Corrective Action Plans

Finding 28033 (2022-002)

Significant Deficiency 2022

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Questioned Costs

Finding ref number: 2022-002 Finding caption: The District?s internal controls were inadequate for ensuring compliance with federal requirements for allowable costs and time-and-effort documentation. Name, address, and telephone of District contact person: Greg Pike 901 Ahlers Ave, Royal City, WA 9...

Finding ref number: 2022-002 Finding caption: The District?s internal controls were inadequate for ensuring compliance with federal requirements for allowable costs and time-and-effort documentation. Name, address, and telephone of District contact person: Greg Pike 901 Ahlers Ave, Royal City, WA 99357 509-346-2222 Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). Business Manager to work with Assistant Superintendent more frequently on staffing plans to reduce the possibility of staffing changes throughout the year. If necessary, changes to the staffing plan will be documented to comply with time and effort requirements. Anticipated date to complete the corrective action: August 31, 2023

View Audit 28471 Questioned Costs: $1

Finding 27972 (2022-006)

Significant Deficiency 2022

Dakota Plains Legal Services, Inc.

SD

Questioned Costs Internal Control / Segregation of Duties Reporting

Legal Services Corporation CFDA #09-742018 Legal Services Corporation - Basic Field - General CFDA #09-742018 Legal Services Corporation - Basic Field - Native American Reporting Significant Deficiency in Internal Control over Compliance 2022-006 Condition: DPLS entered into a lease of personal pr...

Legal Services Corporation CFDA #09-742018 Legal Services Corporation - Basic Field - General CFDA #09-742018 Legal Services Corporation - Basic Field - Native American Reporting Significant Deficiency in Internal Control over Compliance 2022-006 Condition: DPLS entered into a lease of personal property exceeding $25,000 requiring the completion of an application of approval, however, this was not completed. Additionally, DPLS entered a lease to relocate office space for an existing branch office requiring an update to DPLS' Grantee Profile on GrantEase within 15 calendar days, however, this was not completed. Auditor's Recommendation: We recommend DPLS review LSC reporting requirements with applicable employees. Management's Response: The Executive Director of the program will usually be making the decisions with regards to transactions that will fall under this finding. The ED and any other applicable staff will work to ensure that the proper procedures are followed with regards to these types of transactions. Responsible Individuals: Michelle Lovejoy, Program Administrator, Tom Mortland, Executive Director, Annemarie Michaels, Deputy Director. Anticipated Completion Date: December 31, 2023.

View Audit 23914

Finding 27971 (2022-005)

Significant Deficiency 2022

Dakota Plains Legal Services, Inc.

SD

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

Legal Services Corporation CFDA #09-742018 Legal Services Corporation -Basic Field - General CFDA #09-742018 Legal Services Corporation - Basic Field - Native American Eligibility Significant Deficiency in Internal Control over Compliance 2022-005 Condition: One instance identified in which the Gr...

Legal Services Corporation CFDA #09-742018 Legal Services Corporation -Basic Field - General CFDA #09-742018 Legal Services Corporation - Basic Field - Native American Eligibility Significant Deficiency in Internal Control over Compliance 2022-005 Condition: One instance identified in which the Grant Compliance Checklist wasn't completed as required by DPLS policy. Additionally, one instance identified in which Form 1644 Disclosure of Case Information was not completed timely, resulting in the case information not being reported to the Corporation. Auditor's Recommendation: We recommend DPLS review policies and procedures with applicable employees and remind them of the importance of established review and monitoring processes. Management's Response: All employees have received additional training on compliance procedures and new employees will receive the same. All files being closed are now reviewed first for accuracy by the case handler of that file. The files are double checked by the office secretary for accuracy. At the end of the quarter, all files are sent to compliance for a third review. Any needed corrections are noted by compliance and the file is then sent back to the office where it originated from to be corrected. Then the corrections to the file are reported back to compliance to verify that they have been made. Responsible Individuals: Dawn Marshall, Compliance Officer, Tom Mortland, Executive Director, Annemarie Michaels, Deputy Director. Anticipated Completion Date: December 31, 2023.

View Audit 23914

Finding 27970 (2022-004)

Significant Deficiency 2022

Dakota Plains Legal Services, Inc.

SD

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles

Legal Services Corporation CFDA #09-742018 Legal Services Corporation - Basic Field - General CFDA #09-742018 Legal Services Corporation - Basic Field - Native American Activities Allowed and Allowable Costs Significant Deficiency in Internal Control over Compliance 2022-004 Condition: One instanc...

Legal Services Corporation CFDA #09-742018 Legal Services Corporation - Basic Field - General CFDA #09-742018 Legal Services Corporation - Basic Field - Native American Activities Allowed and Allowable Costs Significant Deficiency in Internal Control over Compliance 2022-004 Condition: One instance identified in which hours worked by an employee did not agree to hours paid. Auditor's Recommendation: We recommend DPLS review payroll policies and procedures with applicable employees to ensure compliance with documented procedures. Management's Response: The timesheets are initially being processed by the Administrator of the program. The timesheets are checked for accuracy in the time recorded by the employee, the employee leave balance is verified, and a check is done to verify that they have been reviewed by the supervisor of the employee. Finally, the hours recorded on the timesheet are reviewed to verify that they match the hours the employee has recorded in the Legal Server program. After these procedures have been completed the timesheets then go to the Deputy Director for further review and to verify the accuracy of the managing attorney timesheets. Note: The Executive Director provides review of the Deputy Director timesheet. Only after these procedures have been completed do the timesheets then go to the Administrative Assistant for payroll processing. Management will initiate a further step where all payroll amounts will be double checked by the Program Administrator prior to the issuance of payroll. Responsible Individuals: Michelle LoveJoy, Program Administrator, Tom Mortland, Executive Director, Annemarie Michaels, Deputy Director. Anticipated Completion Date: Immediately.

View Audit 23914

Finding 27966 (2022-001)

Significant Deficiency 2022

Gordon-Conwell Theological Seminary

MA

Questioned Costs Student Financial Aid Reporting

Finding 2022-001 Condition Found During our audit, we noted an instance where 2 dual degree graduated students were inappropriately reported as withdrawn. Upon further review by the Seminary staff, an additional 6 students were identified with the same issue. Corrective Action Plan The Degree Ver...

Finding 2022-001 Condition Found During our audit, we noted an instance where 2 dual degree graduated students were inappropriately reported as withdrawn. Upon further review by the Seminary staff, an additional 6 students were identified with the same issue. Corrective Action Plan The Degree Verify report that is generated by our Student Information System (CAMS) and submitted to the National Student Loan Clearinghouse (Clearinghouse) would produce a separate line item for each degree when a dual degree student would graduate with both degrees in the same semester. This would not be accepted by the Clearinghouse and neither degree would be updated. When the student was reported as not enrolled in subsequent semesters, the Clearinghouse would update the student?s degree status to withdrawn. We have since converted to a new Student Information System (SONIS) and we have also updated the instructions concerning the Degree Verify report. We will now identify each dual degree student and submit only one degree through the report submitted to the Clearinghouse. For each second degree for a student, we will manually update the record within the Clearinghouse. Responsible Party: Gregg Hansen, Chief Financial Officer, 978.646.4016 Anticipated Completion Date: November 18, 2022

View Audit 17839

Finding 27958 (2022-005)

Material Weakness 2022

University of Arkansas for Medical Sciences

AR

Questioned Costs Allowable Costs / Cost Principles § 200.303

Finding 2022-005 In the future, if such a program were available that required a review of diagnosis against a certain set of treatment and diagnostic charges, the Assistant Vice Chancellor for Revenue Cycle will work with the EPIC IT team to develop specific program parameters for billing or a man...

Finding 2022-005 In the future, if such a program were available that required a review of diagnosis against a certain set of treatment and diagnostic charges, the Assistant Vice Chancellor for Revenue Cycle will work with the EPIC IT team to develop specific program parameters for billing or a manual review will be developed and implemented. Responsible official: Assistant Vice Chancellor for Revenue Cycle Anticipated completion date: January 1, 2023

View Audit 18650 Questioned Costs: $1

Finding 27328 (2022-006)

Material Weakness 2022

University of Arkansas for Medical Sciences

AR

Cash Management Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.305

Finding 2022-006 Beginning June 1, 2022, grans accounting staff were trained to utilize a draw report that calculated cleared (paid) expense to ensure expenses were invoiced in accordance with federal and program regulations. During fiscal year 2022, a new director and staff were hired in the grant...

Finding 2022-006 Beginning June 1, 2022, grans accounting staff were trained to utilize a draw report that calculated cleared (paid) expense to ensure expenses were invoiced in accordance with federal and program regulations. During fiscal year 2022, a new director and staff were hired in the grants accounting office. In addition, with completing the implementation of the financial system, we believe adequate controls have been established and are working properly to ensure compliance with cash management regulations. Responsible Official: Associate Vice Chancellor for Finance & Treasurer Implementation Date: February 2023

View Audit 18650 Questioned Costs: $1

Finding 26393 (2022-004)

Material Weakness 2022

University of Arkansas for Medical Sciences

AR

Questioned Costs Allowable Costs / Cost Principles

Finding 2022-004 During fiscal year 2022, additional grants accounting staff were hired and with the implementation of the new financial system, we believe established controls will ensure all expenditures are adequately supported and supporting documents are maintained. Responsible Official: Assoc...

Finding 2022-004 During fiscal year 2022, additional grants accounting staff were hired and with the implementation of the new financial system, we believe established controls will ensure all expenditures are adequately supported and supporting documents are maintained. Responsible Official: Associate Vice Chancellor for Finance & Treasurer Implementation Date: May 2023

View Audit 18650 Questioned Costs: $1

Finding 26392 (2022-003)

Material Weakness 2022

University of Arkansas for Medical Sciences

AR

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Finding 2022-003 During fiscal year 2022, a new director and staff were hired in the grants accounting office. In addition, with completing the implementation of the new financial system, we believe adequate controls have been established and are working properly to ensure compliance with federal a...

Finding 2022-003 During fiscal year 2022, a new director and staff were hired in the grants accounting office. In addition, with completing the implementation of the new financial system, we believe adequate controls have been established and are working properly to ensure compliance with federal and program regulations. Responsible Official: Associate Vice Chancellor for Finance & Treasurer Implementation Date: May 2023

View Audit 18650

Finding 26390 (2022-001)

Material Weakness 2022

University of Arkansas for Medical Sciences

AR

Cash Management Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.305

Finding 2022-001 Beginning June 1, 2022, grants accounting staff were trained to utilize a draw report that calculated cleared (paid) expense to ensure expenses were invoiced in accordance with federal and program regulations. During fiscal year 2022, a new director and staff were hired in the gran...

Finding 2022-001 Beginning June 1, 2022, grants accounting staff were trained to utilize a draw report that calculated cleared (paid) expense to ensure expenses were invoiced in accordance with federal and program regulations. During fiscal year 2022, a new director and staff were hired in the grants accounting office. In addition, with completing the implementation of the financial system, we believe adequate controls have been established and are working properly to ensure compliance with cash management regulations. Responsible Official: Associate Vice Chancellor for Finance & Treasurer Implementation Date: February 2023

View Audit 18650 Questioned Costs: $1

Finding 26377 (2022-002)

Material Weakness 2022

Colorado Springs School District 11

CO

Questioned Costs Special Tests & Provisions Matching / Level of Effort / Earmarking § 200.303 § 200.326

2022-002 Finding: Special Tests - Wage Rate Requirements Federal Assistance Listing Number 84.425D - COVID 19 Elementary and Secondary School Emergency Fund (ESSER) Passed-through Colorado Department of Education Award Number - 4420; Award Year 2022 Summary of Finding: The District did not obtain ce...

2022-002 Finding: Special Tests - Wage Rate Requirements Federal Assistance Listing Number 84.425D - COVID 19 Elementary and Secondary School Emergency Fund (ESSER) Passed-through Colorado Department of Education Award Number - 4420; Award Year 2022 Summary of Finding: The District did not obtain certified payrolls for contractor or subcontractor work performed. The District did not have internal controls in place to identify that certified payrolls were not obtained. Status: Corrective action in progress Client Planned Action: The District concurs with the recommendations and is currently developing and implementing internal controls to ensure compliance. Grants Department personnel met with Facilities personnel to discuss the processes and procedures to implement, and internal controls that would ensure this. These will include a monthly checklist, verified with signatures of Facilities and Grants Department Personnel. This checklist will provide verification that certified payroll is being monitored and reviewed weekly, and is being compared to prevailing wage rates. Client Responsible Party: Annette Bass, Director of Grants Completion Date: Initial implementation of internal controls beginning on August 1. Adjustments and revisions to initial processes as needed. The verifications are to be done on a recurring monthly basis.

View Audit 18323

Finding 26368 (2022-002)

None 2022

Urbana City School District

OH

Questioned Costs Subrecipient Monitoring Cash Management § 200.208 § 200.305

Finding Number: 2022-002 Planned Corrective Action: If the district is required to return to tally sheets for the calculation of site claim forms, more stringent reviews will be put into place between the tally sheets and the entering of the site claim form data. The 2021 ? 2022 school year had sp...

Finding Number: 2022-002 Planned Corrective Action: If the district is required to return to tally sheets for the calculation of site claim forms, more stringent reviews will be put into place between the tally sheets and the entering of the site claim form data. The 2021 ? 2022 school year had special procedures in place due to the ongoing pandemic. Anticipated Completion Date: March 16, 2023 Responsible Contact Person: Mandy Hildebrand, Treasurer

View Audit 27680

Finding 26362 (2022-002)

Significant Deficiency 2022

Barr-Reeve Community Schools, Inc.

IN

Subrecipient Monitoring Reporting Significant Deficiency § 200.302 § 200.328

CORRECTIVE ACTION PLAN FINDING 2022-002 Contact Person Responsible for Corrective Action: Tamara Swartzentruber, Treasurer Contact Phone Number: 812-486-3220 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Treasurer has worked with manageme...

CORRECTIVE ACTION PLAN FINDING 2022-002 Contact Person Responsible for Corrective Action: Tamara Swartzentruber, Treasurer Contact Phone Number: 812-486-3220 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Treasurer has worked with management and will implement better controls when preparing the Annual Data Report on the COVID-19 Education Stabilization Fund. We will work to get the report reviewed and submitted on the correct due date. Anticipated Completion Date: April 2023

View Audit 27982

Finding 26357 (2022-004)

Significant Deficiency 2022

Community Action Association of Pennsylvania

PA

Allowable Costs / Cost Principles Questioned Costs Reporting § 200.430

CORRECTIVE ACTION PLAN February 16, 2023 Community Action Association of Pennsylvania respectfully submits the following corrective action plan for the year ended June 30, 2022. Cognizant or Oversight Agency for Audit: Community Service Block Grant Program Name and address of independent publi...

CORRECTIVE ACTION PLAN February 16, 2023 Community Action Association of Pennsylvania respectfully submits the following corrective action plan for the year ended June 30, 2022. Cognizant or Oversight Agency for Audit: Community Service Block Grant Program Name and address of independent public accounting firm: Hamilton & Musser, PC 176 Cumberland Parkway Mechanicsburg, PA 17055 Audit Period: July 1, 2021 ? June 30, 2022 The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Findings ? Financial Statement Audit Significant Deficiencies #2022-001 ? Significant Deficiency ? Segregation of Duties Recommendation We recommend someone other than the Finance Director, preferably the CEO or another office staff, open the mail and record/scan the checks received into a check log. View of responsible officials and planned corrective action The Executive Administrative Assistant is now tasked with and responsible for opening the mail and recording the checks into a check log. The Executive Administrative Assistant will forward checks to the financial services team for additional action steps. #2022-002 ? Significant Deficiency ? Authorization and Approval Recommendation We recommend that all credit card charges are matched to a receipt and reviewed and approved by both the Board President and Board Treasurer, as is the policy with other payables/disbursements. This eliminates the risk associated with having the CEO issue approval over his own credit card charges. View of responsible officials and planned corrective action All credit card receipts will be submitted by the CEO or appropriate staff member to the financial services team. Credit card reconciliation documentation and appropriate receipts will be provided to the Board Treasurer for regular review. -28- Findings ? Financial Statement Audit (Continued) #2022-003 ? Significant Deficiency ? Authorization and Approval Recommendation Non-cash journal entries make it easy for organizations to overstate their revenue or understate their expenses with unsubstantiated accruals/deferrals. We recommend that all journal entries be authorized and approved by the CEO prior to entry. View of responsible officials and planned corrective action As noted, this is no longer an issue with internal controls having been corrected as of December 31, 2021. All non-recurring journal entries will be approved by the CEO. Findings ? Federal Award Programs Audit Community Service Block Grant, CFDA #93.569 #2022-004 ? Significant Deficiency ? Allowable Costs Recommendation We recommend maintaining weekly timesheets with CEO approval, itemized by time allocated per grant. The financial statement records should be supported by direct time allocated to the grant as indicated on the approved timesheets. View of responsible officials and planned corrective action CAAP will do its due diligence in appropriately allocating costs should similar costs be incurred. If the Community Service Block Grant Program has questions regarding this plan, please call Community Action Association of Pennsylvania Chief Executive Officer Beck Moore at 717-233-1075 extension 12.

View Audit 27273 Questioned Costs: $1

Finding 26356 (2022-003)

Significant Deficiency 2022

Community Action Association of Pennsylvania

PA

Internal Control / Segregation of Duties Questioned Costs Significant Deficiency

CORRECTIVE ACTION PLAN February 16, 2023 Community Action Association of Pennsylvania respectfully submits the following corrective action plan for the year ended June 30, 2022. Cognizant or Oversight Agency for Audit: Community Service Block Grant Program Name and address of independent publi...

CORRECTIVE ACTION PLAN February 16, 2023 Community Action Association of Pennsylvania respectfully submits the following corrective action plan for the year ended June 30, 2022. Cognizant or Oversight Agency for Audit: Community Service Block Grant Program Name and address of independent public accounting firm: Hamilton & Musser, PC 176 Cumberland Parkway Mechanicsburg, PA 17055 Audit Period: July 1, 2021 ? June 30, 2022 The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Findings ? Financial Statement Audit Significant Deficiencies #2022-001 ? Significant Deficiency ? Segregation of Duties Recommendation We recommend someone other than the Finance Director, preferably the CEO or another office staff, open the mail and record/scan the checks received into a check log. View of responsible officials and planned corrective action The Executive Administrative Assistant is now tasked with and responsible for opening the mail and recording the checks into a check log. The Executive Administrative Assistant will forward checks to the financial services team for additional action steps. #2022-002 ? Significant Deficiency ? Authorization and Approval Recommendation We recommend that all credit card charges are matched to a receipt and reviewed and approved by both the Board President and Board Treasurer, as is the policy with other payables/disbursements. This eliminates the risk associated with having the CEO issue approval over his own credit card charges. View of responsible officials and planned corrective action All credit card receipts will be submitted by the CEO or appropriate staff member to the financial services team. Credit card reconciliation documentation and appropriate receipts will be provided to the Board Treasurer for regular review. -28- Findings ? Financial Statement Audit (Continued) #2022-003 ? Significant Deficiency ? Authorization and Approval Recommendation Non-cash journal entries make it easy for organizations to overstate their revenue or understate their expenses with unsubstantiated accruals/deferrals. We recommend that all journal entries be authorized and approved by the CEO prior to entry. View of responsible officials and planned corrective action As noted, this is no longer an issue with internal controls having been corrected as of December 31, 2021. All non-recurring journal entries will be approved by the CEO. Findings ? Federal Award Programs Audit Community Service Block Grant, CFDA #93.569 #2022-004 ? Significant Deficiency ? Allowable Costs Recommendation We recommend maintaining weekly timesheets with CEO approval, itemized by time allocated per grant. The financial statement records should be supported by direct time allocated to the grant as indicated on the approved timesheets. View of responsible officials and planned corrective action CAAP will do its due diligence in appropriately allocating costs should similar costs be incurred. If the Community Service Block Grant Program has questions regarding this plan, please call Community Action Association of Pennsylvania Chief Executive Officer Beck Moore at 717-233-1075 extension 12.

View Audit 27273

Finding 26355 (2022-002)

Significant Deficiency 2022

Community Action Association of Pennsylvania

PA

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN February 16, 2023 Community Action Association of Pennsylvania respectfully submits the following corrective action plan for the year ended June 30, 2022. Cognizant or Oversight Agency for Audit: Community Service Block Grant Program Name and address of independent publi...

CORRECTIVE ACTION PLAN February 16, 2023 Community Action Association of Pennsylvania respectfully submits the following corrective action plan for the year ended June 30, 2022. Cognizant or Oversight Agency for Audit: Community Service Block Grant Program Name and address of independent public accounting firm: Hamilton & Musser, PC 176 Cumberland Parkway Mechanicsburg, PA 17055 Audit Period: July 1, 2021 ? June 30, 2022 The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Findings ? Financial Statement Audit Significant Deficiencies #2022-001 ? Significant Deficiency ? Segregation of Duties Recommendation We recommend someone other than the Finance Director, preferably the CEO or another office staff, open the mail and record/scan the checks received into a check log. View of responsible officials and planned corrective action The Executive Administrative Assistant is now tasked with and responsible for opening the mail and recording the checks into a check log. The Executive Administrative Assistant will forward checks to the financial services team for additional action steps. #2022-002 ? Significant Deficiency ? Authorization and Approval Recommendation We recommend that all credit card charges are matched to a receipt and reviewed and approved by both the Board President and Board Treasurer, as is the policy with other payables/disbursements. This eliminates the risk associated with having the CEO issue approval over his own credit card charges. View of responsible officials and planned corrective action All credit card receipts will be submitted by the CEO or appropriate staff member to the financial services team. Credit card reconciliation documentation and appropriate receipts will be provided to the Board Treasurer for regular review. -28- Findings ? Financial Statement Audit (Continued) #2022-003 ? Significant Deficiency ? Authorization and Approval Recommendation Non-cash journal entries make it easy for organizations to overstate their revenue or understate their expenses with unsubstantiated accruals/deferrals. We recommend that all journal entries be authorized and approved by the CEO prior to entry. View of responsible officials and planned corrective action As noted, this is no longer an issue with internal controls having been corrected as of December 31, 2021. All non-recurring journal entries will be approved by the CEO. Findings ? Federal Award Programs Audit Community Service Block Grant, CFDA #93.569 #2022-004 ? Significant Deficiency ? Allowable Costs Recommendation We recommend maintaining weekly timesheets with CEO approval, itemized by time allocated per grant. The financial statement records should be supported by direct time allocated to the grant as indicated on the approved timesheets. View of responsible officials and planned corrective action CAAP will do its due diligence in appropriately allocating costs should similar costs be incurred. If the Community Service Block Grant Program has questions regarding this plan, please call Community Action Association of Pennsylvania Chief Executive Officer Beck Moore at 717-233-1075 extension 12.

View Audit 27273

Finding 26354 (2022-001)

Significant Deficiency 2022

Community Action Association of Pennsylvania

PA

Internal Control / Segregation of Duties Questioned Costs Significant Deficiency

CORRECTIVE ACTION PLAN February 16, 2023 Community Action Association of Pennsylvania respectfully submits the following corrective action plan for the year ended June 30, 2022. Cognizant or Oversight Agency for Audit: Community Service Block Grant Program Name and address of independent publi...

CORRECTIVE ACTION PLAN February 16, 2023 Community Action Association of Pennsylvania respectfully submits the following corrective action plan for the year ended June 30, 2022. Cognizant or Oversight Agency for Audit: Community Service Block Grant Program Name and address of independent public accounting firm: Hamilton & Musser, PC 176 Cumberland Parkway Mechanicsburg, PA 17055 Audit Period: July 1, 2021 ? June 30, 2022 The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Findings ? Financial Statement Audit Significant Deficiencies #2022-001 ? Significant Deficiency ? Segregation of Duties Recommendation We recommend someone other than the Finance Director, preferably the CEO or another office staff, open the mail and record/scan the checks received into a check log. View of responsible officials and planned corrective action The Executive Administrative Assistant is now tasked with and responsible for opening the mail and recording the checks into a check log. The Executive Administrative Assistant will forward checks to the financial services team for additional action steps. #2022-002 ? Significant Deficiency ? Authorization and Approval Recommendation We recommend that all credit card charges are matched to a receipt and reviewed and approved by both the Board President and Board Treasurer, as is the policy with other payables/disbursements. This eliminates the risk associated with having the CEO issue approval over his own credit card charges. View of responsible officials and planned corrective action All credit card receipts will be submitted by the CEO or appropriate staff member to the financial services team. Credit card reconciliation documentation and appropriate receipts will be provided to the Board Treasurer for regular review. -28- Findings ? Financial Statement Audit (Continued) #2022-003 ? Significant Deficiency ? Authorization and Approval Recommendation Non-cash journal entries make it easy for organizations to overstate their revenue or understate their expenses with unsubstantiated accruals/deferrals. We recommend that all journal entries be authorized and approved by the CEO prior to entry. View of responsible officials and planned corrective action As noted, this is no longer an issue with internal controls having been corrected as of December 31, 2021. All non-recurring journal entries will be approved by the CEO. Findings ? Federal Award Programs Audit Community Service Block Grant, CFDA #93.569 #2022-004 ? Significant Deficiency ? Allowable Costs Recommendation We recommend maintaining weekly timesheets with CEO approval, itemized by time allocated per grant. The financial statement records should be supported by direct time allocated to the grant as indicated on the approved timesheets. View of responsible officials and planned corrective action CAAP will do its due diligence in appropriately allocating costs should similar costs be incurred. If the Community Service Block Grant Program has questions regarding this plan, please call Community Action Association of Pennsylvania Chief Executive Officer Beck Moore at 717-233-1075 extension 12.

View Audit 27273

Finding 26350 (2022-009)

Significant Deficiency 2022

Richmond County

NC

Questioned Costs Eligibility

Finding 2022-009 Inadequate Request for Information Name of contact person: Theressa Smith, Deputy Social Services Director Corrective Action: Training completed on August 23, 2022. Electronic verifications and hierarchy of verifications was discussed with all ...

Finding 2022-009 Inadequate Request for Information Name of contact person: Theressa Smith, Deputy Social Services Director Corrective Action: Training completed on August 23, 2022. Electronic verifications and hierarchy of verifications was discussed with all Medicaid Staff. A follow up training will be scheduled for the first quarter of 2023. Agency will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address accuracy. Agency will send a monthly email reminder to address trending errors. Proposed Completion Date: By March 31, 2023 and ongoing

View Audit 25920

Finding 26349 (2022-008)

Significant Deficiency 2022

Richmond County

NC

Questioned Costs Eligibility Reporting

Finding 2022-008 Untimely Review of SSI Termination Name of contact person: Theressa Smith, Deputy Social Services Director Corrective Action: Training completed on November 3, 2022. Policy MA-1000 and MA-1100 was discussed with all Adult Medicaid Workers. Jo...

Finding 2022-008 Untimely Review of SSI Termination Name of contact person: Theressa Smith, Deputy Social Services Director Corrective Action: Training completed on November 3, 2022. Policy MA-1000 and MA-1100 was discussed with all Adult Medicaid Workers. Job aids and powerpoint from The Learning Gateway were reviewed and distributed to all Adult Medicaid workers. Proposed Completion Date: November 3, 2022 and ongoing

View Audit 25920

Finding 26348 (2022-007)

Significant Deficiency 2022

Richmond County

NC

Questioned Costs Eligibility

Finding 2022-007 Inaccurate Resources Entry Name of contact person: Theressa Smith, Deputy Social Services Director Corrective Action: Training was completed on December 7, 2022 discussing manual MA-2230 and MA-3320 with all Medicaid staff. A documentation tem...

Finding 2022-007 Inaccurate Resources Entry Name of contact person: Theressa Smith, Deputy Social Services Director Corrective Action: Training was completed on December 7, 2022 discussing manual MA-2230 and MA-3320 with all Medicaid staff. A documentation template was created for applications and recerts to include a resource checklist reminder. Agency will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address accuracy. Agency will send a monthly email reminder to address trending errors. Proposed Completion Date: December 7, 2022 and ongoing

View Audit 25920

Finding 26347 (2022-006)

Significant Deficiency 2022

Richmond County

NC

Questioned Costs Eligibility Internal Control / Segregation of Duties

Finding 2022-006 Inaccurate Information Entry Name of contact person: Theressa Smith, Deputy Social Services Director Corrective Action: Training was completed on December 7, 2022. A documentation template was created to remind workers of TWN and other informa...

Finding 2022-006 Inaccurate Information Entry Name of contact person: Theressa Smith, Deputy Social Services Director Corrective Action: Training was completed on December 7, 2022. A documentation template was created to remind workers of TWN and other informational resources available. Agency will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address accuracy. Agency will send a monthly email reminder to address trending errors. Proposed Completion Date: December 7, 2022 and ongoing

View Audit 25920

Finding 26346 (2022-005)

Significant Deficiency 2022

Richmond County

NC

Questioned Costs Eligibility

Finding 2022-005 IV-D Cooperation with Child Support Name of contact person: Theressa Smith, Deputy Social Services Director Corrective Action: Training was completed on December 7, 2022. Will continue to complete second party reviews to monitor compliance with...

Finding 2022-005 IV-D Cooperation with Child Support Name of contact person: Theressa Smith, Deputy Social Services Director Corrective Action: Training was completed on December 7, 2022. Will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address IV-D child support cooperation. Agency will send a monthly email reminder to address trending errors. Proposed Completion Date: December 7, 2022 and ongoing

View Audit 25920

Finding 26329 (2022-001)

Significant Deficiency 2022

Unleashing Potential

MO

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring

Finding 2022-001 Personnel Responsible for Corrective Action: President/CEO ? Darlene Sowell Anticipated Completion Date: November 1, 2023 Corrective Action Plan: The Organization has modified it?s internal control procedures to include a monthly review of actual hours incurred compared to the est...

Finding 2022-001 Personnel Responsible for Corrective Action: President/CEO ? Darlene Sowell Anticipated Completion Date: November 1, 2023 Corrective Action Plan: The Organization has modified it?s internal control procedures to include a monthly review of actual hours incurred compared to the estimated amounts by individuals assigned to federal grant projects prior to requesting reimbursement from the funding source. The review will be performed by an individual, other than the preparer of the reimbursement request, with knowledge of the federal grant program and will be formally documented.

View Audit 21561

Finding 26312 (2022-001)

None 2022

Block Island Ecnmc Dev Fndtn Hsng CORP Dba E. Searles Ball Memorial

CT

Questioned Costs

CORRECTIVE ACTION PLAN July 31, 2023 Federal Audit Clearinghouse 1201 East 10th Street Jefferson, Indiana 47132 Block Island Economic Development Foundation Housing Corporation d/b/a E. Searles Ball Memorial Housing (the Project) respectfully submits the following Corrective Action Plan for the year...

CORRECTIVE ACTION PLAN July 31, 2023 Federal Audit Clearinghouse 1201 East 10th Street Jefferson, Indiana 47132 Block Island Economic Development Foundation Housing Corporation d/b/a E. Searles Ball Memorial Housing (the Project) respectfully submits the following Corrective Action Plan for the year ended December 31, 2022. Hoyt, Filippetti & Malaghan, LLC 1041 Poquonnock Road Groton, Connecticut 06340 Audit Period: Year ended December 31, 2022 The findings from the December 31, 2022 Schedule of Federal Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. 2022-001 RESERVE ACCOUNT FUNDING Grantor: U.S. Department of Agriculture Award Name: Rural Rental Housing Loans Award Year: 2021 Award Numbers: Various CFDA Number: 10.415 Criteria: The Project?s reserve account must be fully funded and maintained in a separate bank account. Condition: During our audit testing, we noted that while the Project maintained a separate bank account for reserves, it was not fully funded. Cause: Yearly budgeted transfers were not made to ensure the account is fully funded. Effect: Reserve bank account is underfunded. Questioned Costs: None noted. Recommendation: The Project should implement controls to ensure that the reserve bank account is fully funded. Management?s Views and Corrective Action Plan: Management will correct this when sufficient funds are able to be transferred into the reserve account If you have any questions regarding this plan, please contact Matthew Scibek at 860-398-5425, or matt@westfordmgt.com.

View Audit 22894

Finding 26311 (2022-001)

None 2022

Tompkins Consolidated Area Transit, Inc.

NY

Questioned Costs Procurement, Suspension & Debarment Equipment & Real Property Management

2022-001 The Organization will work with personnel to ensure that adequate supporting documentation is maintained for disbursements. Completion Date: September 30, 2023 Contact: Julie Ellis-Grove, Controller

View Audit 22893

Corrective Action Plans

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