Corrective Action Plans

Finding 399872 (2023-002)

Significant Deficiency 2023

CA

Questioned Costs Reporting Significant Deficiency

2023-002 LSC Case Information Disclosure Reporting Federal Program: Legal Services Corporation (09-80523) grant period ending December 31, 2023 Corrective Action: Management accepts the finding and will implement additional policies and procedures to ensure timely input of the relevant information...

2023-002 LSC Case Information Disclosure Reporting Federal Program: Legal Services Corporation (09-80523) grant period ending December 31, 2023 Corrective Action: Management accepts the finding and will implement additional policies and procedures to ensure timely input of the relevant information in the case management system for the accurate completion of Case Information Disclosure reports. Additionally, management will provide targeted training to identified users as well as semi-annual trainings for all case handlers. Additionally, the person preparing the reports will send out a reminder one month prior to preparing the report to ensure that all cases in which ICLS prepared a “first filing” on behalf of the client, and to remind staff of the 1644 requirement and have them review all cases in which they had court filings. For the reports in question, amended 1644 reports were submitted to the funder on May 2, 2024. Contact Person: Jaime Cartagena, Deputy Director of Operations Anticipated Completion Date: July 31, 2024, for timely submission of the 1644 semi-annual report.

View Audit 307979

Finding 399869 (2023-001)

Material Weakness 2023

Re: Coded Co.

NY

Material Weakness Reporting § 200.512

Views of Responsible Officials and Corrective Action Plan (Unaudited): As the new responsible person I will establish policies that will allow our Organization to complete our audit on time in the future. Responible Contact Person: Fareed Agha, Director of Finance

View Audit 307970

Finding 399863 (2023-001)

Material Weakness 2023

Guam Power Authority

GU

Reporting

SUBJECT: Corrective Action Plans for FY 2023 Compliance Report This memo presents our corrective action plan in response to the audit findings identified in the FY 2023 Compliance Report. The plan offers corrective actions to address the issues. Audit Finding 2023-001 in the area of Reporting GPA...

SUBJECT: Corrective Action Plans for FY 2023 Compliance Report This memo presents our corrective action plan in response to the audit findings identified in the FY 2023 Compliance Report. The plan offers corrective actions to address the issues. Audit Finding 2023-001 in the area of Reporting GPA personnel responsible for managing federal grant programs and reporting to the grantor agencies will be trained on the preparation of standard forms required for each grant. Personnel will also be notified and encouraged to attend grants management trainings. The Finance Division has started to provide monthly expense reports to personnel on their respective grants. An additional layer of review by the Controller, Assistant Chief Financial Officer or the Chief Financial Officer will be added to ensure that financial data being reported is accurate before these documents can be filed. Should you have any questions please contact Lenora Sanz at (671) 648-3122 or lsanz@gpagwa.com.

View Audit 307969

Finding 399831 (2023-001)

Significant Deficiency 2023

Circle Health Services and Subsidiaries

OH

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.331 § 200.332

Circle Health acknowledges and agrees with this finding. We did have contracts in place with subrecipients, but they were outdated. Both program and finance staff work closely with subrecipients and ensure that they are aware of the grant requirements, reporting requirements, allowable costs, etc....

Circle Health acknowledges and agrees with this finding. We did have contracts in place with subrecipients, but they were outdated. Both program and finance staff work closely with subrecipients and ensure that they are aware of the grant requirements, reporting requirements, allowable costs, etc. Subrecipient monitoring is performed on a regular basis via review of submitted invoices, programmatic meetings and performance reviews. We will create new contracts and have all outstanding, unsigned agreements signed. We will maintain a checklist of due dates for all subrecipient agreements and review periodically throughout the year.

View Audit 307935

Finding 399825 (2023-001)

Significant Deficiency 2023

Island Conservation

CA

Cash Management Allowable Costs / Cost Principles Reporting § 200.514

The Organization has implemented a reivew of summary reimbursement reports

View Audit 307924

Finding 399402 (2023-002)

Significant Deficiency 2023

Department of Housing of the Commonwealth of Puerto Rico

PR

Questioned Costs Subrecipient Monitoring Reporting

VIEWS OF RESPONSIBLE OFFICIALS We implemented the procedures to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) on July 13, 2023. Accordingly, we expect to be in full compliance with the Single Audit for the f...

VIEWS OF RESPONSIBLE OFFICIALS We implemented the procedures to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) on July 13, 2023. Accordingly, we expect to be in full compliance with the Single Audit for the fiscal year 2024. IMPLEMENTATION DATE Single Audit for fiscal year 2023-24 RESPONSIBLE PERSON Félix Hernández Cabán Director of Disaster Recovery for CDBG-DR and Juan R. Rivera Carrillo Assistance Secretary for Finance and Administration

View Audit 307907

Finding 399400 (2023-001)

Material Weakness 2023

Department of Housing of the Commonwealth of Puerto Rico

PR

Questioned Costs Material Weakness Reporting § 200.512

VIEWS OF RESPONSIBLE OFFICIALS During the fiscal year we implemented the Yardi Software to improve the efficiency of the accounting system and the related procedures and ensure that the required financial statements are submitted in compliance with 2 CFR § 200.512 for the Single Audit for fiscal yea...

VIEWS OF RESPONSIBLE OFFICIALS During the fiscal year we implemented the Yardi Software to improve the efficiency of the accounting system and the related procedures and ensure that the required financial statements are submitted in compliance with 2 CFR § 200.512 for the Single Audit for fiscal year 2024. IMPLEMENTATION DATE March 31, 2025 RESPONSIBLE PERSON Juan R. Rivera Carrillo Assistance Secretary for Finance and Administration

View Audit 307907

Finding 399376 (2023-002)

Material Weakness 2023

Albuquerque Housing Authority

NM

Internal Control / Segregation of Duties Material Weakness Reporting

Management will provide a dual review on the unaudited FDS for accuracy and completeness. Hired a consultant to review process.

View Audit 307880

Finding 399366 (2023-001)

Significant Deficiency 2023

City of Donna, Texas

TX

Questioned Costs Reporting Internal Control / Segregation of Duties

Individual responsible for corrective action: David R. Vasquez, Director of Finance and Margaret Lopez, Grants Administrator/Accountant Date corrective action will be implemented: March 2024 Corrective action plan: The City will ensure grant reporting is completed in a timely manner. The G...

Individual responsible for corrective action: David R. Vasquez, Director of Finance and Margaret Lopez, Grants Administrator/Accountant Date corrective action will be implemented: March 2024 Corrective action plan: The City will ensure grant reporting is completed in a timely manner. The Grant administrator will provide a list of all due dates for each grant. Finance will periodically monitor grants to ensure timely reporting. Grant administrator will provide confirmation of each grant filed.

View Audit 307859

Finding 399365 (2023-003)

Significant Deficiency 2023

Rock Island County, Illinois

IL

Questioned Costs Subrecipient Monitoring Reporting § 200.303

The original preparer will provide the report prior to submission to the United States Department of Treasury each quarter to another employee in the Administration office to cross reference totals from New World financial software system and information provided from the Auditor's Office. A written...

The original preparer will provide the report prior to submission to the United States Department of Treasury each quarter to another employee in the Administration office to cross reference totals from New World financial software system and information provided from the Auditor's Office. A written report on findings of this review will be submitted to the Auditor's Office by the due date of the submission to the United States Department of the Treasury.

View Audit 307847

Finding 399358 (2023-006)

Significant Deficiency 2023

Franklin General Hospital

IA

Reporting

American Rescue Plan Rural Distribution, Provider Relief Fund – Assistance Listing No. 93.498 Recommendation: We recommend that management implement a process for preparing the SEFA and implement controls to ensure federal awards are not missed in the future, and that SEFA is fully reconciled to the...

American Rescue Plan Rural Distribution, Provider Relief Fund – Assistance Listing No. 93.498 Recommendation: We recommend that management implement a process for preparing the SEFA and implement controls to ensure federal awards are not missed in the future, and that SEFA is fully reconciled to the general ledger at year-end. We recommend a thorough review of all grant agreements to capture all federal assistance listing numbers, pass-through awards, pass-through award numbers, and related expenditures that should be reported on the SEFA. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will work to improve SEFA preparation and reconciliation process to ensure inclusion of all federal funds, and reach out to auditors for guidance as needed in preparation. Name(s) of the contact person(s) responsible for corrective action: Lee Elbert, CFO Planned completion date for corrective action plan: June 30, 2024

View Audit 307835

Finding 399356 (2023-005)

Significant Deficiency 2023

Franklin General Hospital

IA

Questioned Costs Reporting Significant Deficiency § 200.303

American Rescue Plan Rural Distribution, Provider Relief Fund – Assistance Listing No. 93.498 Recommendation: We recommend that management implement more formal control process surrounding the use of federal awards where there is segregation between individuals identifying or proposing expenditures/...

American Rescue Plan Rural Distribution, Provider Relief Fund – Assistance Listing No. 93.498 Recommendation: We recommend that management implement more formal control process surrounding the use of federal awards where there is segregation between individuals identifying or proposing expenditures/uses of funds and an individual reviewing and approving that expenditure/use. We also recommend for any formal reporting required under federal awards that there be a formal review process where an individual is reviewing and approving the report who did not prepare the report. Documentation of review and approval should be retained in both cases. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will formalize policies and procedures around documenting review and approval for both use of grant funds, and related reporting. Name(s) of the contact person(s) responsible for corrective action: Lee Elbert, CFO Planned completion date for corrective action plan: June 30, 2024

View Audit 307835

Finding 399352 (2023-002)

Significant Deficiency 2023

The Hektoen Institute of Medicine, LLC

IL

Reporting § 200.303

Planned Corrective Action: Management concurs with the recommendation and will review the appropriate guidance and implement enhanced procedures for including secondary level of review. Contact person responsible for corrective action: Mariela Romo, Administrator & Michael Remensnyder, Controller...

Planned Corrective Action: Management concurs with the recommendation and will review the appropriate guidance and implement enhanced procedures for including secondary level of review. Contact person responsible for corrective action: Mariela Romo, Administrator & Michael Remensnyder, Controller Anticipated Completion Date: 8/31/2024

View Audit 307825

Finding 399342 (2023-002)

Material Weakness 2023

Central Midlands Council of Governments

SC

Material Weakness Reporting

Central Midlands Council of Governments has filled all open finance department positions as well as adding a new position in an effort to address staffing levels that have left us vulnerable to delays in meeting reporting and reconciliation requirements necessary for completing a timely audit. Addi...

Central Midlands Council of Governments has filled all open finance department positions as well as adding a new position in an effort to address staffing levels that have left us vulnerable to delays in meeting reporting and reconciliation requirements necessary for completing a timely audit. Additionally, the Council has undertaken to provide a multifaceted in-depth training for new Finance staff to further enhance our ability to meet deadlines in lead up to our single audit. Using the audit requests from the current year, a calendar of due dates has been developed and a goal set to finalize all audit documentation and reconciliations by no later than August 31, 2024, to facilitate a timely audit completion for the FY2024 audit. Anticipated Completion Date: August 31, 2024

View Audit 307822

Finding 399339 (2023-002)

Significant Deficiency 2023

Western Maine Community Action, Inc.

ME

Questioned Costs Reporting Significant Deficiency § 200.512

CFO will be logging into websites necessary for submitting audit ahead of time to prevent login issues. CFO will wait for Auditors to give the approval to submit when the audit is ready to ensure we don’t run into issues with multiple users being logged in. Fiscal team works diligently to get all ...

CFO will be logging into websites necessary for submitting audit ahead of time to prevent login issues. CFO will wait for Auditors to give the approval to submit when the audit is ready to ensure we don’t run into issues with multiple users being logged in. Fiscal team works diligently to get all audit requests submitted in a timely manner during fieldwork. Person(s) Responsible: Chief Financial Officer, Rebecca Gage Timing for Implementation: Effective immediately as of 5/31/2024

View Audit 307817

Finding 399332 (2023-003)

Material Weakness 2023

King Philip Regional School District

MA

Questioned Costs Subrecipient Monitoring Cash Management

The District will utilize DESE's Federal & State Grant Manual document as a guide to ensure compliance with grant management.

View Audit 307806 Questioned Costs: $1

Finding 399330 (2023-004)

Significant Deficiency 2023

Tarrant County B'nai B'rith Housing Corporation

TX

HUD Housing Programs Reporting Internal Control / Segregation of Duties § 200.512

Comments on Finding and Recommendations: We concur that our required financial filings were not made timely with HUD. We agree with the auditor’s recommendations. Planned Corrective Action: We will follow the HUD filing requirements of the regulatory agreement going forward. The financial statement...

Comments on Finding and Recommendations: We concur that our required financial filings were not made timely with HUD. We agree with the auditor’s recommendations. Planned Corrective Action: We will follow the HUD filing requirements of the regulatory agreement going forward. The financial statements for the year ended April 30, 2023 have not been submitted electronically to HUD.

View Audit 307803

Finding 399324 (2023-001)

Significant Deficiency 2023

Tarrant County B'nai B'rith Housing Corporation

TX

Internal Control / Segregation of Duties Reporting Significant Deficiency

Comments on Finding and Recommendations: We concur that certain internal controls were not in place to ensure that the books and records are maintained in accordance with generally accepted accounting principles throughout the year. This is primarily due to system limitations within the accounting s...

Comments on Finding and Recommendations: We concur that certain internal controls were not in place to ensure that the books and records are maintained in accordance with generally accepted accounting principles throughout the year. This is primarily due to system limitations within the accounting system. We agree with the auditor’s recommendations. Planned Corrective Action: We have recorded all adjusting entries to correct misstatements. We will implement measures to ensure all supporting schedules and documents are reconciled to the underlying general ledger accounts consistently and timely going forward.

View Audit 307803

Finding 399280 (2023-002)

Significant Deficiency 2023

Tompkins Cortland Community College

NY

Reporting

• The Vice President of Finance and Administration will maintain a Schedule of Financial Reporting for the College. • New engagements that require reporting will be added to the above mentioned Schedule detailing the type of report and the relevant deadlines • The Comptroller or other designated emp...

• The Vice President of Finance and Administration will maintain a Schedule of Financial Reporting for the College. • New engagements that require reporting will be added to the above mentioned Schedule detailing the type of report and the relevant deadlines • The Comptroller or other designated employee will be assigned with the responsibility to maintain new engagement records and satisfy all of the reporting requirements. • The Comptroller or other designated employee will report the completion of the requirement to the Vice President of Finance and Administration to update the Schedule. • The Schedule of Financial reporting will be shared with auditors to verify compliance.

View Audit 307797

Finding 399261 (2023-002)

Significant Deficiency 2023

Charles Drew Health Center, Inc.

NE

Reporting Cash Management Significant Deficiency

Finding Summary: Two of five reports reviewed were not submitted timely. The SF‐425 report for Award No. H80CS00438 was due on 4/30/23 and was submitted on 6/15/23. The SF‐425 report for Award No. H8FCS40427 was due on 4/30/23 and was submitted on 7/31/2023. Responsible Individuals: Andre Stringfell...

Finding Summary: Two of five reports reviewed were not submitted timely. The SF‐425 report for Award No. H80CS00438 was due on 4/30/23 and was submitted on 6/15/23. The SF‐425 report for Award No. H8FCS40427 was due on 4/30/23 and was submitted on 7/31/2023. Responsible Individuals: Andre Stringfellow, CFO Corrective Action Plan: Management has contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of grant‐related expenditures. Also, the Organization is in the process of creating the administrative infrastructure which includes new staff, new workflow and processes that are designed to report grant activity monthly which includes the timely submission of all grant related reports Anticipated Completion Date: August 2024

View Audit 307789

Finding 399213 (2023-001)

Significant Deficiency 2023

Ada S. McKinley Community Services, Inc. Group Homes

IL

Period of Performance Questioned Costs Allowable Costs / Cost Principles § 200.400 § 200.458

Condition: A duplicate expense was recorded to the program and expenses were recorded to the program prior to the period of performance. Planned Corrective Action: Management acknowledges noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Ma...

Condition: A duplicate expense was recorded to the program and expenses were recorded to the program prior to the period of performance. Planned Corrective Action: Management acknowledges noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management has instituted procedures to provide a review of journal entries to reclass expenses to grant funded programs and promptly record. As well, Finance staff have been added to oversee the accounting function for the grant. Contact person responsible for corrective action: Mary Lawrence, Director of Financial Analysis and Special Initiatives Anticipated Completion Date: 5/15/2024

View Audit 307779

Finding 399209 (2023-001)

None 2023

MacHne Rav Tov

NY

Questioned Costs Cash Management Eligibility

Findings – Federal Award Programs Audit Department of Agriculture 2023-001 Child Nutrition Cluster Program Deficiencies: See Finding 2023-001 Recommendation: Machne Rav Tov will ensure that meal counters are present at the start of each meal service. All required records will be maintained a...

Findings – Federal Award Programs Audit Department of Agriculture 2023-001 Child Nutrition Cluster Program Deficiencies: See Finding 2023-001 Recommendation: Machne Rav Tov will ensure that meal counters are present at the start of each meal service. All required records will be maintained and posted as necessary. The Organization will have proper site supervision during meal services to ensure that meals are served at the approved time, consist of all required components, and are consumed on site. Action Taken: Since the date of the exit conference, we have implemented the above-mentioned comprehensive plan of corrective action. Mrs. Rotenberg, the site supervisor, is designated as being responsible to ensure timely and efficient meal service, and consumption of meals on site. Meal servers will receive relevant training for proper service of meals, including required meal components. An additional site supervisor, Mr. Isaac Ferentz, was hired and trained and will be present on site before the start of each meal time. The supervisors will ensure that meal pattern requirements are met and proper meal counts and food safety procedures are followed. Mrs. M. Stasel is designated as overseeing proper meal counting. Click counters will be used for accurate counting and documenting. Additional training was given to all SFSP staff. We have designated Mr. Hershey Rosenberg as being responsible to oversee the implementation of our plan of corrective action for these findings. Completion Date: May 21, 2024

View Audit 307773 Questioned Costs: $1

Finding 399207 (2023-001)

Significant Deficiency 2023

Hudson Headwaters Health Network, Inc.

NY

Questioned Costs Reporting

May 23, 2024 Year Ended December 31, 2023 To Health Resources and Services Administration GEORGE PURDUE ADMINISTRATIVE BUILDING 9 CAREY ROAD QUEENSBURY, NY 12804 518-761-0300 WWW.HHHN.ORG Hudson Headwaters Health Network and Affiliates (the Network) respectfully submits the following corrective act...

May 23, 2024 Year Ended December 31, 2023 To Health Resources and Services Administration GEORGE PURDUE ADMINISTRATIVE BUILDING 9 CAREY ROAD QUEENSBURY, NY 12804 518-761-0300 WWW.HHHN.ORG Hudson Headwaters Health Network and Affiliates (the Network) respectfully submits the following corrective action plan for the year ended December 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Federal Award Findings: Finding 2023.001 - Reporting Recommendation The Network should ensure that the reporting over the provider relief funds is accurate prior to submission. Action Taken The Network has all supporting documentation for provider relief reports previously submitted and any corrected adjustments that were required. No further action needed. If there are any question regarding this plan, please e-mail Laura Pasco at LPasco@hhhn.org, Chief Financial Officer

View Audit 307760

Finding 399191 (2023-001)

Material Weakness 2023

For Kids Only Afterschool, Inc.

MA

Material Weakness Reporting § 200.512

Views of Responsible Officials and Corrective Action Plan: We will be more proactive in obtaining year end data in advance of the filing dates. Responsible contract person: Director of Finance

View Audit 307758

Finding 399189 (2023-003)

Significant Deficiency 2023

Town of Watertown, Connecticut

CT

Reporting

FINDING 2023-003 – Significant Deficiency in Internal Control over Compliance – Reporting Description of Finding: Controls should be in place to ensure the accuracy of reporting submitted for federal awards programs. The reporting submitted to the Connecticut State Department of Education was not re...

FINDING 2023-003 – Significant Deficiency in Internal Control over Compliance – Reporting Description of Finding: Controls should be in place to ensure the accuracy of reporting submitted for federal awards programs. The reporting submitted to the Connecticut State Department of Education was not reviewed by an individual independent of the preparation process. The report contained an error of more than $13 million, which may have been identified during a review process. Statement of Concurrence or Nonconcurrence: The Town and Board of Education agrees with this finding. Corrective Action: The Board of Education will implement a policy for an independent review of all grant reports to be submitted. Name of Contact Person: Marie Kashuba, Board of Education Business Manager. Projected Completion Date: June 30, 2024

View Audit 307757

Corrective Action Plans

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