Corrective Action Plans

Finding 391442 (2023-003)

Significant Deficiency 2023

City of Humboldt

IA

Reporting Internal Control / Segregation of Duties

A policy and procedure will be established to ensure the annual Project and Expenditure Report is submitted prior to the reporting deadline.

View Audit 301938

Finding 391441 (2023-002)

Significant Deficiency 2023

Community Action Partnership of Oregon

OR

Reporting § 200.62

Corrective Action: The fiscal tasks and responsibilities needed to adequately manage all 5 SSVF grants in FY 23 were substantial, and without sufficient staff, it was up to the SSVF Program Manager and an administrative support staff to review invoices, approve sub payments, prepare draw requests fo...

Corrective Action: The fiscal tasks and responsibilities needed to adequately manage all 5 SSVF grants in FY 23 were substantial, and without sufficient staff, it was up to the SSVF Program Manager and an administrative support staff to review invoices, approve sub payments, prepare draw requests for Executive Director approval, and manage overall grant funds. In October of 2023, CAPO hired a full time Finance and Grants Manager, and in February of 2024, we hired a full time SSVF Accounts Coordinator (reporting to the Finance Manager) to assume all fiscal tasks for SSVF. The Program Manager still approves the allowability of subrecipient expenditures, however all invoicing, PMS draws, and overall grant tracking are provided and managed by our new central office fiscal team. This has significantly improved the pace of invoicing and payments to subrecipients, as well as the accuracy of coding and timeliness of fund draws. Person Responsible: Janet Allanach, Executive Director Timing for Implementation: Complete as of February 2024

View Audit 301926

Finding 391440 (2023-001)

Significant Deficiency 2023

Community Action Partnership of Oregon

OR

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Corrective Action: Susan Matlack Jones (SMJ) took over as CAPO’s fiscal service provider in July of 2022. The first six months were spent largely cleaning and correcting journal entries from FY22 – a significant task. CAPO did not begin to receive truly accurate and trustworthy financial statements ...

Corrective Action: Susan Matlack Jones (SMJ) took over as CAPO’s fiscal service provider in July of 2022. The first six months were spent largely cleaning and correcting journal entries from FY22 – a significant task. CAPO did not begin to receive truly accurate and trustworthy financial statements until early in 2023. CAPO also experienced two staff losses in the finance department from March through May of 2023. In light of our growth and increased administrative needs, we revised our job posting to increase the level of fiscal skill and responsibility needed for the Finance Manager role. In September of 2023, CAPO was successful in hiring a Finance and Grants Manager with experience in federal fund accounting for Community Action and in SSVF (our major grant). Since that time, he has organized, revamped, and significantly improved internal processes to assure timely review of all finances and reconciliations and works closely with SMJ to assure overall accuracy. Person Responsible: Janet Allanach, CAPO Executive Director Timing for Implementation: Complete as of October 2023

View Audit 301926

Finding 391432 (2023-004)

Material Weakness 2023

County of Nevada

CA

Reporting Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking § 200.302 § 200.303

The Auditor-Controller’s office will provide additional training to applicable departments to educate staff on appropriate records maintenance related to grant files and the importance documented review and approval processes. This training will provide additional education over appropriate supporti...

The Auditor-Controller’s office will provide additional training to applicable departments to educate staff on appropriate records maintenance related to grant files and the importance documented review and approval processes. This training will provide additional education over appropriate supporting documentation to verify internal controls and compliance requirements are being reasonably followed

View Audit 301919

Finding 391385 (2023-002)

Significant Deficiency 2023

Bethany Lutheran College, Inc.

MN

Student Financial Aid Reporting Significant Deficiency

Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.038, 84.268, 84.033, 84.007, 84.063 Recommendation: We recommend the College review its reporting procedures to ensure that students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation ...

Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.038, 84.268, 84.033, 84.007, 84.063 Recommendation: We recommend the College review its reporting procedures to ensure that students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Issue: Taylor Theiste began official withdrawal process on 1/31/23. This date was used in Return of Title IV calculations, and entered into PowerFAIDS system. Student was asked to unenroll from the courses by the Registrar, which she did, but not until 2 days later. Resolution: Jeff Younge (Director of Financial Aid) met with Sergio Salgado (Registrar) and Lisa Shubert (Manager of Administrative Computing and Institutional Reporting) on 11/29/23. Going forward, when student indicates intent to withdraw, Registrar will unenroll the student from courses using the withdrawal date used for Title IV purposes. This will ensure that the correct date is reported to Clearinghouse, and then to NSLDS. Issue: Ben Draper began official withdrawal process on 1/20/23. Since this was the 10th day of class, he was not included in the Census Report that was run at the end of the day (although correct date was used for Return of Title IV calculations, and transcript shows Ws). Consequently, he was treated for reporting purposes as if he did not return for spring semester, and withdrawal date sent to Clearinghouse, and then on to NSLDS, reverted to last day of the previous fall semester, which was 12/15/22. Resolution: On December 20, 2023, meeting was held in Luther Hall that included the following: (Stacey Dawley, Jeff Lemke, Jason Lowrey, Ted Manthe, Daniel Mundahl, Sergio Salgado, Lisa Shubert, Renee Tatge, Estelle Vlieger, Jeff Younge) Proposal was made (and accepted by this group, and later the President) that stated the following: 1. Add/Drop period is day 1-5 of fall and spring semester. During this time, classes can be added, and dropped courses disappear from student schedule/transcript, as if student did not begin the class. Courses withdrawn from after 5th day result in a grade on the transcript (W, WP/WF, or F, depending on the timing of the withdrawal). This is the current policy, not a proposed change. 2. Change wording of refund policy, so that instead of Week 1, Week 2, Week 3...it is worded as Day 1-5, Day 6-10, Day 11-15... (This solves the issue of 1st week being only 4 days in the fall, but 5 days in the spring, and the day after Labor Day being the 10th day of class, but 3rd week of the semester). 3. Change Census report figures from being (10th day) to (end of 5th day). That does not mean census report is available on the 5th day, but just that the information is “locked” as of that day for reporting purposes. Name of the contact person responsible for corrective action: Jeff Younge, Director of Financial Aid Planned completion date for corrective action plan: 3/26/2024

View Audit 301916

Finding 391382 (2023-002)

Material Weakness 2023

Marshall Public Schools

WI

Reporting

Finding #2023-002 – Lack of Financial Close Process and Delayed Accounting Condition: Cash and other accounts were adjusted during the audit process. Many audit journal entries were required to record and adjust activity. Multiple grant claims were not filed throughout the year and large adjustmen...

Finding #2023-002 – Lack of Financial Close Process and Delayed Accounting Condition: Cash and other accounts were adjusted during the audit process. Many audit journal entries were required to record and adjust activity. Multiple grant claims were not filed throughout the year and large adjustments were needed to record revenues. Effect: Financial reporting from the District’s general ledger could be materially misstated. Delayed grant claims could cause cash flow issues. Cause: The District did not have procedures in place to ensure that all transactions were properly recorded on the general ledger prior to the audit. Criteria: During the close of the monthly financial statements, other balances should be reconciled to subsidiary detailed listings. Grant claims should be reconciled to the general ledger and submitted throughout the year. Receivables should be recorded as of year end as needed. Recommendation: The District should develop procedures to timely reconcile cash and other balance sheet accounts. The reconciliations should be reviewed by someone other than the person preparing the reconciliations. The reviewer should initial and date the reconciliations when the review is complete. Reconcile payroll liabilities. Develop procedures to review and submit grant claims throughout the year and reconcile to the general ledger. Response: The District will work to establish procedures to reconcile accounts monthly and grant claims are reconciled and submitted throughout the year. Marshall School District's Corrective Action Plan: School Business Manager Kristin Wilkinson will engage in the following tasks to better understand and put processes in place to address the finding: Meet with experienced School Business Managers Wendy Brockert and Tim Stellmacher in regards to reconciling payroll liabilities. When By 6/30/2024. Attend WASBO University class through Wisconsin Association of School Business Officials, specifically Internal Controls for the School Business Office. When Ongoing. This specific course completed 3/19/2024. Complete one full year as School Business Manager at Marshall Public Schools (first position in this role in any district) learning about the role, structures and processes that are in place, need to be put in place, and need to be refined. When May 2, 2024. Reconcile cash and balance sheet accounts monthly. Review will be done by mentor School Business Manager or by Accounts Payable Specialist. When By March 30, 2024. Review and submit grant claims throughout the year and reconcile to the general ledger. When Ongoing work By 6/30/2024. Contact Person: Kristin Wilkinson, Business Manager Anticipated Completion Date: 6/30/2024

View Audit 301915

Finding 391379 (2023-003)

Material Weakness 2023

Ifoster, Inc.

CA

Material Weakness Reporting Internal Control / Segregation of Duties

Finding 2023-003 Finding Summary: Management is responsible for establishing and maintaining an effective system of internal control over financial reporting. Ensuring accruals and expenses are recorded in the appropriate time period and meet the criteria for recognition is a key component of effect...

Finding 2023-003 Finding Summary: Management is responsible for establishing and maintaining an effective system of internal control over financial reporting. Ensuring accruals and expenses are recorded in the appropriate time period and meet the criteria for recognition is a key component of effective internal control over financial reporting. Certain expenses were not recorded in the correct financial reporting period. Responsible Individuals: Mike Maxfield, Controller Corrective Action Plan: Acknowledged. Payroll accruals, which have in the past been immaterial, are being accrued on a monthly basis in fiscal year ending June 30, 2024. Anticipated Completion Date: Ongoing

View Audit 301914

Finding 391378 (2023-002)

Material Weakness 2023

Ifoster, Inc.

CA

Material Weakness Reporting Internal Control / Segregation of Duties

Finding 2023-002 Finding Summary: Internal controls should be in place to provide reasonable assurance that protects iFoster, Inc. from errors or omissions. iFoster, Inc. internal control system did not require consistent approval of grant expenditures as well as properly allocating costs within the...

Finding 2023-002 Finding Summary: Internal controls should be in place to provide reasonable assurance that protects iFoster, Inc. from errors or omissions. iFoster, Inc. internal control system did not require consistent approval of grant expenditures as well as properly allocating costs within the accounting program. Responsible Individuals: Mike Maxfield, Controller Corrective Action Plan: Acknowledged. Due to the compressed timeframe between initial single audits, corrective action could not be implemented. All grant expenditures now require approval and QuickBooks will be used to allocate costs in fiscal year ending June 30, 2024 rather than using Excel. Anticipated Completion Date: April 20, 2024

View Audit 301914

Finding 391377 (2023-001)

Material Weakness 2023

Ifoster, Inc.

CA

Material Weakness Reporting Internal Control / Segregation of Duties

Finding 2023-001 Finding Summary: Management is responsible for establishing and maintaining an effective system of internal control over financial statement reporting. One of the components of an effective system of internal control over financial reporting is the preparation of full disclosure fin...

Finding 2023-001 Finding Summary: Management is responsible for establishing and maintaining an effective system of internal control over financial statement reporting. One of the components of an effective system of internal control over financial reporting is the preparation of full disclosure financial statements that do not require adjustment as part of the audit process. A second component is that reconciliations and transactions are properly reviewed and approved by the appropriate personnel. As auditors, we were requested to draft the financial statements and accompanying notes to the financial statements. Certain reconciliations and journal entries were not reviewed and approved. Responsible Individuals: Mike Maxfield, Controller Corrective Action Plan: Acknowledged. Due to the compressed timeframe between initial single audits, corrective action could not be implemented. All journal entries are now approved as a part of our month end close process. Although we anticipate the auditor to continue to prepare the financial statements, we believe addressing the internal control noted above will address any material errors noted. Anticipated Completion Date: Ongoing

View Audit 301914

Finding 391338 (2023-001)

Material Weakness 2023

Lifespire, Inc.

NY

Allowable Costs / Cost Principles Reporting

The main reason for the discrepancy in income was a result of using actual units/services billed (from the billing software) and not what is recorded in the financials because, usually what is recorded every month in the financials is based on estimates and later adjusted based on actual billing and...

The main reason for the discrepancy in income was a result of using actual units/services billed (from the billing software) and not what is recorded in the financials because, usually what is recorded every month in the financials is based on estimates and later adjusted based on actual billing and payments for services received. With this approach we were comfortable that, if necessary, we could trace the income to the actual service rather than an estimate. An unintended consequence was that income received in a year for a service in a prior year was not accounted for. While, immaterial, this resulted in discrepancies. We are committed that in the future, we would take additional steps to review the information by other employees who are not involved in the process in order to get a different perspective, and seek outside help, like a CPA, if necessary.

View Audit 301904

Finding 391324 (2023-006)

Material Weakness 2023

Ashley Medical Center

ND

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Reporting Federal Agency Name: Department of Hea lth and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center claimed lost revenues that were incorrectly calculated or not supp...

Reporting Federal Agency Name: Department of Hea lth and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Medical Center claimed lost revenues that were incorrectly calculated or not supported. These were improperly included within the HHS Report Period 4 and caused the Report to be inaccurate. Responsible Individuals: Corey Ulmer, CFO Corrective Action Plan: We will implement internal control policies to ensure that the required reports are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: 6/30/2024

View Audit 301891

Finding 391303 (2023-007)

Significant Deficiency 2023

Chestnut Hill College

PA

Student Financial Aid Reporting Significant Deficiency

Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.063, 84.268, 84.379 Recommendation: We recommend the College evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There...

Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.063, 84.268, 84.379 Recommendation: We recommend the College evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The college will evaluate our procedures and review regulations to ensure the appropriate enrollment information is reported, timely. In the summer of 2023, the financial aid office implemented weekly COD mismatch updates and real time R2T4 adjustments. In doing so, we are ensuring that COD has the most accurate information and adjustments are reported in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson – Director of Financial Aid and Michael Reig – Registrar. Planned completion date for corrective action plan: June 30, 2024

View Audit 301881

Finding 391301 (2023-006)

Significant Deficiency 2023

Chestnut Hill College

PA

Reporting Student Financial Aid Significant Deficiency

Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College evaluate its procedures and review regulations set by the Department of Education around NSLDS to ensure the College understands the definitions for each enrollment information that gets re...

Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College evaluate its procedures and review regulations set by the Department of Education around NSLDS to ensure the College understands the definitions for each enrollment information that gets reported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The college will evaluate our procedures and review regulations to ensure the appropriate enrollment information is reported, timely. Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson – Director of Financial Aid and Michael Reig – Registrar. Planned completion date for corrective action plan: June 30, 2024

View Audit 301881

Finding 391294 (2023-003)

Significant Deficiency 2023

Chestnut Hill College

PA

Student Financial Aid Reporting Significant Deficiency

Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There is no disagreem...

Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Financial Aid policies and procedures will be reviewed and amended as necessary. In conjunction with the Registrar’s Office all student changes and information will be reported and reconciled timely. Name(s) of the contact person(s) responsible for corrective action: Jossie Johnson – Director of Financial Aid Planned completion date for corrective action plan: September 30, 2024

View Audit 301881

Finding 391288 (2023-004)

Material Weakness 2023

Des Moines Area Metropolitan Planning Organization

IA

Reporting Internal Control / Segregation of Duties

The corrective action plan was documented in our response to the auditor’s comment. See the Schedule of Findings and Questioned Costs.

View Audit 301879

Finding 391257 (2023-001)

Significant Deficiency 2023

Commonwealth of Puerto Rico Municipality of Sabana Grande

PR

Reporting Significant Deficiency Internal Control / Segregation of Duties

The Municipality will be implementing the internal controls and procedures to assure that the required reports are completed and be submitted as per program regulations on the 15th day of the following month; the expenses were incurred.

View Audit 301875

Finding 391248 (2023-003)

Significant Deficiency 2023

Saint Elizabeth University

NJ

Student Financial Aid Matching / Level of Effort / Earmarking Subrecipient Monitoring

Common Origination and Disbursement (COD) Reporting Planned Corrective Action: The University’s Financial Aid Office will update the anticipated disbursement date to reflect the actual disbursement for 2022-23. We will review the current award year to ensure that the anticipated disbursement dates...

Common Origination and Disbursement (COD) Reporting Planned Corrective Action: The University’s Financial Aid Office will update the anticipated disbursement date to reflect the actual disbursement for 2022-23. We will review the current award year to ensure that the anticipated disbursement dates reflect the actual disbursement date. Person Responsible for Corrective Action Plan: Nicholas Capodice, Director of Financial Aid Anticipated Date of Completion: April 30, 2024

View Audit 301872

Finding 391238 (2023-006)

Material Weakness 2023

City and County of Honolulu

HI

Reporting § 200.328 § 200.329

Finding No. 2023-006: Reporting (Material Weakness - Internal Control Over Compliance) Federal Award: 21.023 - COVID‐19 – Emergency Rental Assistance Program (ERA) Audit Recommendation: We recommend the City be more diligent in following its policies and procedures for submitting quarterly infor...

Finding No. 2023-006: Reporting (Material Weakness - Internal Control Over Compliance) Federal Award: 21.023 - COVID‐19 – Emergency Rental Assistance Program (ERA) Audit Recommendation: We recommend the City be more diligent in following its policies and procedures for submitting quarterly information to the Department of Treasury. We also recommend the City implement retention procedures to track the reports and supporting information submitted to the Department of Treasury. Administration’s Comments: The City will follow policies and procedures for submitting quarterly information to the Department of Treasury and also implement retention procedures to track the reports and supporting information submitted to the Department of Treasury. Office of Economic Revitalization (OER) will provide Fiscal with a copy of the reports. Anticipated Completion Date: May 1, 2024 Contact Person(s): Denise Obrero, Mayor’s Office, Planner VII Rowena Santamaria, Department of Budget and Fiscal Services, Fiscal Officer II

View Audit 301866

Finding 391235 (2023-005)

Significant Deficiency 2023

City and County of Honolulu

HI

Reporting HUD Housing Programs

Finding No. 2023-005: Eligibility (Significant Deficiency - Internal Control Over Compliance) Federal Award: 17.258, 17.259, 17.278 - WIOA Cluster Audit Recommendation: We recommend the City be more diligent in following its policies and procedures for tracking, documenting and performing its ex...

Finding No. 2023-005: Eligibility (Significant Deficiency - Internal Control Over Compliance) Federal Award: 17.258, 17.259, 17.278 - WIOA Cluster Audit Recommendation: We recommend the City be more diligent in following its policies and procedures for tracking, documenting and performing its exit processes. Administration’s Comments: The City will adhere to established policies and procedures for effectively tracking, documenting and executing its exit processes. The "Exit & Follow Up Services Form" will undergo revision to incorporate the following statement and signature line: "This form has been reviewed and approved by the WIOA Manager." Anticipated Completion Date: March 31, 2024 Contact Person(s): Leinaala Nakamura, Department of Community Services, Program Administrator Lee Ann Williams-Naelo, Department of Community Services, Job Resource Specialist V

View Audit 301866

Finding 391233 (2023-004)

Material Weakness 2023

City and County of Honolulu

HI

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking

Finding No. 2023-004: Reporting (Material Weakness - Internal Control Over Compliance) Federal Award: 14.218 - CDBG – Entitlement Grants Cluster Audit Recommendation: We recommend that the City establish procedures to ensure that subawards are uploaded to the FSRS system timely. Administration’...

Finding No. 2023-004: Reporting (Material Weakness - Internal Control Over Compliance) Federal Award: 14.218 - CDBG – Entitlement Grants Cluster Audit Recommendation: We recommend that the City establish procedures to ensure that subawards are uploaded to the FSRS system timely. Administration’s Comments: The City will establish and follow policies and procedures to ensure that subawards are uploaded to the FSRS system timely. City will establish roles to improve execution of the reporting process. Anticipated Completion Date: June 30, 2024 Contact Person(s): Timothy Ho, Department of Community Services, Planner VII Holly Kawano, Department of Budget and Fiscal Services, Federal Grants Coordinator

View Audit 301866

Finding 391208 (2023-001)

Material Weakness 2023

Higher Horizons Day Care Center, Inc.

VA

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness

Based on FY2022 findings, Higher Horizons implemented internal control policies and procedures, effective May 1, 2023. The procedures address all the segregation of duties from journal entries to posting, reconciliation to reporting, and access to the accounting software. The implementation of the i...

Based on FY2022 findings, Higher Horizons implemented internal control policies and procedures, effective May 1, 2023. The procedures address all the segregation of duties from journal entries to posting, reconciliation to reporting, and access to the accounting software. The implementation of the internal control policies and procedures were initiated in May and June of 2023 (the last two months of FY 2023). During FY2024, these procedures were enforced to mitigate risks due to lack of sound internal control. To further strengthen the internal control system, Higher Horizons changed the requisition and accounts payable paper-based to paperless (electronic) process effective July 1, 2023. The electronic requisition system (Microix) is integrated with the accounting software (Abila), which has noticeably enhanced the internal control system.The Microix electronic requisition system eliminates the need to monitor the flow of paper documents, eliminates the risk of losing documents, and disallows purchases without approval. Microix features also require allowability of requisitions to be determined, all changes & communications to be captured, eliminates re-keying the information into Abila, minimizes manual interventions in entering & posting transactions, and much more. Higher Horizons will continue assessing & monitoring the effectiveness of our internal control, review the outcomes, and as needed, will further strengthen the process. Higher Horizons will monitor individual access to general ledger, subsidiary ledger, assets of the organization, accounting software, and Paycom. Access control procedures will be developed and implemented before the end of May 2024. As indicated in FY2023 audit findings, one of the causes for inadequate segregation of duties is the small number of staff in the Finance Department. Higher Horizons will contract with a finance consultant to review the current finance department staffing structure. The consultant will provide feedback and recommendation for adequately staffing the finance department to ensure segregation of duties. The finance management staff will conduct a comprehensive study of accounting and financial tasks, policies and procedures, and standard operating procedures by contracting the financial consultant before the end of June 2024. The study will be presented to the Board for approval, and OFC and OHS for funding.

View Audit 301845

Finding 391207 (2023-001)

Material Weakness 2023

St. Claire Regional Medical Center, Inc.

KY

Cash Management Material Weakness Reporting

April 1, 2024 U.S. Department of Health and Human Services St. Claire Regional Medical Center, Inc. respectively submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Blue & Co., LLC 2650 Eastpoint Parkway, Suite 300 ...

April 1, 2024 U.S. Department of Health and Human Services St. Claire Regional Medical Center, Inc. respectively submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Blue & Co., LLC 2650 Eastpoint Parkway, Suite 300 Louisville, Kentucky 40223 Audit Period: Year ended June 30, 2023 The findings from the Schedule of Findings and Questioned Costs for the year ended June 30, 2023, are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. FINDINGS – FEDRAL AWARD PROGRAM AUDITS 2023-001 Condition: Untimely disbursement of federal grant funds received: When receiving federal grants funds for the HHS Rural Health Care Services Outreach, Rural Health Network Development, and Small Health Care Provider Quality Improvement Plan Program, the Hospital did not disburse federal grant funds received within 3 working days. Action: Management implemented internal control procedures by December 31, 2023 to ensure proper and timely disbursements of federal grant funds to ensure proper cash management of future HHS Rural Health Care Services Outreach, Rural Health Network Development, and Small Health Care Provider Quality Improvement Plan Program funds.

View Audit 301841

Finding 391202 (2023-001)

Significant Deficiency 2023

Chicago Association for Retarded Citizens

IL

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking § 200.430

Audit Firm: RSM US LLP 30 South Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 07/01/2022 – 06/30/2023 Contract Number: FSCWJ00302 Award Year: 2022 – 2023 Comments on Findings and Recommendations: Finding 2023-001—Certification over payroll cost allocation (Control Finding)— Envision Un...

Audit Firm: RSM US LLP 30 South Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 07/01/2022 – 06/30/2023 Contract Number: FSCWJ00302 Award Year: 2022 – 2023 Comments on Findings and Recommendations: Finding 2023-001—Certification over payroll cost allocation (Control Finding)— Envision Unlimited allocated staff salaries and related fringe benefits to the federal program based on budgeted estimates, which were determined before the services were provided. There was no employee certification or documented review of actual time and effort incurred for the payroll costs charged to the grant at the time audit procedures were performed. 2 CFR 200.430(i) Standards for Documentation of Personnel Expenses (1) Charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Budget estimates (i.e., estimates determined before the services are performed) alone do not qualify as support for charges to federal awards, but may be used for interim accounting purposes, provided that the non-federal entity's system of internal controls includes processes to review after-the-fact interim charges made to a federal award based on budget estimates. All necessary adjustments must be made such that the final amount charged to the federal award is accurate, allowable, and properly allocated. Action Taken- Employee certifications were obtained and reviewed by supervisors for all grant payroll costs charged during the award year and were provided to the auditors. A new process is in place for quarterly certifications to follow 2CFR 200.430(i). The required corrective action for Finding 2023-001 for the period 07/01/2022 – 06/30/2023 was completed in December 2023. The person now responsible for completion of the corrective action plan is Dennis James, Chief Financial Officer.

View Audit 301814

Finding 391200 (2023-003)

None 2023

Boys and Girls Clubs of Puerto Rico INC

PR

Reporting

Finding No. 2023-003 Management Response: Management agrees with findings. This was discussed by our Fiscal Manager with the Agency during a meeting on November 15, 2022. The period between our month end close procedures and the report deadlines is to short considering an AUP needs to be performed b...

Finding No. 2023-003 Management Response: Management agrees with findings. This was discussed by our Fiscal Manager with the Agency during a meeting on November 15, 2022. The period between our month end close procedures and the report deadlines is to short considering an AUP needs to be performed before each submission. However, we have taken some actions to advance some of the program information to comply. The report scheduled for January 2024 was submitted on time. Corrective Action Plan:  Management has been reviewing the procedures and identifying steps that can be performed before month end closing.  A formal extension request will be submitted at the renewal of the award. Contact Person: Roxana Rivera Manuel Joglar Team: Fiscal Manager, Fiscal Agent, Program leaders. Anticipated Completion Date: Next report deadline May 17, 2024

View Audit 301810

Finding 391197 (2023-004)

Significant Deficiency 2023

Puerto Rico Highways and Transportation Authority

PR

Internal Control / Segregation of Duties Reporting Significant Deficiency

The Authority will perform an internal review of the toll credits usage Excel spreadsheet and will reconcile all credits used by the projects with a starting date in FY 2023 and later with the last version of the Federal-Aid Project Agreement approved by FHWA. Also, the credits summary will be deliv...

The Authority will perform an internal review of the toll credits usage Excel spreadsheet and will reconcile all credits used by the projects with a starting date in FY 2023 and later with the last version of the Federal-Aid Project Agreement approved by FHWA. Also, the credits summary will be delivered on a quarterly basis to the Executive Staff for the approval process. For the fiscal year 2024, the manual process of reconciling toll credits balance of the new projects with a starting date of January 2024 and later will be changed to an automated process with the PMIS Program, as agreed in Section II of the Memorandum of Understanding (MOU) signed in February 2016 between FHWA and the Authority. In addition, current toll credits tracking, reconciliation, and approval processes are reviewed by FHWA PR Division for compliance. Responsible: Mr. Enrique J. Rosa Torres, Budget Office Auxiliary Director Status: In process. Expected to be completed on or before June 30, 2025.

View Audit 301808

Corrective Action Plans

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