Corrective Action Plans

Finding 480513 (2023-002)

Material Weakness 2023

PA

Cash Management Reporting Internal Control / Segregation of Duties

The Manager acknowledges that there is no separation of duties, but with the Authority being very small and there only being three (3) office employees; it does not make financial sense to hire an additional person to oversee the grant proceeds. The Manager will make sure that going forward all ite...

The Manager acknowledges that there is no separation of duties, but with the Authority being very small and there only being three (3) office employees; it does not make financial sense to hire an additional person to oversee the grant proceeds. The Manager will make sure that going forward all items pertaining to the grant are reviewed by the Board and Engineer to help off-set that separation of duty issue. The Authority Manager did not disclose the grant receivable as it was not yet received at the end of 2023 and should have been booked as an accrual and not a cash basis receipt. The Manager will ensure that going forward items are booked based on the accrual and not the cash basis.

View Audit 316706

Finding 480511 (2023-002)

Significant Deficiency 2023

Southwest Ohio Regional Transit Authority

OH

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring

Views of Responsible Official: The Project Grant Administrator did prepare and submit the FRA quarterly reports. This person was the official reviewer of the project progress for the FRA quarterly report submission. The financial information for the report was first compiled by the Capital Project...

Views of Responsible Official: The Project Grant Administrator did prepare and submit the FRA quarterly reports. This person was the official reviewer of the project progress for the FRA quarterly report submission. The financial information for the report was first compiled by the Capital Projects and Grant Tracking (CPGT) Administrator Accountant. (Note that CPGT is reconciled with CODA, the SORTA accounting system, before this information is provided.) The Project Grant Administrator received project implementation information from the Construction Project Manager. The Grant Administrator married this information with what was provided by the CPGT Administrator/Accountant, as well as what was in Maximo (the SORTA procurement system), The Project Grant Administrator also visited the project site to verify progress of the FRA project(s) when needed. The final quarterly reports were used by the Director of Grants as well as FRA to keep up with the implementation progress of the project(s). Any actual draw down of funding for the project was prepared separately by the CPGT Administrator/Accountant and signed off by the Director of Accounting. We concur with the finding that the FFATA report for reporting of an award to a subrecipient above a certain dollar threshold was submitted in November of 2023, which was after the regulatory date for submission. Description of Corrective Action Plan: The Federal Railroad Administration (FRA) CRISI Grant- that this finding relates to has been completed and is now closed. Thus, there will not be any further Quarterly reports prepared or submitted under this particular Grant. And, it is not anticipated that SORTA will be administering any other FRA CRISI Grants in the foreseeable future. In relation to the FFATA reporting, the Grants Department will add the FFATA reporting requirements to the Grants Processes and Procedures so that should SORTA encounter a grant subrecipient situation with a future grant, Grants staff will have a reminder and reference to help ensure the reporting requirements are performed in a timely manner. Responsible Party and Timeline for Completion: Federal regulation requires name and title of person overseeing corrective action plan and anticipated completion date. The Director or Grants, Mary Huller, will complete the modification to the Processes and Procedures to include FFATA reporting requirements by the end of August 2024.

View Audit 316703

Finding 480508 (2023-001)

Material Weakness 2023

County of Adams

PA

Reporting Internal Control / Segregation of Duties

The County should implement internal control procedures to ensure the Project and Expenditure Report is properly reviewed prior to submission. Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The County of Adams has developed and imp...

The County should implement internal control procedures to ensure the Project and Expenditure Report is properly reviewed prior to submission. Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The County of Adams has developed and implemented a process to ensure all respective reports submitted to the respective granting agency reflect accurate amounts in the period of benefit as of July 2024.

View Audit 316697

Finding 480494 (2023-001)

None 2023

Children First Community Homes and Services, INC

FL

Subrecipient Monitoring Reporting § 200.512

VIEWS OF RESPONSIBLE OFFICIALS & CORRECTIVE ACTION PLAN: Management will begin the single audit process as soon as possible when the books close. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The Organization ...

VIEWS OF RESPONSIBLE OFFICIALS & CORRECTIVE ACTION PLAN: Management will begin the single audit process as soon as possible when the books close. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The Organization will implement the recommendation. Officials Responsible for Ensuring CAP: The Organization’s appointed staff member is the official responsible for ensuring corrective action. Planned Completion Date for CAP: The planned completion date for the CAP is June 30, 2024. Plan to Monitor Completion of CAP: The Board of Directors will be monitoring this corrective action plan.

View Audit 316682

Finding 480465 (2023-001)

Material Weakness 2023

Arbor Place INC

WI

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

We recommend Arbor Place to implement internal controls over reporting and allowable costs to ensure all financial records are complete and accurate.

View Audit 316660

Finding 480450 (2023-009)

Significant Deficiency 2023

People (projects to Empower & Organ Psychiatrically Labeled), Inc.

NY

Reporting Significant Deficiency

Per grant contract for Covid Peer Vaccine Education Organization was required to submit quarterly report detailing analyzing the quantitative aspects of the program. Statement of Concurrence or Nonconcurrence: Concur Corrective Action: Organization will create a better overall system of tracking all...

Per grant contract for Covid Peer Vaccine Education Organization was required to submit quarterly report detailing analyzing the quantitative aspects of the program. Statement of Concurrence or Nonconcurrence: Concur Corrective Action: Organization will create a better overall system of tracking all contracts and grants with reporting periods reviewed timely. We will also submit quarterly expenditure reports when they are due to the Office of Mental Health. Responsible Person to Oversee Corrective Action Plan: George Thomas Chief Financial Officer 845-452-2728 ext. 224 Date Corrective Plan will be put in Place: Starting today immediately June 13, 2024

View Audit 316636

Finding 480446 (2023-007)

Significant Deficiency 2023

People (projects to Empower & Organ Psychiatrically Labeled), Inc.

NY

Reporting Significant Deficiency

Controls over Records Per the Westchester County Contract the Organization did not keep individual records of program participants Statement of Concurrence or Nonconcurr nce: Concur 1. Corrective Action: Team Leader Chris Rivera will review all notes on a weekly basis and sign off on documentation a...

Controls over Records Per the Westchester County Contract the Organization did not keep individual records of program participants Statement of Concurrence or Nonconcurr nce: Concur 1. Corrective Action: Team Leader Chris Rivera will review all notes on a weekly basis and sign off on documentation after review. 2. Best practice standards are that notes should be entered by the end of the next business day for the previous day's encounters. 3. The deadline for notes to be entered for the previous week's encounters is Monday at noon. If staff have not completed notes by Monday morning, they are mandated to complete notes prior to leaving the office for visits and other staff members will help with coverage needs. 4. Staff will identify an hour on their schedule daily to stay up to date on documentation. 5. The Program Assistant will run a monthly report of open participants in the Westchester Crisis Stabilization Team program on the last day of every month. Inactive participants or discharges will be completed at the time of discharge. Review of the monthly open participants will ensure that any inactive participants are quickly identified, and proper discharge process will occur by the 5th of every month. 6. Current caseload rosters will be provided to team members and Team Leader for review and printed out by Program Assistant by the 1st of every month. 7. Program Assistant will provide an update of completed discharges to the Team Leader upon completing discharge. 8. Quarterly waste, fraud, abuse audits will be completed by Quality Assurance and the Team Leader 9. Routine monthly audits of 2 charts at random will be completed by the Team Leader Responsible Person to Oversee Corrective Action Plan: Tammy Robson Assistant Executive Director 845-264-7399 Christopher River Westchester Crisis Stabilization Team Date Corrective Plan will be put in Place: Corrective action measures are currently being implemented and will be in effect as of 7/1/24. Chart audits and discharges of inactive participants will be completed by 7/15/24.

View Audit 316636

Finding 480443 (2023-006)

Material Weakness 2023

People (projects to Empower & Organ Psychiatrically Labeled), Inc.

NY

Reporting Material Weakness

Organization was unable to provide Schedule of Expenditures of Federal Awards (SEFA) Statement of Concurrence or Nonconcurrence: Concur Corrective Action: We were unaware of the responsibility to provide this and did not know the origin of all grants received. Due to the information learned we are n...

Organization was unable to provide Schedule of Expenditures of Federal Awards (SEFA) Statement of Concurrence or Nonconcurrence: Concur Corrective Action: We were unaware of the responsibility to provide this and did not know the origin of all grants received. Due to the information learned we are now aware and have taken measures to inquire about the origin of all grants received going forward. With the help of the newly hired compliance officer, we will not have such a finding again because we will track revenues and expenditures for all grants prominently federal awards when they are received and spent to properly record them on the SEFA Responsible Person to Oversee Corrective Action Plan: George Thomas Chief Financial Officer 845-452-2728 ext. 224

View Audit 316636

Finding 480435 (2023-022)

Material Weakness 2023

State of New Hampshire

NH

Reporting

HSEM concurs with the finding. Corrective actions are currently in place to address the accuracy of HSEM’s federal reporting, adding an additional review process prior to submittal. Corrected 425s have already been submitted to FEMA.

View Audit 316627

Finding 480433 (2023-021)

Material Weakness 2023

State of New Hampshire

NH

Special Tests & Provisions Subrecipient Monitoring Cash Management

HSEM concurs with the finding. As a result of the audit, the practice of using individual emails to submit correspondence to FEMA was immediately addressed with staff and future correspondence will only be sent using the general shared email inbox. Regularly during staff meetings employees are remin...

HSEM concurs with the finding. As a result of the audit, the practice of using individual emails to submit correspondence to FEMA was immediately addressed with staff and future correspondence will only be sent using the general shared email inbox. Regularly during staff meetings employees are reminded to copy communications to the general shared inbox. Additionally, HSEM is currently working with the State’s Department of Information and Technology to gain access to prior staff’s emails. To note, the final paragraph in the Conditions section makes an incorrect statement regarding the submittal timeline requirements for Project Completion and Certification reports. PCCs are due within 90 days of project completion, not project obligation.

View Audit 316627

Finding 480431 (2023-019)

Material Weakness 2023

State of New Hampshire

NH

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

(SSA 4513) The department concurs with this finding and plans to work on the following areas to make reviewing and understanding of the reports an easier process: NHDDS will make sure that line 7 on the 4513 report is checked appropriately on all future reporting. NH DDS will update all process d...

(SSA 4513) The department concurs with this finding and plans to work on the following areas to make reviewing and understanding of the reports an easier process: NHDDS will make sure that line 7 on the 4513 report is checked appropriately on all future reporting. NH DDS will update all process directions for all fiscal reporting. For these directions, NH DDS will update all spreadsheets used for reporting purposes, add labels to column headers and link to cells when able for better understanding of our business processes and where amounts are pulled from. NH DDS will keep all backup documentation needed for these directions, to review all current open grant years. NHDDS will create “Mock” documents of each reporting process to help in any further reviews. (SSA 4514) Administrator runs a leave report for a 1-month time frame. Put in alpha order and date order. In an excel spreadsheet, staff are in alpha order. Leave time is added to each individual staff member for a time frame of 3 months (quarterly report). The total for each individual staff member is then populated to a second spread sheet which is broken out by position categories and each position total is then populated to the 4514 report. • On Duty Hours (column A) are the number of days worked in a quarter, times 7.50 hours per day. • Holiday/Leave Hours (column B) are the number of Holidays (7.50 hours per day) during that quarter plus the amount of leave (hours and minutes) per individual staff member during that quarter. • Total Hours (column C) is the amount of column A, plus column B, equals column C. • Total Part-Time Personnel-Is the number of hours the physician worked during that quarter. A report is run in Virtual Time Clock for the quarterly time frame and hours are entered into Part-Time, Medical Consultants (h.) Prior to completing the quarterly report, the excel spread sheet, sheet 2, will be reviewed to ensure cell equations are correct to eliminate formula errors used to calculate quarterly hours. When emailing the Administrator, the quarterly report for signature, the following statement will be in the body of the email to certify cell equations were reviewed prior, to eliminate formula errors: “I certify that I reviewed the SSA-4514 prior to completion, to ensure that cell equations were correct to eliminate formula errors.” Sent to the Administrator for signature then sent off to Region. Sent emails will be saved in an outlook folder for future reference and proofs that reports were sent.

View Audit 316627

Finding 480426 (2023-016)

Material Weakness 2023

State of New Hampshire

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

Corrective Action Plans

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