Corrective Action Plans

Finding 40153 (2022-001)

Material Weakness 2022

Virginia Union University

VA

Student Financial Aid Cash Management Reporting

See corrective action plan for chart/table.

View Audit 53516

Finding 40145 (2022-026)

Material Weakness 2022

State of North Carolina

NC

Subrecipient Monitoring Reporting

Errors in FFATA Reporting Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Sheryl Plummer - (984) 236-5353 The Division of Mental Health, Developmental Disabilities, and Substance Use Services (DMH/DD/SUS) is updating and strengthening its app...

Errors in FFATA Reporting Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Sheryl Plummer - (984) 236-5353 The Division of Mental Health, Developmental Disabilities, and Substance Use Services (DMH/DD/SUS) is updating and strengthening its approach to Federal Funding Accountability and Transparency Act (FFATA) reporting. DMH/DD/SUS is in the final phase of filling the vacant Business Manager position within the Budget and Finance section. The Business Manager will be responsible for developing formalized FFATA reporting policies and procedures, ensuring staff receive cross-training on FFATA reporting, and reviewing FFATA reports for accuracy before submission. Anticipated Completion Date: December 31, 2023.

View Audit 53638

Finding 40141 (2022-020)

Significant Deficiency 2022

State of North Carolina

NC

Subrecipient Monitoring Reporting

FFATA Reporting Not Completed Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Lisa Allnutt - (919) 527-6854; Felicia Harris - (919) 527-6416; Curtis Terry - (984) 236-5355 Department-wide FFATA training was provided on August 12, 2022. In add...

FFATA Reporting Not Completed Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Lisa Allnutt - (919) 527-6854; Felicia Harris - (919) 527-6416; Curtis Terry - (984) 236-5355 Department-wide FFATA training was provided on August 12, 2022. In addition, the Department will implement a FFATA Data Reporting Form and provide communication to all divisions regarding the use of the form. Anticipated Completion Date: March 31, 2023. Division of Social Services The Business Operations Budget section filled three positions, two of which are assigned responsibilities for the FFATA reporting process. The FFATA reporting procedures were updated to ensure segregation of the review and approval processes and to include step by step instructions. The Business Operations Budget section will continue to hire additional positions to ensure FFATA duties are reassigned in the event of employee turnover. Anticipated Completion Date: March 31, 2023. Division of Mental Health The Division is in the final phase of filling the vacant Business Manager position within the Budget and Finance section. This position will be responsible for assigning FFATA reporting responsibilities and confirming submitted reports are accurate. In addition, the Division will establish a contingency plan to ensure FFATA reporting is completed when essential staff turnover occurs. Anticipated Completion Date: March 31, 2023.

View Audit 53638

Finding 40140 (2022-019)

Significant Deficiency 2022

State of North Carolina

NC

Reporting

Inaccurate TANF Data on Families Was Submitted to the Federal Government Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Shauna Cuffee - (919) 527-6265; Heather Bohanan - (919) 527-6264 The Department will perform the following actions: ? A t...

Inaccurate TANF Data on Families Was Submitted to the Federal Government Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Shauna Cuffee - (919) 527-6265; Heather Bohanan - (919) 527-6264 The Department will perform the following actions: ? A table to capture participant months has been created by NC FAST. The Applications System Specialist from the Client Services Data Warehouse team will update the ACF-199 code to pull month counts from this table. ? The programming code will be corrected to ensure cases are only counted once per month. Anticipated Completion Date: June 30, 2023.

View Audit 53638

Finding 40139 (2022-018)

Significant Deficiency 2022

State of North Carolina

NC

Subrecipient Monitoring Reporting

FFATA Reporting Not Completed Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Lisa Allnutt - (919) 527-6854; Felicia Harris - (919) 527-6416; Candice Bailey - (919) 609-2100 Department-wide FFATA training was provided on August 12, 2022. In a...

FFATA Reporting Not Completed Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Lisa Allnutt - (919) 527-6854; Felicia Harris - (919) 527-6416; Candice Bailey - (919) 609-2100 Department-wide FFATA training was provided on August 12, 2022. In addition, the Department will implement a FFATA Data Reporting Form and provide communication to all divisions regarding the use of the form. Anticipated Completion Date: March 31, 2023. Division of Social Services The Business Operations Budget section filled three positions, two of which are assigned responsibilities for the FFATA reporting process. The FFATA reporting procedures were updated to ensure segregation of the review and approval processes and to include step by step instructions. The Business Operations Budget section will continue to hire additional positions to ensure FFATA duties are reassigned in the event of employee turnover. Anticipated Completion Date: March 31, 2023. Division of Child Development and Early Education DCDEE staff attended Department-wide FFATA training on August 12, 2022. DCDEE Contracts staff will be responsible for reporting TANF subawards administered through DCDEE contracts. Anticipated Completion Date: March 31, 2023.

View Audit 53638

Finding 40137 (2022-016)

Significant Deficiency 2022

State of North Carolina

NC

Subrecipient Monitoring Reporting Allowable Costs / Cost Principles

Errors in FFATA Reporting Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Jeneen Preciose - (919) 428-6102 The Division of Public Health (DPH) has updated the FFATA reporting policy to include report monitoring and standardization guidance. I...

Errors in FFATA Reporting Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Jeneen Preciose - (919) 428-6102 The Division of Public Health (DPH) has updated the FFATA reporting policy to include report monitoring and standardization guidance. In addition, DPH will establish a contingency plan to ensure FFATA reporting is completed during a public health emergency or other disruption. Anticipated Completion Date: March 31, 2023.

View Audit 53638

Finding 40134 (2022-013)

Material Weakness 2022

State of North Carolina

NC

Reporting

Errors in FFATA Reporting Department Name: Public Instruction Contact Name / Telephone Number of Person Responsible for CAP: LaTricia Townsend - (984) 236-2787 See 2022-008 for Corrective Action Plan.

View Audit 53638

Finding 40132 (2022-011)

Material Weakness 2022

State of North Carolina

NC

Reporting

Errors in FFATA Reporting Department Name: Public Instruction Contact Name / Telephone Number of Person Responsible for CAP: LaTricia Townsend - (984) 236-2787 See 2022-008 for Corrective Action Plan.

View Audit 53638

Finding 40129 (2022-008)

Material Weakness 2022

State of North Carolina

NC

Subrecipient Monitoring Reporting

Errors in FFATA Reporting Department Name: Public Instruction Contact Name / Telephone Number of Person Responsible for CAP: LaTricia Townsend - (984) 236-2787 The Office of Federal Programs will continue to interface with the federal agency regarding the technical difficulties of the system. A data...

Errors in FFATA Reporting Department Name: Public Instruction Contact Name / Telephone Number of Person Responsible for CAP: LaTricia Townsend - (984) 236-2787 The Office of Federal Programs will continue to interface with the federal agency regarding the technical difficulties of the system. A data entry plan will be developed and implemented to input required data as quickly as possible with system constraints. Staff will enter and track subaward information in accordance with the plan. Anticipated Completion Date: September 30, 2023.

View Audit 53638

Finding 40121 (2022-002)

Material Weakness 2022

Spencer-Owen Community Schools

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.303

FINDING 2022-002 Contact Person Responsible for Corrective Action: Annette Brown, Treasurer Contact Phone Number: (812) 829-2233 Views of Responsible Official: We concur with the Audit Finding Description of Corrective Action Plan: The School Corporation will implement procedures and processes to en...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Annette Brown, Treasurer Contact Phone Number: (812) 829-2233 Views of Responsible Official: We concur with the Audit Finding Description of Corrective Action Plan: The School Corporation will implement procedures and processes to ensure that the reporting compliance requirement is met for the Education Stabilization Fund. All reporting information will be gathered either by the Treasurer, Payroll Clerk or Accounts Payable depending on the information being requested. The information will then be reviewed for accuracy by the Grant Administrator or Superintendent before being submitted. All documentation will be signed and dated by the appropriate individuals and be filed with the appropriate ESF. Anticipated Completion Date: Will begin this process moving forward with future reporting after February 2023.

View Audit 53434

Finding 40116 (2022-001)

Material Weakness 2022

Cordova Community Medical Center

AK

HUD Housing Programs Material Weakness Reporting

2022-001 Provider Relief Fund Reporting of Lost Revenue Corrective action planned: Use of the new methodology for calculating net patient revenue for all subsequent reporting periods. Anticipated completion date: Complete as of May 11, 2023 Contact person responsible for corrective action: Denna Sta...

2022-001 Provider Relief Fund Reporting of Lost Revenue Corrective action planned: Use of the new methodology for calculating net patient revenue for all subsequent reporting periods. Anticipated completion date: Complete as of May 11, 2023 Contact person responsible for corrective action: Denna Stavig, Director of Finance

View Audit 51015

Finding 40108 (2022-001)

Material Weakness 2022

Center for the Future of Arizona

AZ

Reporting Material Weakness

Preparation of the Financial Statements, Schedule of Expenditures of Federal Awards and Material Audit Adjustments Material Weakness Condition: As auditors, we were requested to draft the financial statements from data provided by CFA. The data included material misstatements which, if not correct...

Preparation of the Financial Statements, Schedule of Expenditures of Federal Awards and Material Audit Adjustments Material Weakness Condition: As auditors, we were requested to draft the financial statements from data provided by CFA. The data included material misstatements which, if not corrected through audit adjustments, would have resulted in financial statements that were materially misstated. The data also contained an error considered to be a prior period adjustment that overstated current revenue by $129,408. Additionally, the schedule of expenditures of federal awards was completed by the auditors with data provided by CFA that was incorrect as a result of audit adjustments. Cause: CFA has limited staff to prepare full disclosure financial statements. Management?s Response and Corrective Action Plan: The year-end closing process will be revised to include accrual of revenue for expenses allocated to reimbursable grants that are reimbursed in the next fiscal year. Responsible Individuals: Amanda Burke, Jessi Black Anticipated Completion Date: 6/30/23

View Audit 51004

Finding 40106 (2022-001)

Material Weakness 2022

Bainbridge Island School District No. 303

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles

Finding Ref number: 2022-001 Finding caption: The District?s internal controls were inadequate for ensuring compliance with requirements for time-and-effort documentation. Name,...

Finding Ref number: 2022-001 Finding caption: The District?s internal controls were inadequate for ensuring compliance with requirements for time-and-effort documentation. Name, address, and telephone of District contact person: Kelly Pearson 8489 Madison Avenue N. Bainbridge Island, WA 98110 (206) 780-1061 Corrective action the auditee plans to take in response to the finding: All federal grants will be reviewed by the Grant Manager at the start of the grant to determine if Time and Effort reporting is required. The Grant Manager will coordinate with Human Resources and the manager of the federal grant to ensure proper forms and instructions are provided. The Grant Manager will monitor Time and Effort form submission throughout the grant period. Anticipated date to complete the corrective action: Immediately

View Audit 49875

Finding 40098 (2022-001)

Significant Deficiency 2022

Aids Foundation Houston, Inc.

TX

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

September 26, 2023 AIDS Foundation Houston, Inc. dba Allies in Hope respectfully submits the following corrective action plan in response to our single audit results for the year ended December 31, 2022. Carr, Riggs & Ingram, LLC Two Riverway, 15th Floor Houston, Texas 77056 Audit Period: Fiscal Yea...

September 26, 2023 AIDS Foundation Houston, Inc. dba Allies in Hope respectfully submits the following corrective action plan in response to our single audit results for the year ended December 31, 2022. Carr, Riggs & Ingram, LLC Two Riverway, 15th Floor Houston, Texas 77056 Audit Period: Fiscal Year January 1, 2022 ? December 31, 2022 The finding from the schedule of findings and questioned costs dated September 26, 2023, is discussed below. The finding is numbered consistently with the number assigned in the schedule. 2022-001 Internal Controls over Reporting (Significant Deficiency) Recommendation: The Foundation review its controls and ensure that the copies of the submission emails be part of the Foundation?s grant records. Corrective Action: Effective 10/1/23 we are using a shared system to house and track our reporting to our funders and will save emails sent to funders in this shared system in order to document the submission of the reports. Responsible Parties: Chief Financial Officer, Chief Program Officer, and Director of Compliance Date Expected to be Corrected: 10/1/23 If the U.S. Department of Housing and Urban Development has any questions regarding this plan, please contact Nicholas Williams, CFO at 713-623-6796 x285. Sincerely yours, Nicholas Williams Nicholas Williams Chief Financial Officer

View Audit 48673

Finding 40078 (2022-002)

Material Weakness 2022

The Crisis Center of Tampa Bay, INC

FL

Cash Management Material Weakness Reporting

Finding 2022-002 ? Material Weakness Controls Over Grant Review and Reporting Federal Assistance Listing Number: 16.575 ? Crime Victim Assistance We are implementing the following policies to address the audit finding 2022-002: The department had significant turnover in the Grant Manager position du...

Finding 2022-002 ? Material Weakness Controls Over Grant Review and Reporting Federal Assistance Listing Number: 16.575 ? Crime Victim Assistance We are implementing the following policies to address the audit finding 2022-002: The department had significant turnover in the Grant Manager position during the fiscal year along with insufficient staff for an independent review of reimbursements prior to submission. The following procedure has been implemented: - The contributing departments have a deadline each month to submit the information so that that grant manager has sufficient time to enter the information into the Crime Victim Assistance?s portal. - The Controller will review the supporting documentation prior to submission of the invoice. - Any denials will be reviewed by Grant Manager and approved by Controller upon receipt of denial. - The resubmitted information will be uploaded to the portal within the timeline assigned by the grantor. Anticipated completion date: May 31, 2023

View Audit 45013

Finding 40066 (2022-005)

Significant Deficiency 2022

Legal Services Alabama, INC

AL

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding 2022-005 ? Internal Control over Reporting (Significant Deficiency) Corrective Action: LSA will resume a review and approval of every grant report and document the review as of the date of this audit report. Contact Person: David Roberson, Director of Finance; (334) 223-0251; droberson@al...

Finding 2022-005 ? Internal Control over Reporting (Significant Deficiency) Corrective Action: LSA will resume a review and approval of every grant report and document the review as of the date of this audit report. Contact Person: David Roberson, Director of Finance; (334) 223-0251; droberson@alsp.org

View Audit 45011

Finding 40037 (2022-001)

Significant Deficiency 2022

Ucr of Holly Springs, Mississippi, Inc. D/b/a Hollyview Place

OH

HUD Housing Programs Internal Control / Segregation of Duties Eligibility

1. Comments on Findings and Recommendation Management acknowledges failure to comply with timely EIV Master File Reports required to be completed as part of tenant move in certification process and EIV Master File process. 2. Actions Taken or Planned The Corporation will regularly monitor and recon...

1. Comments on Findings and Recommendation Management acknowledges failure to comply with timely EIV Master File Reports required to be completed as part of tenant move in certification process and EIV Master File process. 2. Actions Taken or Planned The Corporation will regularly monitor and reconcile the creation and retention of background checks and Income reports as part of the move in process. Additional training was provided and corrective action was taken. Management is reviewing and revising the EIV policy. 3. Status of Corrective Actions on Prior Findings The Corporation did not remediate the prior year finding for failure to comply with timely EIV Income Reports.

View Audit 45251

Finding 40031 (2022-001)

None 2022

Illinois Valley Community College Dist. No.513

IL

Special Tests & Provisions Student Financial Aid Reporting

2022-001: Late Return of Title IV Financial Aid - Student Financial Aid Cluster ? Assistance Listing #s 84.007, 84.033, 84.063, 84.268 - Grant Period - Year Ended June 30, 2022 ...

2022-001: Late Return of Title IV Financial Aid - Student Financial Aid Cluster ? Assistance Listing #s 84.007, 84.033, 84.063, 84.268 - Grant Period - Year Ended June 30, 2022 Condition: During our Return of Title IV Fund testing, we noted that the College did not return Title IV Student Financial Aid for one out of twenty-five students tested until after 45 days when the student ceased attendance. We consider the untimely calculation and Return of Title IV Student Financial Aid to be an instance of noncompliance relating to the Special Tests and Provisions Compliance Requirement. Corrective Action Plan: We have updated our Intercession Procedures to include an early date to return Title IV Student Financial Aid, to occur prior to the 45 days when a student would cease attendance. With the earlier to occur date this will prevent this noncompliance issue from happening again. Responsible Person for Corrective Action Plan: Eric Johnson- Director of Financial Aid Implementation Date of Corrective Action Plan: 10/6/2022

View Audit 44197

Finding 40028 (2022-002)

Significant Deficiency 2022

Bradley University

IN

Subrecipient Monitoring Reporting Significant Deficiency

2022-002 Higher Education Emergency Relief Fund ? Assistance Listing Number: 84.425E and 84.425F Recommendation: We recommend the University reevaluate its procedures and review policies surrounding reporting requirements to ensure accurate and timely reporting. Explanation of disagreement with audi...

2022-002 Higher Education Emergency Relief Fund ? Assistance Listing Number: 84.425E and 84.425F Recommendation: We recommend the University reevaluate its procedures and review policies surrounding reporting requirements to ensure accurate and timely reporting. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: Staff time constraints caused the finding. Reporting responsibilities have been reassigned to available staff. The University has subsequently complied with the guidelines and submitted all reporting requirements. Procedures are in place to meet all future reporting deadlines. Name of the contact person responsible for corrective action: Dennis Koch, Assistant Vice President of Financial Services Planned completion date for corrective action plan: Completed

View Audit 44191

Finding 40027 (2022-001)

Significant Deficiency 2022

Bradley University

IN

Reporting Significant Deficiency Internal Control / Segregation of Duties

2022-001 Terminated employee with check signing authority Recommendation: We recommend the University enhance termination procedures to include a control to ensure employees lose authorized signer rights upon termination. Explanation of disagreement with audit finding: There is no disagreement with ...

2022-001 Terminated employee with check signing authority Recommendation: We recommend the University enhance termination procedures to include a control to ensure employees lose authorized signer rights upon termination. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: Management has updated authorized users and the signature plate to Sheryl Cox, CFO. Name of the contact person responsible for corrective action: Dennis Koch, Assistant Vice President of Financial Services Planned completion date for corrective action plan: Completed

View Audit 44191

Finding 40023 (2022-004)

Material Weakness 2022

County of Cambria, Pennsylvania

PA

Material Weakness Reporting

A list of required reporting due dates has been prepared by the agency Administrator and given to the new Fiscal Officer. The Administrator will monitor report submissions to ensure that all filings are timely.

View Audit 37558

Finding 40010 (2022-001)

Material Weakness 2022

County of Cambria, Pennsylvania

PA

Material Weakness Reporting

Cambria County concurs with the finding. The County will prepare a listing of required reporting due dates for the Medical Assistance Transportation Program. The Chief Clerk will monitor report submissions in order to ensure timely filings.

View Audit 37558

Finding 40004 (2022-007)

None 2022

God's Bible School, College and Missionary Training Home

OH

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

FINDING 2022-007 ? NSLDS Reporting ALN and Program Expenditures: 84.268 ($149,449) Award Number: P268K223976 Federal Award Year: July 1, 2021 to June 30, 2022 Questioned Costs: None Condition Found: The incorrect effective date of an enrollment status change was reported to the National Stud...

FINDING 2022-007 ? NSLDS Reporting ALN and Program Expenditures: 84.268 ($149,449) Award Number: P268K223976 Federal Award Year: July 1, 2021 to June 30, 2022 Questioned Costs: None Condition Found: The incorrect effective date of an enrollment status change was reported to the National Student Loan Database System (?NSLDS?) for one of the twenty-eight students selected for testing. Corrective Action Plan: The Financial Aid Director updated the withdrawal date in NSLDS for the student in question in November 2022. Procedures will be improved to ensure that the correct withdrawal date is reported in NSLDS. Anticipated Completion Date: The corrective action was completed in November 2022. Contact Person Valorie Quesenberry, Financial Aid Coordinator 513-763-6659

View Audit 48799

Finding 39994 (2022-005)

Significant Deficiency 2022

One Vision

IA

Allowable Costs / Cost Principles Eligibility Reporting § 200.303

Finding 2022-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Applicable Federal Award Number and Year ? Period 2 TIN #420953968 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowe...

Finding 2022-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Applicable Federal Award Number and Year ? Period 2 TIN #420953968 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: The Organization?s Period 2 report to HHS included expenditures that were not properly supported. Responsible Individuals: Mario Van Dijk, CFO Corrective Action Plan: Management is aware of the expenditures, even though small in amount, that were not properly supported, and lost revenue calculation and some of the expenditure listings not being reviewed separate from the preparer. The organization has created processes around preparing and reviewing for items such as this. The finance team is committed to these changes to improve accuracy of our work. Anticipated Completion Date: September 28, 2023

View Audit 45801

Finding 39993 (2022-004)

Material Weakness 2022

One Vision

IA

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Finding 2022-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Applicable Federal Award Number and Year ? Period 2 TIN #420953968 Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Findin...

Finding 2022-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Applicable Federal Award Number and Year ? Period 2 TIN #420953968 Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Organization selected option ii to calculate lost revenue, which consists of a comparison of actual results during the period of availability to the approved budget. The Organization did not have a budget for the entire reporting period that was approved prior to March 27, 2020. For the periods that the Organization did not have an approved budget, the Organization calculated lost revenues using a budget approved by their board after March 27, 2020. The Organization also did not adjust patient revenue for certain adjusting entries identified as part of the financial statement audit, which should have been included to calculate net patient revenue. In addition, the Organization, did not back out lost revenues that had been claimed by other funds. When the Organization tried to reopen their report during the single audit, the Organization was informed that amendments were not allowed. Finally, the Organization?s lost revenue claimed under the program as an allowable cost was not fully reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Mario Van Dijk, CFO Corrective Action Plan: Our budget for FY 2020 was approved prior to the March 2020 deadline identified. We therefore used Method 2 since the budget had been approved. However, we should?ve used Method 3 which would?ve allowed FY 2021 and later to compare actual to budget. We contacted HRSA during our single audit to try and have our reporting reopened so that we could amend the reporting, however that request was denied. If we had been able to reopen our report, we also would have adjusted lost revenue for adjusting entries identified as part of the financial statement audit and other sources that used lost revenue. However, the total lost revenue used to claim PRF would not have changed as we had significant excess lost revenue, so net effect in changes would be none. Anticipated Completion Date: September 28, 2023

View Audit 45801

Corrective Action Plans

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