Corrective Action Plans

Finding 404253 (2023-001)

Material Weakness 2023

Dewitt Medical District D.b.a. Cuero Regional Hospital

TX

Internal Control / Segregation of Duties Reporting

Corrective Action Plan for Finding 2023-001 We are in receipt of the Finding Required to be Reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting. Management agrees with the finding. Policies and procedures over federal grant reporting will be modified t...

Corrective Action Plan for Finding 2023-001 We are in receipt of the Finding Required to be Reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting. Management agrees with the finding. Policies and procedures over federal grant reporting will be modified to ensure reports are prepared using complete and accurate information. We will increase compensating controls by introducing additional oversight and review for future COVID-19 Provider Relief Fund reporting. Lynn Falcone, CEO will be responsible to ensure this is accomplished The District had enough lost revenues within Period 4 that the amount of the error does not impact the finding received. The corrective action plan will be implemented by September 30, 2024.

View Audit 311013

Finding 404250 (2023-003)

Significant Deficiency 2023

City of Craig

AK

Reporting Significant Deficiency § 200.512

Finding 2023-003 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Kimber Mikulecky, Finance Director Corrective Action Plan: Management will carefully review report deadlines and ensure that submission of reports is made before they are due. Management will al...

Finding 2023-003 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Kimber Mikulecky, Finance Director Corrective Action Plan: Management will carefully review report deadlines and ensure that submission of reports is made before they are due. Management will also carefully review reporting requirements and ensure that requirements are adhered to. This includes the following program: National Forest Receipts- Municipal & Regional Assistance. Proposed Completion Date: Fiscal year 2024

View Audit 311004

Finding 404249 (2023-002)

Material Weakness 2023

Oficina De Proteccion Y Defensa De Las Personas Con Impedimentos

PR

Reporting

The Agency made the efforts to submit the SF 270 on a timely manner how ever since the agency is in a transition one of our grantors as they policy stop the evaluation of our SF 270 until the successor in interest was completed. In addition the Agency hire a staff accountant beginning July 1st 2024...

The Agency made the efforts to submit the SF 270 on a timely manner how ever since the agency is in a transition one of our grantors as they policy stop the evaluation of our SF 270 until the successor in interest was completed. In addition the Agency hire a staff accountant beginning July 1st 2024 who will be in charge of completing and submitting the SF 270 as established in our SOP an required by the regulations. The Agency made the efforts to submit the SF 270 on a timely manner how ever since the agency is in a transition one of our grantors as they policy stop the evaluation of our SF 270 until the successor in interest was completed. In addition the Agency hire a staff accountant beginning July 1st 2024, who will be in charge of completing and submitting the SF 270 as established in our SOP an required by the regulations.

View Audit 310999

Finding 404248 (2023-001)

Material Weakness 2023

Oficina De Proteccion Y Defensa De Las Personas Con Impedimentos

PR

Reporting

Hire the external auditor in the month of September with the objective of providing a reasonable time to comply with the reporting process by March 2025.

View Audit 310999

Finding 404236 (2023-003)

Significant Deficiency 2023

Southeast Polk Community School District

IA

Cash Management Reporting

Response and Corrective Action Plan: The District (Kevin Baccam) will implement a process to review and retain meal claim reporting documentation as outlined by the Iowa Department of Education and Office of Management and Budget.

View Audit 310997

Finding 404232 (2023-001)

Material Weakness 2023

Olmsted County Housing and Redevelopment Authority

MN

HUD Housing Programs Reporting

The PHA’s HQS enforcement sample of case files with failed HQS inspections shows that for at least 98% of sampled cases, HQS deficiencies were not corrected within the required time frame, the PHA did not stop housing assistance payments beginning no later than the first of the month following the...

The PHA’s HQS enforcement sample of case files with failed HQS inspections shows that for at least 98% of sampled cases, HQS deficiencies were not corrected within the required time frame, the PHA did not stop housing assistance payments beginning no later than the first of the month following the correction period and/or take prompt and vigorous action to enforce the family obligations. Due to the transition to a new software system, the required settings to facilitate necessary reporting and tracking mechanisms were not fully functional until recently. Reports indicating failed inspections, late inspections, and the need for abatements are now being run on a scheduled basis so that action can be taken timely. A new inspection application within the software has now been implemented to aid in recording and tracking deficiencies. Additionally, the PHA is working diligently with the software provider and a software consultant to determine if there are additional features that are able to be put into place to assist in streamlining the abatement process. Staff training for these new features will also be occurring throughout the year.

View Audit 310988

Finding 404223 (2023-005)

Material Weakness 2023

Atrium Health, Inc.

NC

Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303

Corrective Action Plan: Atrium Health CMHA management will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT systems specific to the SFA program. Proposed Completion Date: ...

Corrective Action Plan: Atrium Health CMHA management will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT systems specific to the SFA program. Proposed Completion Date: Management will complete the corrective action plan by the end of 2024.

View Audit 310986

Finding 404221 (2023-003)

Material Weakness 2023

Atrium Health, Inc.

NC

Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

Corrective Action Plan: Atrium Health CMHA management will address the gap in SFA transactional review and approval internal controls, arising due to the SFA program size and limited number of subject matter experts, by implementing mitigating controls and policies to ensure accuracy and completene...

Corrective Action Plan: Atrium Health CMHA management will address the gap in SFA transactional review and approval internal controls, arising due to the SFA program size and limited number of subject matter experts, by implementing mitigating controls and policies to ensure accuracy and completeness of transactions. Proposed Completion Date: Management will complete the corrective action plan by October 2024.

View Audit 310986

Finding 404220 (2023-002)

Material Weakness 2023

Atrium Health, Inc.

NC

Student Financial Aid Matching / Level of Effort / Earmarking Special Tests & Provisions

Corrective Action Plan: As part of the audit planning for 2024, Atrium Health CMHA management will ensure that the internal controls within the SFA IT Systems are documented and tested, or compensating controls implemented. Proposed Completion Date: In November of 2024, management would intend ...

Corrective Action Plan: As part of the audit planning for 2024, Atrium Health CMHA management will ensure that the internal controls within the SFA IT Systems are documented and tested, or compensating controls implemented. Proposed Completion Date: In November of 2024, management would intend to incorporate and complete this IT systems controls testing into the planning phase of the December 31, 2024 reporting period audit.

View Audit 310986

Finding 404196 (2023-002)

Significant Deficiency 2023

National Resource Center on Domestic Violence, Inc.

PA

Reporting

View of Responsible Officials: Continuity of grant portal access will be maintained by the Finance Team and CEO to ensure timely certification of submitted reports in the various grant portals. If technical issues arise, reports can be submitted via e-mail.

View Audit 310970

Finding 404189 (2023-001)

Significant Deficiency 2023

Housing Authority of the City of Deerfield Beach

FL

HUD Housing Programs Reporting Internal Control / Segregation of Duties

Criteria: Financial Data Schedule (FDS) submission for unaudited financials are due within 2 months after the fiscal year end (24 CFR section 5.801) Condition: Management missed the deadline for its unaudited REAC FDS submission. Context: The Authority’s unaudited FDS submission was due on Decembe...

Criteria: Financial Data Schedule (FDS) submission for unaudited financials are due within 2 months after the fiscal year end (24 CFR section 5.801) Condition: Management missed the deadline for its unaudited REAC FDS submission. Context: The Authority’s unaudited FDS submission was due on December 15th 2023. The Authority did not submit the submission until December 28th, 2023. Management Response: Management received guidance from HUD Chicago Office of Public Housing, that Section 8 only housing authorities have a 30-day grace period to submit unaudited FDS submission. Which is December 31st. In the future we will submit within the 15-day grace period.

View Audit 310962

Finding 404150 (2023-003)

Material Weakness 2023

Bucks County Community College

PA

Reporting Material Weakness

Finding 2023-003: Reporting Condition: The College’s publicly available Higher Education Emergency Relief Funds reports for the institutional and student expenditures overstated the total amount of expenditures the College incurred during the fiscal year ending June 30, 2023. The College overstated...

Finding 2023-003: Reporting Condition: The College’s publicly available Higher Education Emergency Relief Funds reports for the institutional and student expenditures overstated the total amount of expenditures the College incurred during the fiscal year ending June 30, 2023. The College overstated the total amount of student expenditures by $3,301,290 and overstated institutional expenditures by $1,127,289. Criteria: As described under Section 314 (e) of the Coronavirus Response and Relief Supplemental Appropriations Act of 2021 (CRRSAA), Public Law 116-260, and defined by the United States Education Department, an institution shall submit a quarterly expense report documenting the expenditures for both the student portion of HEERF money as well as institutional use of the HEERF money. These reports should be posted to the College’s website in a timely and accurate manner for the previously ended quarter. Cause: The College did not reconcile the reports posted to their publicly facing website with the underlying accounting records including the schedule of expenditures of federal awards. Effect of the Condition: Failure to comply with HEERF reporting requirements could jeopardize future federal funding. Action Taken: The College will review and reconcile the reports to the underlying accounting records including the schedule of expenditures of federal awards to ensure the reports reflect the activity that occurred during the reporting period. Name(s) of Contact Person(s) Responsible for Corrective Action: Patricia Smallacombe, Interim Associate Dean, Academic Partnerships Anticipated Completion Date: July 31, 2024

View Audit 310937

Finding 404132 (2023-001)

Significant Deficiency 2023

Hias & Council Migration Service of Philadelphia

PA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Management agrees with the finding and has taken corrective action by purchasing and implementing software which will track the employee’s actual time spent. This software was placed in service on October 1, 2023.

View Audit 310920

Finding 404129 (2023-001)

Significant Deficiency 2023

Amskills, Inc.

FL

Reporting Internal Control / Segregation of Duties

Management intends to implement an accounting period closing checklist that addresses the following: Revenue Transactions: Verify that all revenue transactions for the month have been recorded accurately and in accordance with AmSkills revenue recognition policies. Confirm that revenue is recognized...

Management intends to implement an accounting period closing checklist that addresses the following: Revenue Transactions: Verify that all revenue transactions for the month have been recorded accurately and in accordance with AmSkills revenue recognition policies. Confirm that revenue is recognized when it is earned and the criteria for revenue recognition are met. Billing and Invoicing Processes: Ensure that all billings and invoices for services rendered during the month are processed and issued promptly. Review billing records to confirm accuracy and completeness of invoices issued. Expense Recognition: Review expense transactions to ensure they are recorded in the correct period. Verify that expenses incurred during the month are properly recognized and classified according to AmSkills’ accounting policies.Perform Reconciliations and Adjustments: - Conduct reconciliations between financial records and supporting documentation. Identify any discrepancies or variances and make necessary adjustments to ensure financial accuracy.

View Audit 310912

Finding 404123 (2023-002)

Significant Deficiency 2023

Hampton Roads Community Action Program, Inc.

VA

Questioned Costs Allowable Costs / Cost Principles Reporting

DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-002 Head Start Cluster- Federal Assistance Listing Number 93.600 - Significant Deficiency in Internal Control over Allowable Costs Recommendation: Internal Controls should be implemented around expense cutoff to ensure all expenses relate to the appropria...

DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-002 Head Start Cluster- Federal Assistance Listing Number 93.600 - Significant Deficiency in Internal Control over Allowable Costs Recommendation: Internal Controls should be implemented around expense cutoff to ensure all expenses relate to the appropriate period, or in this case, school year. Action taken: We concur with the recommendation. On May 30, 2024, HRCAP drafted Accounting Policy 3.10 to be reviewed for addition to the Finance Policy Manual. This policy would serve to provide internal control procedures for grant-related transactions in accordance with Generally Accepted Accounting Principles (GAAP). Specifically, it outlines precise year end and cut-off procedures tailored to grant revenue and expenses, emphasizing the critical importance of recording these transactions within the appropriate grant period. Sincerely yours, Audrea Lambert, Chief Financial Officer

View Audit 310907 Questioned Costs: $1

Finding 404118 (2023-003)

Significant Deficiency 2023

Veterans, Inc. and Affiliate

MA

Cash Management Reporting Significant Deficiency

Audit Finding Reference: 2023-003 Internal Controls Over Cash Management and Reporting Planned Corrective Action: Our systems have required review and approvals procedures as described below but the notation of review and approval were not evident. Going forward either through email or sign-off, i...

Audit Finding Reference: 2023-003 Internal Controls Over Cash Management and Reporting Planned Corrective Action: Our systems have required review and approvals procedures as described below but the notation of review and approval were not evident. Going forward either through email or sign-off, it will show approval. a. Cash Drawdowns: i. Currently, all cash drawdowns are prepared by our grant accountant; and reviewed and approved verbally by our grant manager. In addition, all cash drawdowns are reviewed and approved by the national office of the grantor. Going forward, prior to the submission to the national office for approval, the cash drawdowns will be reviewed and approved via email or signature by upper management. b. Financial Reporting: i. Currently, all financial reports (FFR; SF-425; etc.) are prepared by our grant manager, with the assistance of information obtained from our grant accountant from the general ledger. These reports are reviewed and approved verbally by our Vice President of Finance, Development and Administration. In addition, all financial reports are reviewed and approved by the national office of the grantor. Going forward, prior to submitting the reports to the national office for approval, the reports will be reviewed and approved via email or signature by upper management. c. Performance Reporting: i. Performance reports are prepared by the grant lead, and verbally approved by their manager. Managers are copied on the emails to the Federal Office, verifying their approval of the report. Going forward, prior to submitting to the national office for approval, the reports will be reviewed and approved via email or signature by upper management. Planned Implementation Date of Corrective Action: 06/01/2024 Person Responsible for Corrective Action: Vice President – Finance, Development & Administration

View Audit 310900

Finding 404112 (2023-004)

Significant Deficiency 2023

Catholic Charities West Michigan

MI

Reporting Significant Deficiency

Action Taken: Timely reporting as well as documented approvals are very important to Catholic Charities West Michigan and we agree that we must demonstrate that proper reviews or reports have occurred. We have implemented a process including monthly meetings with the Program Manager and the Finance...

Action Taken: Timely reporting as well as documented approvals are very important to Catholic Charities West Michigan and we agree that we must demonstrate that proper reviews or reports have occurred. We have implemented a process including monthly meetings with the Program Manager and the Finance Accountant to review activity and close the month. All reporting is now filed timely with proper documented review.

View Audit 310898

Finding 404106 (2023-002)

Significant Deficiency 2023

Catholic Charities West Michigan

MI

Reporting Cash Management Significant Deficiency

Action Taken: Modifications of the Administrative Financial Management and Cash Management policies will be made to further address concerns identified in the Single Audit. In addition, the reconciliation process will be reviewed and improved to assure timely preparation of the SEFA. CCWM will rec...

Action Taken: Modifications of the Administrative Financial Management and Cash Management policies will be made to further address concerns identified in the Single Audit. In addition, the reconciliation process will be reviewed and improved to assure timely preparation of the SEFA. CCWM will reconcile federal programs to the passthrough agencies 9 months into the fiscal year at a minimum as part of the preparation of the SEFA report.

View Audit 310898

Finding 404103 (2023-001)

None 2023

Tufts Medical Center Inc. and Affiliates

MA

Reporting Internal Control / Segregation of Duties

Re: Finding 2023-001 – Lost Revenue Reporting, Corrective Action Plan To whom it may concern: We agree with the auditor’s finding that the Home Health Visiting Nurse Association (VNA) erroneously filed Reporting Period 5 separately from the Tufts Medicine filing, with data inconsistent with the pre...

Re: Finding 2023-001 – Lost Revenue Reporting, Corrective Action Plan To whom it may concern: We agree with the auditor’s finding that the Home Health Visiting Nurse Association (VNA) erroneously filed Reporting Period 5 separately from the Tufts Medicine filing, with data inconsistent with the previous filings and methodologies. Management has implemented controls to ensure access is limited and that the reporting will be communicated and submitted by the Tufts Medicine Corporate Finance team. Management has communicated the matter with HHS and is currently in communications to resolve. Tufts Medicine Finance

View Audit 310888

Finding 404102 (2023-001)

Material Weakness 2023

City of Groveland, Florida

FL

HUD Housing Programs Reporting Matching / Level of Effort / Earmarking § 200.303

The City agrees with the recommendation to strengthen internal controls over grant reporting processes. To enhance accountability and accuracy, grant reports authored by the designated grant recipient, who is the City employee tasked with managing the grant activity, will now undergo a review by som...

The City agrees with the recommendation to strengthen internal controls over grant reporting processes. To enhance accountability and accuracy, grant reports authored by the designated grant recipient, who is the City employee tasked with managing the grant activity, will now undergo a review by someone else in the City independent of the report preparation. This review will focus on ensuring the reports are complete, accurate, and fully compliant with all stipulated grant requirements.

View Audit 310883

Finding 404098 (2023-001)

None 2023

Appalachian School of Law

VA

Reporting

WE CONCUR WITH THE RECOMMENDATION AND IT WAS IMPLEMENTED IMMEDIATELY. THE CONDITION THAT LED TO THE FINDING WAS AN ANOMALY AND NOT EXPECTED TO OCCUR AGAIN.

View Audit 310874

Finding 404097 (2023-001)

Material Weakness 2023

Midland County Hospital District

TX

Questioned Costs Allowable Costs / Cost Principles Reporting

Management agrees with the finding that the Period 4 Provider Relief Fund report included expenses for utility and insurance expenditures that were not directly related to the District's prevention, preparation and/or response to the COVID-19 pandemic. Management reviewed HRSA guidance and examples...

Management agrees with the finding that the Period 4 Provider Relief Fund report included expenses for utility and insurance expenditures that were not directly related to the District's prevention, preparation and/or response to the COVID-19 pandemic. Management reviewed HRSA guidance and examples of allowable expenses prior to completing Period 4 Provider Relief Fund reporting and concluded these expenses were considered allowable as general and administrative expenses incurred during our response to the COVID-19 pandemic. Management notes that expenses and lost revenue reported exceed the amount of PRF funding received even if these expenses were excluded. We have taken corrective action for the review of completeness and accuracy for inclusion of allowable expenditures. PRF reporting, subsequent to this audit, will be reviewed prior to submission to ensure accuracy of reporting. Chief Financial Officer, Marie Castro, is responsible for ensuring the corrective action plan is followed. The corrective action plan will be implemented on June 30, 2024.

View Audit 310873 Questioned Costs: $1

Finding 404072 (2023-012)

Significant Deficiency 2023

Lutheran Social Services of New York, Inc.

NY

Reporting School Nutrition Programs

This has been resolved.

View Audit 310870

Finding 404071 (2023-011)

Significant Deficiency 2023

Lutheran Social Services of New York, Inc.

NY

Reporting

We will review all reporting requirements and ensure that these are recorded, reconciled and analyzed in a timely manner.

View Audit 310870

Finding 404041 (2023-002)

Material Weakness 2023

Sunrise County Economic Council

ME

Reporting Material Weakness § 200.508 § 200.510

We provided the NOAA Award label and CFDA# as soon as we were able to obtain it from the program manager. We corrected the CFDA# for the Highway Planning and Construction as soon as we were able to obtain them from the MEDOT. The contract documents did not include that information. We reported the ...

We provided the NOAA Award label and CFDA# as soon as we were able to obtain it from the program manager. We corrected the CFDA# for the Highway Planning and Construction as soon as we were able to obtain them from the MEDOT. The contract documents did not include that information. We reported the revenue for the State and Local Recovery Funds in the award column. We now know to put the unspent revenue in deferred. We did not know the $310,000 was Federal Funds, we will know for the future. We will be sure to include Covid-19 labels and all the award dates in the future. We will look for training to prepare a SEFA document, it will be on our professional development list in this year.

View Audit 310862

Corrective Action Plans

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