporting documentation to confirm Native American eligibility, we will update our PRC policies to reflect a more standardized and robust procedure for collecting and storing patient eligibility documentation, including periodic ...

Management’s Response – To ensure that K'ima:w Medical Center has all supporting documentation to confirm Native American eligibility, we will update our PRC policies to reflect a more standardized and robust procedure for collecting and storing patient eligibility documentation, including periodic review of our patient records in compliance with IHS standards and requirements. Additionally, we have some understanding in our Medical Records Department, which we plan to fill by next fiscal year.

View Audit 309572

Finding 401429 (2022-006)

Significant Deficiency 2022

County of Columbia, Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Federal Program: Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Condition/Context: The County’...

Federal Program: Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Condition/Context: The County’s required report for the quarter ended December 31, 2022 was due to be filed by January 31, 2023. The County filed its report on March 23, 2023, 48 days after the required due date. Recommendation: We recommend that the County revisit its policies and procedures related to reporting to ensure future reports are completed and submitted within the appropriate time period. Planned Corrective Actions: The County is current on all reporting. Name(s) of Contact Person(s) Responsible for Corrective Action: David Witchey, Chief Clerk

View Audit 309542

Finding 401421 (2022-004)

None 2022

County of Columbia, Pennsylvania

PA

Questioned Costs Student Financial Aid Subrecipient Monitoring

Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Ag...

Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Agency, Pass-Through Entity Identifying Numbers: C000071546, C000073444, C000075689, C000075284, C000080637, and PEMA-2022-007 Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Assistance Listing #21.023, COVID-19 Emergency Rental Assistance Program, U.S. Department of Treasury, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available Assistance Listing #93.658, Foster Care - Title IV-E, U.S. Department of Treasury, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available Condition/Context: The County’s December 31, 2022 Single Audit was not completed and submitted within the required time period. Recommendation: We recommend that as the County gets up and running on the new accounting system, the audit be prioritized in future periods. Planned Corrective Action: Management understands that the organization receiving these funds receives a single audit also. We will continue to work with this agency ensuring that policies and procedures are understood and will follow the requirements. Name(s) of Contact Person(s) Responsible for Corrective Action: David Witchey, Chief Clerk Anticipated Completion Date: For the 2023 audit.

View Audit 309542

Finding 401387 (2022-011)

Material Weakness 2022

Libson Regional School District

NH

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

Audit Finding Reference: 2022-011 Management’s View and Planned Corrective Action: Management learned about 7 CFR, 210.14(b) when asked to create an Excess Food Service Fund Spend Down Plan this school year. We are now monitoring this and will make sure to spend down funds appropriately each year...

Audit Finding Reference: 2022-011 Management’s View and Planned Corrective Action: Management learned about 7 CFR, 210.14(b) when asked to create an Excess Food Service Fund Spend Down Plan this school year. We are now monitoring this and will make sure to spend down funds appropriately each year when operating the food service program. In addition, management is taking on a bigger role in overseeing the entire Food Service operation in regards to the Federal Regulations associated with the National School Lunch Program. Name of Contact Person and Completion Date: Name 1 Toni Butterfield Name 2 Anticipated Completion Date – 6/30/25

View Audit 309473 Questioned Costs: $1

Finding 401321 (2022-001)

Material Weakness 2022

Community Healthcare System Inc.

KS

Questioned Costs Allowable Costs / Cost Principles Cash Management

Allowable costs related to the program are expenses or losses that were not reimbursed from other sources or that other sources were not obligated to reimburse. The System did not reduce COVID-19 related costs claimed under the PRF program for cost-based reimbursements received from the Medicare pro...

Allowable costs related to the program are expenses or losses that were not reimbursed from other sources or that other sources were not obligated to reimburse. The System did not reduce COVID-19 related costs claimed under the PRF program for cost-based reimbursements received from the Medicare program for the COVID-19 related expense. The System will ensure the costs included in all subsequent Provider Relief Fund reporting is reduced for amounts reimbursed by other sources. Status: Completed Name of Responsible Official: Monica Holthaus Chief Financial Officer Community Healthcare Systems NE Kansas 785-889-5036

View Audit 309423

Finding 401244 (2022-004)

Significant Deficiency 2022

Hale County Hospital

AL

Questioned Costs Reporting Significant Deficiency

Finding 2022-004 – Reporting (Late Filing) – Significant Deficiency We are implementing policies to address the audit finding 2022-004 as follows: We are continuing to institute processes and procedures to complete timely reconciliations to allow for future filings to be made prior to the deadline....

Finding 2022-004 – Reporting (Late Filing) – Significant Deficiency We are implementing policies to address the audit finding 2022-004 as follows: We are continuing to institute processes and procedures to complete timely reconciliations to allow for future filings to be made prior to the deadline. Anticipated completion date: September 30, 2024

View Audit 309234

Finding 401242 (2022-002)

Material Weakness 2022

Hale County Hospital

AL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Finding 2022-002 – COVID-19 Provider Relief Fund – Assistance Listing Number 93.498 – Lack of Documentation of Review (Material Weakness) We are implementing policies to address the audit finding 2022-002 as follows: We have implemented a policy to ensure that all expenses are reviewed prior to dis...

Finding 2022-002 – COVID-19 Provider Relief Fund – Assistance Listing Number 93.498 – Lack of Documentation of Review (Material Weakness) We are implementing policies to address the audit finding 2022-002 as follows: We have implemented a policy to ensure that all expenses are reviewed prior to disbursement and that such evidence of approval is documented and retained. Anticipated completion date: September 30, 2024

View Audit 309234

Finding 401139 (2022-002)

Significant Deficiency 2022

Intermountain Centers for Human Development Inc. and Subsidiaries

AZ

Questioned Costs

The audit finding was for the timeframe of the first quarter FYE 9/30/22. lntermountain was aware that it was necessary to have an enterprise-wide electronic time tracking system in place for grant hours worked and by February of 2022 the company had implemented the Ceridian/Day Force Project Tracke...

The audit finding was for the timeframe of the first quarter FYE 9/30/22. lntermountain was aware that it was necessary to have an enterprise-wide electronic time tracking system in place for grant hours worked and by February of 2022 the company had implemented the Ceridian/Day Force Project Tracker platform. This system is an extension of our human resources and payroll platform and allows for actual time worked to be used for accurate grant costing of payroll and benefits.

View Audit 309174

Finding 401085 (2022-005)

Material Weakness 2022

Promise Healthcare Nfp

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

Special Tests & Provisions Questioned Costs 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 401076 (2022-003)

Significant Deficiency 2022

Promise Healthcare Nfp

IL

Special Tests & Provisions Questioned Costs Significant Deficiency

Special Tests and Provisions – Assistance Listing No. 93.224/93.527 Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection a...

Special Tests and Provisions – Assistance Listing No. 93.224/93.527 Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection and verification of patient information for each patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: to start 1. Review current policies and procedures: in progress a. Conduct a comprehensive review of existing procedures for collection and verification of patient information to identify weaknesses, gaps, and areas for improvement. b. Conduct review of current front desk workflow to determine if policies and procedures are followed correctly. c. Enhance policies and procedures as necessary to improve accuracy and consistency of patient information 2. Verification Process: to start a. Review documentation requirements for verifying accuracy of sliding fee information and standardize/improve where necessary. 3. Training and Education: to start a. Review training materials and create/improve where necessary to provide clear instructions and comply with policy and procedure b. Train front desk staff on standardized forms, templates and scripts for collecting information from patients c. Require periodic training and re-training to improve front desk workflow and retention of process to consistently collect and verify information from patients 4. Quality Assurance: to start a. Conduct regular audits and quality assurance checks to monitor the accuracy and integrity of sliding fee information and implementation of sliding fee discount b. Implement corrective actions to address any discrepancies or deficiencies identified during audits or reviews Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: Summer/Fall 2024

View Audit 309100

Finding 401010 (2022-003)

Significant Deficiency 2022

Urban Indian Center of Salt Lake

UT

Cash Management Questioned Costs Reporting § 200.305

Criteria: Recipients of federal awards must minimize the time elapsing between the receipt of funds from the U.S. Treasury and disbursement by the Organization set out at 2 CFR section 200.305(b). Audit Recommendation: We recommend that the Organization 1) maintains timely and accurate recording of ...

Criteria: Recipients of federal awards must minimize the time elapsing between the receipt of funds from the U.S. Treasury and disbursement by the Organization set out at 2 CFR section 200.305(b). Audit Recommendation: We recommend that the Organization 1) maintains timely and accurate recording of disbursements in its job‐costing system and 2) regularly request grant funds based on amounts expended as report in the Organization’s job‐costing system. Auditee Response: The Organization is implementing a grant tracking system in addition to its job costing system to better comply with these requirements. Together, these systems will be used to request only the amount attributable to the program for reimbursement. Corrective Action Plan: (1) Records will be kept in a newly developed spend down report for each grant/contract and reviewed with Division Directors and DFO monthly. All transactions are now being logged in QuickBooks with respective grant codes and departments, will not be processed without. (2) Monthly and quarterly invoicing according to each grant / contract agreement will be enforced by the GDCM and DFO in compliance with 2 CFR section 200.305(b). (3) The Organization has enrolled with the Treasury’s Invoice Processing Platform (IPP) to ensure all future Invoicing and payments can be easily tracked to the program/grant. Person Responsible: Matt Poss, Director of Finance Operations Timeline: All expenses and disbursements being coded to proper Grant/Type in QuickBooks Online – January 2023 Treasury Invoice Processing Platform (IPP) Onboarded – April 18th, 2023 Invoicing Timeline Created per collaboration with GDCM and DFO – May 18th, 2023 Revenue Reconciliation and clearing out of uncollectible or overbooked revenue – June 30th, 2023

View Audit 309064

Finding 401009 (2022-002)

Significant Deficiency 2022

Urban Indian Center of Salt Lake

UT

Matching / Level of Effort / Earmarking Questioned Costs Procurement, Suspension & Debarment § 200.430

Criteria: Recipients of federal awards must follow the costs principles set out at 2 CFR section 200.430 to substantiate compensation and other purchases charged to a federal program. “Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performe...

Criteria: Recipients of federal awards must follow the costs principles set out at 2 CFR section 200.430 to substantiate compensation and other purchases charged to a federal program. “Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: …(iii) reasonable reflect the total activity for which the employee is compensated by the non‐Federal entity” 2 CFR section 200.430(i). The Organization’s processes did not maintain sufficient documentation of the approval of the activity of each employee or the purchase of goods/services. Audit Recommendation: We recommend the Organization ensure it 1) maintains records of each employee’s activity and 2) monitors compliance with the job‐costing system implemented. Auditee Response: The Organization believes the paychecks and purchases identified were approved prior to payment. We will ensure that documentation is downloaded each pay period to ensure such documentation is not lost when a change in servicer is made. Corrective Action Plan: UICSL has implemented a new payroll system Paycom to help account for these Labor Allocation and Grant Codes. Employees are automated to each program and there is a designated reporting function allowing us to review what is assigned. UICSL also now has Directors for each division so there is clearly defined approvers and supervisors for each purchase and transaction. Person Responsible: Matt Poss, Director of Finance Operations Timeline: UICSL transitioned to Paycom in back‐half of 2023 and Leadership was designated and assigned for 2023.

View Audit 309064

Finding 400905 (2022-006)

Material Weakness 2022

West Virginia School of Osteopathic Medicine Clinic, Inc. D/b/a Robert C. Byrd Clinic

WV

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.303

Federal Agency Name: Department of Homeland Security Program Name: COVID‐19 Disaster Grants – Public Assistance Federal Financial Assistance Listing #97.036 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs Principles and Period of Performance Finding Summary: The rev...

Federal Agency Name: Department of Homeland Security Program Name: COVID‐19 Disaster Grants – Public Assistance Federal Financial Assistance Listing #97.036 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs Principles and Period of Performance Finding Summary: The review and approval of the expenditure listing was not retained. Responsible Individuals: David Meadows, Interim CFO Corrective Action Plan: Management agrees with the finding and has reviewed the operating procedures of Robert C. Byrd Clinic. Furthermore, we will implement procedures to retain expenditure listings and other support for federal awards as well as the related review. Anticipated Completion Date: Ongoing

View Audit 308944

Finding 400903 (2022-005)

Material Weakness 2022

West Virginia School of Osteopathic Medicine Clinic, Inc. D/b/a Robert C. Byrd Clinic

WV

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 2 TIN#4550559322 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activitie...

Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 2 TIN#4550559322 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs Principles and Reporting Finding Summary: The original expenditure listing which would have included the review of the expenditure listing, was not retained. As a part of the single audit, the Clinic recreated the expenditure listing to support the expenditures reported on the special report submitted to the Department of Health and Human Services for Period 2, however there was no control in place to retain the original documentation of the determination of expenditures and their related review. In addition, there was no retained documentation of the review and approval of the Clinic’s special report submitted to the Department of Health and Human Services for Period 2 TIN #4550559322. Responsible Individuals: David Meadows, Interim CFO Corrective Action Plan: Management agrees with the finding and has reviewed the operating procedures of Robert C. Byrd Clinic. Furthermore, we will implement procedures to retain expenditure listings and other support for federal awards as well as the related review. Anticipated Completion Date: Ongoing

View Audit 308944

Finding 400874 (2022-005)

Significant Deficiency 2022

City of South Fulton, Ga

GA

Questioned Costs Allowable Costs / Cost Principles Reporting

Name of the Contact Person Responsible: Rodney Green, Deputy Chief Financial Officer Corrective Action Plan: The City will strengthen its internal controls over federal reporting to ensure compliance with all requirements of the federal award program and other reporting requirements. Anticipated ...

Name of the Contact Person Responsible: Rodney Green, Deputy Chief Financial Officer Corrective Action Plan: The City will strengthen its internal controls over federal reporting to ensure compliance with all requirements of the federal award program and other reporting requirements. Anticipated Completion Date: June 30, 2024

View Audit 308897

Finding 400806 (2022-008)

Material Weakness 2022

Healthhiv

DC

Questioned Costs Material Weakness Reporting

The transitioning to the new Finance Director continued during year and additional account reviews were required. This has caused a delay in the timing of our filing. HealthHIV will continue to addressed our internal control on filing our audit report timely and by the FAC due date.

View Audit 308831

Finding 400773 (2022-004)

Significant Deficiency 2022

Great Northwest Education Cooperative

ND

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

Contact Person – Ben Schafer, Executive Director Corrective Action Plan – The Executive Director will review and approve, with documentation, all invoices prior to payment being made. Completion Date – The Coop will implement this corrective action plan in the next fiscal year.

View Audit 308791

Finding 400604 (2022-005)

Significant Deficiency 2022

Tca Health, Inc.

IL

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

TCA Health will address the Allowable Costs and Activities first, by hiring additional accounting professionals both internally and as third- party consultants to support the grants management process in place at TCA. As part of that work, the third-party consultant will review the Time and Effort r...

TCA Health will address the Allowable Costs and Activities first, by hiring additional accounting professionals both internally and as third- party consultants to support the grants management process in place at TCA. As part of that work, the third-party consultant will review the Time and Effort reporting policy and model. TCA currently feels that what the process that they utilized to allocate salary and wage expense to the grant related to this finding was allowable from a Uniform Grants Guidance perspective, however they were not compliant with their policy and will work to revise their policy to less restrictive (although still in compliance with the UGG). The iCFO will create greater monitoring of the month-end process as it relates to the allocation of payroll costs to be consistent with the personnel activity reports and the Health Center’s revised policy.

View Audit 308641

Finding 400602 (2022-004)

Material Weakness 2022

Tca Health, Inc.

IL

Questioned Costs Cash Management Material Weakness § 200.303

The COO at TCA Health will address Cash Management first, reviewing the policy and procedure to ensure it’s up to date with today’s best practices and modern standards. In doing so, TCA will review the organization chart to assess if the policy and procedure to match the personnel structure that’s c...

The COO at TCA Health will address Cash Management first, reviewing the policy and procedure to ensure it’s up to date with today’s best practices and modern standards. In doing so, TCA will review the organization chart to assess if the policy and procedure to match the personnel structure that’s currently in place. Changes will be made if necessary. Additionally, TCA has hired a third-party consulting firm that can assist with grant best practices.

View Audit 308641

Finding 400600 (2022-003)

Material Weakness 2022

Tca Health, Inc.

IL

Questioned Costs Eligibility Material Weakness

The COO at TCA Health will address the Special Provisions weakness by coaching and training front desk staff members. Specifically, staff will be trained in the sliding fee scale and its requirements. Staff will become proficient in the collection of data from patients, properly storing and recordin...

The COO at TCA Health will address the Special Provisions weakness by coaching and training front desk staff members. Specifically, staff will be trained in the sliding fee scale and its requirements. Staff will become proficient in the collection of data from patients, properly storing and recording it in the EMR, and the calculation of the slide according to the Federal Poverty Guidelines. Lastly, the team will be updated on the latest EMR module that experienced an upgrade and taught how to effectively apply the slide. TCA will also assess the current staff to ensure the proper personnel is in in place.

View Audit 308641

Finding 400572 (2022-003)

Material Weakness 2022

Lutheran Family Services of Nebraska, Inc. and Affiliates

NE

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

Condition: Refugee case files, specifically related to the Afghan Placement and Assistance Program, lacked certain documentation required by the Cooperative Agreements. Planned Corrective Action Management is reviewing and improving internal controls over review of refugee case file documentation. T...

Condition: Refugee case files, specifically related to the Afghan Placement and Assistance Program, lacked certain documentation required by the Cooperative Agreements. Planned Corrective Action Management is reviewing and improving internal controls over review of refugee case file documentation. The Cooperative Agreement specific to the Afghan Placement and Assistance Program directed the Organization to focus on the provision of services and to include documentation of such activities to the extent possible. Furthermore, the Organization’s funding agencies have performed numerous monitoring reviews of the case files, including reviews specific to the Afghan Placement and Assistance Program. While the results of these reviews did note similar findings, subsequent to year-end, the Organization received written documentation that all such findings have satisfactorily been resolved and that the Organization is in compliance with the terms and conditions of the Cooperative Agreement. Contact Person: Amy Carolus, Chief Financial Officer Anticipated Completion Date: December 31, 2023

View Audit 308632

Finding 400566 (2022-006)

Material Weakness 2022

Pembroke Hill School

NH

School Nutrition Programs Internal Control / Segregation of Duties Questioned Costs § 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 400552 (2022-003)

Significant Deficiency 2022

Meals on Wheels of Middle Georgia, Inc.

GA

Questioned Costs Internal Control / Segregation of Duties Special Tests & Provisions

Views of Responsible Officials and Planned Corrective Actions: See Comment 2022-001 and 002. Date to be implemented: See Comment 2022-001 and 002. Persons responsible: See Comment 2022-001 and 002.

View Audit 308581

Corrective Action Plans

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