Corrective Action Plans

Finding 480426 (2023-016)

Material Weakness 2023

NH

Reporting Subrecipient Monitoring

The Department underwent turnover and medical issues during the reporting period. The Department has hired additional program staff and arranged for annual training through a federal contractor to assist in reporting requirements. The Department is also in the process of procuring a new weatherizat...

The Department underwent turnover and medical issues during the reporting period. The Department has hired additional program staff and arranged for annual training through a federal contractor to assist in reporting requirements. The Department is also in the process of procuring a new weatherization and fuel assistance system which will assist in providing timely and accurate reporting data. The Department is also reviewing and updating policies and procedures, to include cross training and turnover contingencies.

View Audit 316627

Finding 480420 (2023-013)

Significant Deficiency 2023

State of New Hampshire

NH

Matching / Level of Effort / Earmarking Reporting

The Department continues to work with its federal partners to ensure timely access to required reports.

View Audit 316627

Finding 480414 (2023-010)

Material Weakness 2023

State of New Hampshire

NH

Reporting Subrecipient Monitoring Material Weakness § 200.303

This function (FFATA reporting) has now been designated to our Federal Reporting Group, which will allow for redundancy in personnel. A new policy and procedure, which will include internal controls, will be developed and implemented.

View Audit 316627

Finding 480402 (2023-008)

Material Weakness 2023

State of New Hampshire

NH

Subrecipient Monitoring Reporting Material Weakness § 200.303

The Office of ESEA Title programs and Covid-19 education programs have established an internal process to sample and test reports compiled to ensure operations are executed as intended. These internal controls include a monthly reporting sign off Excel sheet, certification on each FFATA submission a...

The Office of ESEA Title programs and Covid-19 education programs have established an internal process to sample and test reports compiled to ensure operations are executed as intended. These internal controls include a monthly reporting sign off Excel sheet, certification on each FFATA submission and a secondary certification for accuracy verification, and a division wide process for FFATA filing and verification. Division wide training occurred on October 26, 2023. Due to grant award notification (GAN) changes and development within our grants management system (GMS), the FFATA process has also been developing and shifting; therefore the FFATA process will be revisited annually and updated as needed. A revised procedure for FFATA reporting will be completed prior to additional training being offered. To ensure that processes are being followed, newly hired staff is trained appropriately, and updates to the GAN process are considered within the FFATA process we will hold another training this spring, March 14th, 2024, prior to new subawards being issued.

View Audit 316627

Finding 480400 (2023-006)

Material Weakness 2023

State of New Hampshire

NH

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

BEA will evaluate existing internal controls in place to ensure that the precision level of the control is such that it would detect an error in the expenditures reported in comparison to the expenditures incurred within the general ledger, account for precision level control when changing guidance ...

BEA will evaluate existing internal controls in place to ensure that the precision level of the control is such that it would detect an error in the expenditures reported in comparison to the expenditures incurred within the general ledger, account for precision level control when changing guidance exists, and that all documentation used to support the amounts reported on the federal report are properly maintained. Condition A has been completed. In January 2024, BEA evaluated internal controls related to the review and approval of expenditures. The following additional reconciliation step was added to the processes of preparation of expenditure draws and reporting preparation: • Broadband program Accountant II performs a data extract from NHFirst and reconciles the drawdown calculation totals as well as “dashboard” reporting totals to the NHFirst data extract to confirm accuracy of all data points. This second data validation step has been added to ensure all expenditures recorded in NHFirst are evaluated against program guidelines, submitted for reimbursement and included on required reports. Condition B & C to be completed no later than 12/31/2024.

View Audit 316627

Finding 480396 (2023-002)

Material Weakness 2023

State of New Hampshire

NH

Internal Control / Segregation of Duties Cash Management Material Weakness § 200.303

For clarity the Department will create a redundant manual ledger that duplicates the functions of the current ledger and Detailed Transaction Register (DTR). DMAVS has existing policies and procedures in place to track all federal funds, state funds and mixed funds, and uses spreadsheets for all tr...

For clarity the Department will create a redundant manual ledger that duplicates the functions of the current ledger and Detailed Transaction Register (DTR). DMAVS has existing policies and procedures in place to track all federal funds, state funds and mixed funds, and uses spreadsheets for all transactions that reconciles every month to NH First Detail Transaction Register (DTR), Federal Fund tracking sheet, and Federal reimbursement tracking sheet with backup documents. The tracking sheet for the federal register is not intended to account for the state share of billing. The state share is accurately accounted for in the DTR, the cumulative accounting in the SF-270 and associated back up documentation. Supporting documentation to substantiate the accuracy of lines a, c, e, and f is in the DTR, the cumulative accounting of each SF-270, the supporting documentation sent with the billing to the Federal Government, and Year-end Agency Report for Federal Awards. This includes reconciliation and analysis of SADB expenditures and revenues to the Statement of Appropriations by each Program Accounting Unit. The SF-270 form is continuous cumulative data that starts Oct 1st and runs through the end of that Federal Fiscal Year. The SF-270 is the required federal form DMAVS submits to the Federal National Guard Appendix Program Manager for reimbursement. Back up documentation is submitted with the SF-270. The National Guard Appendix Program Manager, National Guard Grants Officer Representative, and National Guard United States Property Fiscal Officer (USPFO)/controller located in Concord, NH review, sign and submit the form to the Department of Defense to affect the cash draw. DMAVS does not unilaterally make cash draws to the federal government. The USPFO, who is substantially involved provides an independent review and reconciles any discrepancies prior to approving any requests for reimbursement. One possible explanation for the finding is that the selected test works were not continuous.

View Audit 316627

Finding 480351 (2023-006)

Material Weakness 2023

Morgan County Water District

KY

Reporting Matching / Level of Effort / Earmarking § 200.502 § 200.510

No response was provided.

View Audit 316607

Finding 480345 (2023-001)

None 2023

Clermont County

OH

Reporting § 200.329

The Auditor’s office with work with the Department of Job and Family Services and provide training on the importance of grant reporting and tracking. We will also explain and show how using the ERP system can aid in the tracking of expenses and help to ensure better accounting for grants. The Aud...

The Auditor’s office with work with the Department of Job and Family Services and provide training on the importance of grant reporting and tracking. We will also explain and show how using the ERP system can aid in the tracking of expenses and help to ensure better accounting for grants. The Auditor’s office will implement an additional level of control for this department’s grant award, reporting, and reimbursements to be reviewed by our office for accuracy. Use online state and federal agency websites to verify grant awards amounts and disbursements.

View Audit 316600

Finding 480321 (2023-001)

Material Weakness 2023

Baptist Health Deaconess Madisonville, Inc.

KY

Reporting Material Weakness

Finding 2023-001 Federal Agency Name: Department of the Treasury Program Name: COVID-19 Claims Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing #21.027 Compliance Requirement: Preparation of Schedule of Expenditures of Federal Awards Finding Summary: Management ...

Finding 2023-001 Federal Agency Name: Department of the Treasury Program Name: COVID-19 Claims Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing #21.027 Compliance Requirement: Preparation of Schedule of Expenditures of Federal Awards Finding Summary: Management prepared the Schedule for the year ended August 31, 2023. During the audit process, changes were proposed to include the COVID‐19 Claims Coronavirus State and Local Fiscal Recovery Funds, which were not originally included on the Schedule. Responsible Individuals: Kim Ashby, Vice President of Finance Corrective Action Plan: When funds for this grant were initially awarded in fiscal year 2021, the grant was state funded and not subject to A-133 audit. During fiscal year 2022, a portion of the grant became federally funded and subject to A-133 audit, but this was not discovered until the current fiscal year 2023 audit. Management has implemented a procedure to check the funding status of grants at the beginning of each fiscal year. Anticipated Completion Date: August 1, 2024

View Audit 316547

Finding 480320 (2023-002)

Significant Deficiency 2023

Klamath Watershed Partnership

OR

Reporting

Views of responsible officials and planned corrective actions: Management agrees that the reports had inaccuracies that were created by including information that is listed as optional in SF-425 instructions. The staff will avoid reporting optional information in the future.

View Audit 316546

Finding 480317 (2023-001)

Significant Deficiency 2023

Corewell Health & Affiliates

MI

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding 2023-001 Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) Pass-Throug...

Finding 2023-001 Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) Pass-Through Grantor: Not applicable Pass-Through Award Number: Not applicable Pass-Through Award Period: 1/1/2020-12/31/2023 (Periods 5 and 6) Summary of Finding: The “Total Lost Revenues for the Period of Availability (January 1, 2020 to June 30, 2023)” line in the HRSA PRF portal for Spectrum Health System (the Parent), TIN 383382353, General Distribution HRSA PRF report in Reporting Period 5 was $108,697,843. The correct amount of lost revenue reported for Period 5 should have been $107,045,743. The difference represents a $1.6M error in adjusting for targeted funds to determine the Parent lost revenue for period 5. Corrective Action Plan: No further lost revenue reporting is required on the HRSA PRF Portal. Management will implement more robust internal controls in preparation for similar future filings. Individuals responsible for corrective action: Cindy Brink, Director, System Accounting and Reporting Timing of corrective action: July 1, 2024 and going forward.

View Audit 316542

Finding 480316 (2023-004)

Material Weakness 2023

Mount Vernon Community School District

IA

Cash Management Reporting Internal Control / Segregation of Duties

1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding Administration will add additional internal controls where the benefit exceeds the cost. 3. Official Responsible for Ensuring CAP Michael Marshall, Board Secre...

1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding Administration will add additional internal controls where the benefit exceeds the cost. 3. Official Responsible for Ensuring CAP Michael Marshall, Board Secretary/Treasurer, is the official responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP The planned completion date for the CAP is June 30, 2024. 5. Plan to Monitor Completion of CAP The School Board will be monitoring this CAP.

View Audit 316541

Finding 480313 (2023-001)

Significant Deficiency 2023

Middleborough Housing Authority

MA

HUD Housing Programs Subrecipient Monitoring Reporting

The Authority had a change in Executive Director and Fee Accountant, which resulted in delayed access to the FASPHA system. The Authority will ensure timely submissions going forward.

View Audit 316534

Finding 480305 (2023-002)

Significant Deficiency 2023

City of Miami

OK

Reporting Internal Control / Segregation of Duties

Reporting Requirements ...

Reporting Requirements Condition: The City’s internal controls over required reporting requirements were not timely monitored and tracked. In conjunction with our FY2023 audit, please see the City’s corrective action plan below: Management Response: With the turnover in staff and management in the department, the new Finance Director submitted for login credentials to SLFRF@treasury.gov in order to complete required reporting. The email for login credentials was sent on April 28, 2023. Once login credentials were received, the final report was submitted on November 6, 2023. To date, no penalties have been reported by the Treasury. Additionally, we are working to centrally track grants and loans moving forward and communicating this with department heads and the interim city manager. Expected completion date: 4.30.24 We completed this reporting requirement on time for this FY 23-24. Party Responsible: Jennifer Watts, Finance Director Contact Information: jwatts@miamiokla.net

View Audit 316516

Finding 480298 (2023-002)

Significant Deficiency 2023

Christ Community Health Services, Inc.

TN

Reporting

Audit Finding Reference Number 2023-002 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) for each calendar year and an annual Federal Financial Report (FFR) for each grant year. These re...

Audit Finding Reference Number 2023-002 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) for each calendar year and an annual Federal Financial Report (FFR) for each grant year. These reports are to be prepared using accurate financial information. Questioned cost – None. Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the nineteen inputs tested, one exceptions were noted related to the annual UDS report. Effect – Potential errors were made on the annual UDS report. Cause – The Organization was unable to provide supporting documentation that agreed to the line items tested on the report. Identification as a repeat finding, if applicable – Not a repeat finding. Recommendation – The Organization should review its policy over federal reporting and ensure proper staff education on the policy is established to ensure reports are prepared using accurate information and that supporting documentation for federal grant reports is maintained. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions – Management will ensure the Grants Management Policy within the Finance Department will be adhered to when doing all external reporting. To ensure this is followed the additional protocol will be put into place: -All reporting involving federal reporting will be reviewed and approved by the CFO with supporting documentation to ensure accuracy of the report. -Staff preparing reports that contain federal grant data will participate in training to ensure reports are prepared accurately and in accordance with Uniform Guidance. The interim CFO, Jessica Hughes, is responsible for this corrective action plan. Implementaiton of the items are expected to be completed by December 31, 2024 before the next reporting cycle of the annual UDS report.

View Audit 316511

Finding 480285 (2023-001)

Significant Deficiency 2023

Cambridge Manor Tenant Council

IL

Questioned Costs Internal Control / Segregation of Duties Eligibility

Finding No. 2023-01: Tenant income is to be reconciled to reports run by the Enterprise Income Verification system (EIV) Recommendation: Management should use the EIV system properly to verify tenant employment and income during recertifications and calculate subsidy payments correctly. Action Taken...

Finding No. 2023-01: Tenant income is to be reconciled to reports run by the Enterprise Income Verification system (EIV) Recommendation: Management should use the EIV system properly to verify tenant employment and income during recertifications and calculate subsidy payments correctly. Action Taken or Planned: Management is conducting proper reconciliation between EIV system and tenant declared income at recertification. Responsible Person: James Watt, Senior Vice President, Management Company Completion Date: January 1, 2024

View Audit 316498 Questioned Costs: $1

Finding 480284 (2023-003)

Material Weakness 2023

Sherburne County

MN

Material Weakness Reporting Internal Control / Segregation of Duties

Federal Agency: U.S. Department of Treasury Federal Program Name: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: SLFRP1643 - 2021 Award Period: March 3, 2021 through December 31, 2024 Type of Finding: • Material Weakn...

Federal Agency: U.S. Department of Treasury Federal Program Name: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: SLFRP1643 - 2021 Award Period: March 3, 2021 through December 31, 2024 Type of Finding: • Material Weakness in Internal Control over Compliance Recommendation: We recommend that County management reviews the controls around payroll journal entries that are reclassifying payroll to federal grants to ensure the payroll that is being reclassified is supported and accurate and that such review continues to be formally documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement the recommendation immediately. Name of the contact person responsible for corrective action plan: Loraine Rupp, Sherburne County Auditor-Treasurer Planned completion date for corrective action plan: Already corrected

View Audit 316496

Finding 480262 (2023-003)

Material Weakness 2023

Human Relations Area Files, Inc.

CT

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Management intends to be more meticulous when inputting expenses into the reporting system as well as submissions to granting agencies. Additionally, management intends to maintain supporting documentation for all grant expenses going forward.

View Audit 316492 Questioned Costs: $1

Finding 480259 (2023-002)

Material Weakness 2023

Human Relations Area Files, Inc.

CT

Reporting Internal Control / Segregation of Duties

A large part of the delay was that we had a major transition in personnel at the end of the fiscal year in question and the office manager/bookkeeper who left did not adequately train the new person, Amanda Westcott. At the same time, the previous accounting system was overly complicated with too ma...

A large part of the delay was that we had a major transition in personnel at the end of the fiscal year in question and the office manager/bookkeeper who left did not adequately train the new person, Amanda Westcott. At the same time, the previous accounting system was overly complicated with too many categories, making the transition more difficult. Accordingly, we implemented a new accounting system, which went live in July 2023 for the FY2024 audit. We anticipate this will assist with timeliness and transparency of documents as the current office manager becomes increasingly familiar with the new system. We will move to implement monthly reconciliations as soon as the 2023 audit is finalized. We plan to have HRAF's Treasurer and an accountant review these and if needed we will take additional corrective action.

View Audit 316492

Finding 480255 (2023-003)

Material Weakness 2023

Lee's Summit Housing Authority

MO

Reporting Internal Control / Segregation of Duties

Due to shredding and poor record keeping by the agency's former Administration, records for the period of October 2022- September 2023 some records could not be provided as none of the previous staff that worked during that tenue was still employed with LSHA. LSHA has established internal processes ...

Due to shredding and poor record keeping by the agency's former Administration, records for the period of October 2022- September 2023 some records could not be provided as none of the previous staff that worked during that tenue was still employed with LSHA. LSHA has established internal processes that include electronic filing of invoices, bank statements, and payroll registers. LSHA is also analyzing internal processes with the Fee Accountant to ensure budget compliance. LSHA is moving in the direction of changing its' Fee Accountant by July 1, 2024, as it appears that there is a failure in that department as well when it comes to LSHA's electronic and financial controls. The current Executive Director and staff continue to work diligently in retrieving and recreating records and documents, while also ensuring that current documents are reconciled and uploaded properly.

View Audit 316488

Finding 480252 (2023-001)

Material Weakness 2023

Westhaven of Englewood, Ltd.

IL

Questioned Costs HUD Housing Programs Reporting

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2023-001: Section 8 Housing Assistance Payments, CFDA 14.195 Recommendation: Management should arrange to transfer the amount due to the residual receipts account as soon as possible. Corrective Actions Taken: Management has acknowledged the findin...

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2023-001: Section 8 Housing Assistance Payments, CFDA 14.195 Recommendation: Management should arrange to transfer the amount due to the residual receipts account as soon as possible. Corrective Actions Taken: Management has acknowledged the finding and promised to transfer the amount due to the residual receipts account as soon as possible. Contact: Greg Miller, Management Agent Anticipated Completion Date: November 30, 2023

View Audit 316486 Questioned Costs: $1

Finding 480251 (2023-001)

Material Weakness 2023

Paradise Haven Homes, Ltd. 071-Eh537

IL

Questioned Costs HUD Housing Programs Reporting

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2023-001: Section 8 Housing Assistance Payments, CFDA 14.195 Recommendation: Management should arrange to transfer the amount due to the residual receipts account as soon as possible. Corrective Actions Taken: Management has acknowledged the findin...

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2023-001: Section 8 Housing Assistance Payments, CFDA 14.195 Recommendation: Management should arrange to transfer the amount due to the residual receipts account as soon as possible. Corrective Actions Taken: Management has acknowledged the finding and promised to transfer the amount due to the residual receipts account as soon as possible. Contact: Greg Miller, Management Agent Anticipated Completion Date: December 31, 2023

View Audit 316485 Questioned Costs: $1

Finding 480250 (2023-004)

Significant Deficiency 2023

County of Columbus

NC

HUD Housing Programs Reporting Significant Deficiency

2023-004 Significant Deficiency over Reporting Information on the Federal Program: Low Income Housing Assistance Program (Section 8), Assistance Listing Number 14.871, U.S. Department of Housing and Urban Development. Criteria: Public Housing Agencies (PHAs) are required to report submit timely a ...

2023-004 Significant Deficiency over Reporting Information on the Federal Program: Low Income Housing Assistance Program (Section 8), Assistance Listing Number 14.871, U.S. Department of Housing and Urban Development. Criteria: Public Housing Agencies (PHAs) are required to report submit timely a Financial Assessment Sub-system (FASS-PH): GAAP-based unaudited and audited financial information electronically to HUD. Name of Contact Person: Heather Woody, Deputy Finance Director Corrective Action Plan: The County will establish and maintain proper internal controls to ensure financial statements are presented in accordance with GAAP, on a timely basis. The County will then be able to complete timely reporting of the FASS-PH. Proposed Completion Date: July 1, 2024

View Audit 316481

Finding 480248 (2023-003)

Significant Deficiency 2023

African Development Center

MN

Reporting Subrecipient Monitoring Significant Deficiency § 200.329

Microloan Program – Assistance Listing No. 59.046 Recommendation: We recommend management develop procedures to ensure the required reporting is completed within the timeline allowed by the granting agency. Explanation of disagreement with audit finding: There is no disagreement with the audit find...

Microloan Program – Assistance Listing No. 59.046 Recommendation: We recommend management develop procedures to ensure the required reporting is completed within the timeline allowed by the granting agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: ADC will hire a new loan officer who will also be an SBA Microloan Program Manager then develop and implement procedures to ensure the required reporting is completed within the timeline allowed by the granting agency. Name(s) of the contact person(s) responsible for corrective action: Felicia Ravelomanatsoa (CFO) Planned completion date for corrective action plan: December 31, 2024

View Audit 316477

Finding 480243 (2023-002)

Material Weakness 2023

Brother Bill's Helping Hand

TX

Allowable Costs / Cost Principles Material Weakness Reporting

Explanation: The audit conducted by SFC of Brother Bill’s Helping Hand identified noncompliance with Section 200 of the Code of Federal Regulations, which mandates recipients to establish robust internal controls ensuring adherence to cost principles for all grantrelated transactions. Among the samp...

Explanation: The audit conducted by SFC of Brother Bill’s Helping Hand identified noncompliance with Section 200 of the Code of Federal Regulations, which mandates recipients to establish robust internal controls ensuring adherence to cost principles for all grantrelated transactions. Among the sampled invoices for allowable costs under federal grants, 6 out of 24 lacked documented approval from management. Furthermore, the organization lacked a standardized procedure for documenting management approval of credit card transactions prior to payment. Analysis: Brother Bill’s Helping Hand acknowledges the non-compliance with Section 200 as identified by SFC. However, we maintain that the assertion implying absence of controls or standardized procedures for credit card expenditures is inaccurate. Each reimbursement submission to Dallas County undergoes meticulous scrutiny and personal vetting by CEO Wes Keyes. Mr. Keyes reviews every receipt before reimbursement and, if necessary, consults with the respective staff members regarding any discrepancies. Each reimbursement bears Mr. Keyes’ signature of approval. Nonetheless, SFC has recommended that CEO Keyes review and approve the credit card statement prior to payment, a practice not previously adhered to by BBHH. Actions Taken: Effective June 17, 2024, Mr. Keyes will review and sign each credit card statement prior to payment. These signed statements will be securely stored for potential future documentation needs. Responsibility: CEO Wes Keyes and Operations Manager Sarah Cienfuegos are responsible for implementing the change requiring CEO approval on credit card transactions prior to payment. Timeline: The corrective action has been implemented as of June 17, 2024. Monitoring: No ongoing monitoring is deemed necessary as the corrective measures have already been executed.

View Audit 316476

Corrective Action Plans

Filters