Corrective Action Plans

Finding 32355 (2022-001)

Significant Deficiency 2022

WV

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding 2022-001 Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing Number: 93.498 Criteria: All recipients of Provider Relief Funds (PRF) payments must comply with the reporting requirements described in the PRF terms and conditions an...

Finding 2022-001 Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing Number: 93.498 Criteria: All recipients of Provider Relief Funds (PRF) payments must comply with the reporting requirements described in the PRF terms and conditions and specified in directions issued by the U.S. Department of Health and Human Services. Condition and Context: The System did not complete the PRF reporting for Period 2 in accordance with the U.S. Department of Health and Human Services guidance due to errors in the underlying data that lead to errors in the Period 2 report that was submitted. In the period 2 Submission, the System reported $2,283,650 of COVID-19 expenses, but failed to reduce the expenses by amounts reimbursed by other sources. Management updated their policies and procedures prior to Reporting Period 3 to address this issue. The System had $42,620,438 of lost revenue through Period 2 reporting, and has received $17,690,624 in PRF payments. Corrective Action Plan Corrective Action Planned: Thomas Health System, Inc. and its subsidiaries agrees with the finding, and policy and procedures were updated before reporting Period 3. Period 3 and 4 reporting were completed in accordance with the U.S. Department of Health and Human Services most guidance. The System received a notice from the Department of Health & Human Services dated December 29, 2022 that HRSA's Division of Financial Integrity has determined that the findings cited in the Single Audit Report for fiscal year October 1, 2020 through September 30, 2021 has been satisfactorily resolved. Name of Contact Person Responsible for Corrective Action: Timothy Skeldon, Chief Financial Officer, 4605 MacCorkle Ave SW, South Charleston, WV 25309 Anticipated Completion Date: Completed September 30, 2022

View Audit 28447

Finding 32354 (2022-002)

None 2022

Consolidated High School District 230

IL

Reporting

Finding Synopsis: During the audit, it was noted that the District did not always file expenditure reports within the stated time period for its Title I - Low Income Program. Action Steps: The District will implement an internal procedure to ensure proper filing within 20 days of quarter end to be i...

Finding Synopsis: During the audit, it was noted that the District did not always file expenditure reports within the stated time period for its Title I - Low Income Program. Action Steps: The District will implement an internal procedure to ensure proper filing within 20 days of quarter end to be in reporting compliance. Anticipated Date of Completion: June 30, 2023. Name of Contact Person: Tera Wagner. Management Response: Management concurs with the finding.

View Audit 27455

Finding 32353 (2022-002)

Material Weakness 2022

Spooner Health System

WI

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles

FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2022-002 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend that management review the Provider Relief Fund guidelines to make sure amounts requested for reimbursement are in line with...

FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2022-002 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend that management review the Provider Relief Fund guidelines to make sure amounts requested for reimbursement are in line with the guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the onset of the COVID-19 pandemic and the distribution of the PRF dollars, there were many unknowns and many elements changed including criteria and timelines. The System will continue to review the PRF Terms and Conditions and understand these to the best of our knowledge. However, it is noted that there was sufficient lost revenue to support the PRF distributions received. Name(s) of the contact person(s) responsible for corrective action: Rebecca Busch, CFO Planned completion date for corrective action plan: We look to HRSA for guidance on how to correct the Period 1 report or will correct the error in a future reporting period. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Rebecca Busch, CFO at 715-939-1732.

View Audit 27255 Questioned Costs: $1

Finding 32352 (2022-003)

Material Weakness 2022

Spooner Health System

WI

Material Weakness Reporting Internal Control / Segregation of Duties

2022-003 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend the System review the Provider Relief Fund reporting guidelines to make sure the amounts claimed are in line with the guidelines. We also recommend a review take place to make sure all amounts claimed are corr...

2022-003 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend the System review the Provider Relief Fund reporting guidelines to make sure the amounts claimed are in line with the guidelines. We also recommend a review take place to make sure all amounts claimed are correctly calculated. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the onset of the COVID-19 pandemic and the distribution of the PRF dollars, there were many unknowns and many elements changed including criteria and timelines. The System will continue to review the PRF Terms and Conditions and understand these to the best of our knowledge. Based on the updated lost revenue numbers the System?s lost revenue would have increased from what was reported in the Phase 1 PRF report. Name(s) of the contact person(s) responsible for corrective action: Rebecca Busch, CFO Planned completion date for corrective action plan: We look to HRSA for guidance on how to correct the Period 1 report or will correct the error in future reporting periods. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Rebecca Busch, CFO at 715-939-1732.

View Audit 27255

Finding 32351 (2022-004)

Significant Deficiency 2022

Spooner Health System

WI

Questioned Costs Allowable Costs / Cost Principles Cash Management

2022-004 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend that management review the Provider Relief Fund guidelines to make sure amounts requested for reimbursement are in line with the guidelines and tie back to support. Explanation of disagreement with audit findi...

2022-004 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend that management review the Provider Relief Fund guidelines to make sure amounts requested for reimbursement are in line with the guidelines and tie back to support. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the onset of the COVID-19 pandemic and the distribution of the PRF dollars, there were many unknowns and many elements changed including criteria and timelines. The System will continue to review the PRF Terms and Conditions and understand these to the best of our knowledge. However, it is noted that there was sufficient lost revenue to support the PRF distributions received. Name(s) of the contact person(s) responsible for corrective action: Rebecca Busch, CFO Planned completion date for corrective action plan: We look to HRSA for guidance on how to correct the Period 1 report or will correct the error in a future reporting period. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Rebecca Busch, CFO at 715-939-1732.

View Audit 27255 Questioned Costs: $1

Finding 32335 (2022-001)

Significant Deficiency 2022

Hopeworks of Howard County, Inc.

MD

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Finding: Thirteen reports within three quarters were submitted after the required deadline. We recommend reviewing the controls in place to ensure that all future reports are submitted on time and in accordance with grant requirements. If the Organization expects that there will be a delay in the su...

Finding: Thirteen reports within three quarters were submitted after the required deadline. We recommend reviewing the controls in place to ensure that all future reports are submitted on time and in accordance with grant requirements. If the Organization expects that there will be a delay in the submission of the reports, they should obtain permission to extend the submission date from the awarding agency. Statement of Concurrence or Non-Concurrence Statement of Concurrence: HopeWorks concurs with the finding and recommendation listed above. Corrective Action HopeWorks has implemented a number of streamlined processes in which to expedite the availablity of information needed to file the funder reports more timely. These processes are not limited to electronic import of payroll and benefit entries, implementation and consistent use of Bill.com for expenditures, and prioritization of recording credit card activity. Fifteen days is a strict deadline and if for some reason reporting will be late, HopeWorks will communicate to the funder and document that communication. In FY23, we are also working to streamline the technology and our internal and departmental grant reporting processes to ensure that we are being as efficient as possible with our existing resources, both technological and human.

View Audit 27429

Finding 32302 (2022-001)

Significant Deficiency 2022

City of Chicopee, Massachusetts

MA

Subrecipient Monitoring Reporting Significant Deficiency

Finding 2022-001 Significant Deficiency in Internal Control Over Compliance ? U.S. Department of Treasury ? Coronavirus Relief Fund City Municipal Assistance ? (CFDA No. 21.019) ? Reporting (continued) Passed Through Commonwealth of Massachusetts Executive Office of Administration and Finance Nam...

Finding 2022-001 Significant Deficiency in Internal Control Over Compliance ? U.S. Department of Treasury ? Coronavirus Relief Fund City Municipal Assistance ? (CFDA No. 21.019) ? Reporting (continued) Passed Through Commonwealth of Massachusetts Executive Office of Administration and Finance Name of Person Responsible: Marie T. Laflamme, Treasurer Sharyn Riley, Auditor John Miarecki, School Director of Budget & Finance Corrective Action Planned: The City will immediately review all expenses related to the Coronavirus Relief Funds. The City will take steps to reconcile the Coronavirus Report to our General Ledger. Anticipated Completion Date: May 30, 2023

View Audit 31097

Finding 32272 (2022-020)

Significant Deficiency 2022

State of North Dakota

ND

Questioned Costs Matching / Level of Effort / Earmarking Reporting

Finding: 2022-020 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. These services were provided by a contracted vendor in two separate sites in different cities for over ten years. In October 2018, due to staffing performance concerns...

Finding: 2022-020 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. These services were provided by a contracted vendor in two separate sites in different cities for over ten years. In October 2018, due to staffing performance concerns and licensing investigations, the state ended the contract with this vendor in one city. In April 2019 the vendor ended the contract in the second city. Three Requests for Proposals have been issued since that date and no proposals were received. Market research was conducted with several potential providers and due to lack of interest, capacity concerns, workforce issues as well as the effects of the COVID-19 pandemic, the department has been unable to meet the expenditure requirements. The Department has met several times with the Federal Substance Abuse and Mental Health Services Administration regarding this issue. Currently the Department is requesting funding from the North Dakota Legislative Assembly to develop of a Pregnant and Parenting Women?s Residential Treatment Program within the Department. If approved, the Department will work to secure locations and renovate spaces that is not allowable with the Federal Funds. Contact Person: Lacresha Graham, Manager Addiction Treatment and Recovery Program and Policy Anticipated Completion Date: September 2023

View Audit 36677 Questioned Costs: $1

Finding 32266 (2022-010)

Significant Deficiency 2022

State of North Dakota

ND

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding: 2022-010 Department of Human Services Response/Corrective Action Plan: The Department agrees with the finding. When the Department had to re-procure the Medicaid Expansion MCO contract for a January 1, 2022, start date, the contract was overhauled and made much more specific in terms o...

Finding: 2022-010 Department of Human Services Response/Corrective Action Plan: The Department agrees with the finding. When the Department had to re-procure the Medicaid Expansion MCO contract for a January 1, 2022, start date, the contract was overhauled and made much more specific in terms of the MLR requirements, so we do not anticipate the same issues happening again. Below is contract language that addresses this finding. Appendix E, Article 1 10. Reporting requirements 1. MCO shall submit two reports to STATE that includes at least the following information for each MLR Reporting Year, one of which excludes the adjustments identified in (I) and (C)(3)(d) above: 1. Total incurred claims. 2. Expenditures on quality improving activities. 3. Expenditures related to activities compliant with program integrity requirements (42 C.F.R. ?438.608(a)(1) through (5), (7), (8) and (b)). 4. Non-claims costs. 5. Premium revenue. 6. Taxes, licensing, and regulatory fees. 7. Methodology(ies) for allocation of expenditures. 8. Any credibility adjustment applied. 9. The calculated MLR. 10. Any remittance owed to STATE, if applicable. 11. A comparison of the information reported in this paragraph with the audited financial report required under 42 C.F.R. ?438.3(m). 12. A description of the aggregation method used under paragraph (F) of this article. 13. The number of Member Months. 2. MCO must require any third-party vendor providing claims adjudication activities to provide all underlying data associated with MLR reporting to that MCO within 180 days of the end of the MLR Reporting Year or within 30 days of being requested by MCO whichever comes sooner, regardless of current contractual limitations, to calculate and validate the accuracy of MLR reporting. 3. Prior to ten (10) months following the applicable MLR Reporting Year, MCO must submit the report required in paragraph (I)(1) of this article based on data including eight (8) months of claims run out. 4. MCO shall attest to the accuracy of the calculation of the MLR in accordance with requirements of this article when submitting the report required under this paragraph. 2. Prior to eleven (11) months following the applicable MLR Reporting Year or a mutually agreed upon alternative date, STATE shall finalize the MLR Reporting Year with any balance due to STATE as required in paragraph (H) of this article within sixty (60) days. Contact Person: Jared Ferguson, Medicaid Expansion Administrator Anticipated Completion Date: Already Completed

View Audit 36677

Finding 32240 (2022-002)

Significant Deficiency 2022

Regina Coeli Child Development Center

LA

Questioned Costs Equipment & Real Property Management Procurement, Suspension & Debarment

2022-002 - Equipment and Real Property Management- Failure to Obtain Approval for Disposition of Property Acquired with Federal Awards- The Center concurs with the finding. The Center has implemented procedures to ensure approval for disposition of property acquired with federal funds. New personnel...

2022-002 - Equipment and Real Property Management- Failure to Obtain Approval for Disposition of Property Acquired with Federal Awards- The Center concurs with the finding. The Center has implemented procedures to ensure approval for disposition of property acquired with federal funds. New personnel have been hired who are being adequately trained regarding this process.

View Audit 35779 Questioned Costs: $1

Finding 32235 (2022-001)

Material Weakness 2022

Fairfield Medical Center

OH

Material Weakness Reporting Internal Control / Segregation of Duties

Fairfield Medical Center and Subsidiaries December 31, 2022 CORRECTIVE ACTION PLAN The finding from the schedule of findings and questioned costs for the year ended December 31, 2022 are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. Finding 2022-0...

Fairfield Medical Center and Subsidiaries December 31, 2022 CORRECTIVE ACTION PLAN The finding from the schedule of findings and questioned costs for the year ended December 31, 2022 are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. Finding 2022-001 Condition: The Organization does not have a review process in place relate to reviewing PRF submissions. The Organization calculated its period 4 payments applied toward lost revenue using option ii and attested to using budgets approved prior to March 27, 2020. Planned Corrective Action: Management has implemented a process to ensure review of the reporting submissions prior to finalization. Management has updated its method for calculating lost revenues in the period 5 submission by comparing 2020 budget to 2020 ? 2023 actual revenues. Management believes this is an allowable method under option iii. The period 5 filing was submitted September 19, 2023. Anticipated Completion Date: September 30, 2023 Responsible Contact Person: Julie Grow, Chief Financial Officer

View Audit 34812

Finding 32228 (2022-002)

Material Weakness 2022

Kootenai Health

ID

Reporting Material Weakness

Finding 2022-002 Federal Agency Name: Department of Homeland Security and the State of Idaho Department of Health & Welfare Program Name: Disaster Grants-Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing #97.036 Federal Agency Name: Department of Health and...

Finding 2022-002 Federal Agency Name: Department of Homeland Security and the State of Idaho Department of Health & Welfare Program Name: Disaster Grants-Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing #97.036 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution CFDA #93.498 Finding Summary: Eide Bailly LLP assisted with preparation of the schedule of expenditures of federal awards (Schedule) and accompanying notes to the Schedule. Responsible Individuals: Michele Bouit, CFO and Kimberley Jones, Director of Accounting Corrective Action Plan: Management agrees with the finding and will review processes over the updating and reviewing of the Schedule. Anticipated Completion Date: 12/31/2023

View Audit 33101

Finding 32206 (2022-001)

None 2022

University of Saint Katherine

CA

Reporting § 200.329

Education Stabilization Fund Reporting Planned Corrective Action: The University is no longer accepting HEERF Funding. 2021 HEERF (reported 2022) has been revised and will be resubmitted March 2023, during the US Department of Education?s submission window. All future applicable reporting will b...

Education Stabilization Fund Reporting Planned Corrective Action: The University is no longer accepting HEERF Funding. 2021 HEERF (reported 2022) has been revised and will be resubmitted March 2023, during the US Department of Education?s submission window. All future applicable reporting will be completed within the required timeframe(s). All required reports will be put on the University?s website. Person Responsible for Corrective Action Plan: Laurel Maguire, Controller Anticipated Date of Completion: March 2023

View Audit 27151

Finding 32205 (2022-002)

None 2022

Northwest Compass

IL

Reporting § 200.512

Oversight Agency: U.S. Department of Housing and Urban Development Northwest Compass, Inc. respectfully submits the following corrective action plans for the year ended June 30, 2022. Auditor: Dugan & Lopatka, CPA?s 4320 Winfield Road Suite 450 Warrenville, IL 60555 Audit Period: For th...

Oversight Agency: U.S. Department of Housing and Urban Development Northwest Compass, Inc. respectfully submits the following corrective action plans for the year ended June 30, 2022. Auditor: Dugan & Lopatka, CPA?s 4320 Winfield Road Suite 450 Warrenville, IL 60555 Audit Period: For the year ended June 30, 2022 The findings from the schedule of finding and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 2022-002 Youth Homelessness Demonstration Program, CFDA #14.276 Auditor?s Recommendation: We recommend that upon receiving the final reporting package, the Organization completes all requirements with the Federal Audit Clearinghouse. Northwest Compass has adopted this policy for FY2022. If the funding agency has questions regarding this plan, please call me at (847) 392-2344.

View Audit 27861

Finding 32197 (2022-003)

None 2022

Regional School Unit #4

ME

Reporting School Nutrition Programs

Management Response/Corrective Action Plan: All schools in the RSU are now using the same software and process at their point of sales. All impacted staff have been trained on this new software and the Business Department will continue to review reports for meal counts on a monthly basis.

View Audit 35037

Finding 32196 (2022-001)

Material Weakness 2022

Howard County Public School System

MD

Internal Control / Segregation of Duties Reporting

A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Financial Statement Findings: Finding 2022-001 a. Comments on the Finding and Each Recommendation: Management agrees with the finding and concurs with the recommendation. b. Action(s) Taken or Planned on the Fin...

A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Financial Statement Findings: Finding 2022-001 a. Comments on the Finding and Each Recommendation: Management agrees with the finding and concurs with the recommendation. b. Action(s) Taken or Planned on the Finding: To ensure the integrity of its financials, HCPSS is in the process of reengineering its internal processes as it pertains to the accounting of its Restricted Programs Fund. As such, the following actions will be taken: 1. HCPSS is working with their IT department to configure its financial system to differentiate between the different types of grants within its Restricted Programs Fund. This will allow for greater oversight and ensure revenue is being recognized correctly in compliance with generally accepted accounting principles throughout the year. 2. HCPSS has funding allocated to hiring a Grant Budget Analyst and Grant Accountant III. With these additional resources supporting the Restricted Programs Fund, there will be an improvement in internal controls as well as more thoroughly defined roles and responsibilities. This will include a more refined monthly analysis of the individual grants comprising the Restricted Programs Fund

View Audit 32134

Finding 32193 (2022-001)

None 2022

Universal Technology College of Puerto Rico, INC

PR

Questioned Costs Student Financial Aid Subrecipient Monitoring

Audit Firm: J&J CPA LLC Certified Public Accountants & Consultants Audit Period: October 1 2021 to September 30 2022 Finding No: 2022-001: CFDA No: 84.063 Program Name: Pell Grant Compliance Requirement: Disbursements ? Reporting disbursements within 15 days and inaccurate ...

Audit Firm: J&J CPA LLC Certified Public Accountants & Consultants Audit Period: October 1 2021 to September 30 2022 Finding No: 2022-001: CFDA No: 84.063 Program Name: Pell Grant Compliance Requirement: Disbursements ? Reporting disbursements within 15 days and inaccurate recordkeeping Criteria According to 34 CFR 668.164 an institution must disburse during the current payment period the amount of title IV, HEA program funds that a student enrolled at the institution, or the student?s parent, is eligible to receive for that payment period. Cause Both disbursements were made on the same date; however, inadvertently the correct steps were not performed in ED Express in order for the return to be processed. Recommendation The Institution must reinforce disbursement control procedures to ensure that all disbursements are correctly posted and the amounts between COD and student?s ledger are a match. Management Response and Corrective Action Plan The finding has been detected and the institution has already established all the necessary measurements to assure that the Title IV Office is following all the policies and regulations that rule the Pell Grant Program. The monthly evaluation, verification and reconciliation will include an internal audit performed by another office responsible for comparing the COD system with the student ledger to reinforce the actual disbursement control procedures ensuring that all disbursements are correctly posted and that the student?s ledger correctly shows all the activity performed on the COD system. The institution already refunded the questioned cost of $3,247.50

View Audit 30794 Questioned Costs: $1

Finding 32192 (2022-001)

Material Weakness 2022

International Registration Plan, Inc.

VA

Internal Control / Segregation of Duties Material Weakness Reporting

2022 CORRECTIVE ACTION PLAN June 30, 2023 Federal Motor Carrier Safety Administration International Registration Plan, Inc. respectfully submits the following Corrective Action Plan for the year ended September 30, 2022. Name and address of independent public accounting firm: Blue & Co., LLC 250 We...

2022 CORRECTIVE ACTION PLAN June 30, 2023 Federal Motor Carrier Safety Administration International Registration Plan, Inc. respectfully submits the following Corrective Action Plan for the year ended September 30, 2022. Name and address of independent public accounting firm: Blue & Co., LLC 250 West Main Street, Suite 2900 Lexington, KY 40507 Audit period: October 1, 2021 - September 30, 2022 The findings from the June 30, 2023, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section II - Financial Statement Findings 2022-001 Finding: Preparation of Financial Statements Criteria or specific requirement: Management is responsible for establishing and maintaining effective internal controls over financial reporting. Effective internal controls are an important component of a system that supports accurate external financial reporting. Condition: IRP does not have in place the processes and controls that would assure the preparation of external year-end financial statements and related note disclosures in accordance with accounting principles generally accepted in the United States of America. Effect: Recognizing the above condition IRP engages the external independent auditors to assist with the drafting of the year-end external financial statements. Once drafted, the financial statements are submitted to management for review, revision, and approval. While this practice is common and practical, it is considered a material weakness in internal control over financial reporting since the year-end external financial statement preparation cannot be performed in-house. Cause: Such preparation would require the in-house ability to maintain appropriate technical knowledge, including the ability to research current and changing accounting standards as well as unique industry considerations. Recommendation: The external auditors have recommended management review and, if practical, enhance the external financial reporting procedures and controls in place to address the preparation and review of external year-end financial statements. Views of responsible officials and planned corrective actions: Management concurs with the above finding and, accordingly, has engaged the auditors to assist with the preparation of the 2022 year-end external financial statements. Management is currently reviewing the procedures and controls in place to address the preparation and review of external year-end financial statements and will revise and enhance as warranted. Respectfully submitted, Timothy A. Adams CEO IRP, Inc.

View Audit 36723

Finding 32162 (2022-006)

Material Weakness 2022

City of Richmond

VA

Subrecipient Monitoring Material Weakness Reporting

2022-006 CDBG Entitlement Grant Cluster and COVID-19 ? Community Development Block Grant - CV ? Assistance Listing No. 14.218 Recommendation: We recommend the City develop internal controls and procedures to ensure that FFATA reporting requirements are met. We further recommend the City develop cont...

2022-006 CDBG Entitlement Grant Cluster and COVID-19 ? Community Development Block Grant - CV ? Assistance Listing No. 14.218 Recommendation: We recommend the City develop internal controls and procedures to ensure that FFATA reporting requirements are met. We further recommend the City develop controls and procedures to ensure that all required subawards are reported accurately and timely to FSRS no later than the end of the month following the month of issuance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Housing and Community Development will work with the appropriate Federal regulatory department and review applicable guidance to determine the required reporting frequency, register with all necessary reporting systems, and receive any necessary training by June 30, 2023. Beginning July, 2023, Housing and Community Development will begin submitting the fiscal year 2024 reports while concurrently submitting any and all delinquent reports for fiscal year 2023. Name(s) of the contact person(s) responsible for corrective action: Sherrill Hampton Planned completion date for corrective action plan: October 31, 2023

View Audit 35530

Finding 32159 (2022-002)

Material Weakness 2022

Imagine the Possibilities, Inc.

IA

Reporting Material Weakness

Finding 2022-002: Preparation of Schedule of Expenditures of Federal Awards Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provide Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year Period 2 TIN#237224698 Federa...

Finding 2022-002: Preparation of Schedule of Expenditures of Federal Awards Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provide Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year Period 2 TIN#237224698 Federal Financial Assistance Listing/CFDA Number: 93.498 Finding Summary: The Organization does not have an internal control system designed to provide for a complete and accurate schedule being audited. We were requested to draft the schedule and notes to the schedule. Responsible Individuals: Megan Simmons, CFO Corrective Action Plan: Management agrees with the finding. However, management feels that committing the resources necessary to remain current on SEFA reporting requirements and corresponding footnote disclosures would lack benefit in relation to the cost, but will continue to evaluate on a regular basis. Anticipated Completion Date: Ongoing

View Audit 35066

Finding 32145 (2022-002)

Significant Deficiency 2022

College of Mount Saint Vincent

NY

Student Financial Aid Special Tests & Provisions Eligibility

In regard to the two students who were never reported as graduated, the College did in fact submit the required documentation to the National Student Clearinghouse (?NSC?) for further processing to the NSLDS, but the updates were reported as rejected due to errors by the NSLDS. The College has updat...

In regard to the two students who were never reported as graduated, the College did in fact submit the required documentation to the National Student Clearinghouse (?NSC?) for further processing to the NSLDS, but the updates were reported as rejected due to errors by the NSLDS. The College has updated the students' records on the NSC and will monitor the NSLDS portal weekly to ensure that all student updates are processed and correct on both the campus and program levels. In regard to the publication of the length of the Master?s level program, the College is revising its documentation and publication of the length of the Master?s program to reflect adjustments to the program that reduced the amount of time needed to complete the program. In addition, the College?s student information system was reviewed/updated to accurately reflect the published length for each program. To assure that the information is being transmitted correctly, the College will monitor the next six months of enrollment updates to ensure that each student, in the different programs, has the correct publication program length.

View Audit 31463

Finding 32144 (2022-001)

Significant Deficiency 2022

College of Mount Saint Vincent

NY

Student Financial Aid Reporting Significant Deficiency

The College reviewed and updated the effectiveness of its procedures governing the reporting of Federal Direct Loan and Pell Grant disbursements to COD no later than 15 days after disbursements to students. The College is reporting the disbursements to COD within the 15-day timeframe to allow for mo...

The College reviewed and updated the effectiveness of its procedures governing the reporting of Federal Direct Loan and Pell Grant disbursements to COD no later than 15 days after disbursements to students. The College is reporting the disbursements to COD within the 15-day timeframe to allow for more timely drawdowns of federal funds. Those measures were and continue to be to extract and submit reporting to COD on a minimum weekly basis (with a goal of daily) to remain within the 15-day reporting requirement. Between the 2021-2022 aid years, the College?s Financial Aid department has experienced the leadership transition of three directors, and our current Director is identifying and implementing process refinements to previous steps taken to further improve internal controls. Further, the College has taken steps to both continue and enhance ongoing staff professional development sessions and training. In addition, the College contracted a Financial Aid consultant in the Fall of 2022 for an assessment of our system configurations and processes. The consultant has been retained to undertake a quarterly review of our setups and processes and assist in training the team. In accordance with best practices, Financial Aid?s goal is to continue to eliminate such errors. The findings continue to be addressed.

View Audit 31463

Finding 32083 (2022-005)

Significant Deficiency 2022

Southern Maryland Tri-County Community Action Committee, Inc.

MD

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.501

Finding Reference: 2022-005 Federal Agency: Department of Health and Human Services Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Federal Program: Impacts All Federal...

Finding Reference: 2022-005 Federal Agency: Department of Health and Human Services Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Federal Program: Impacts All Federal Award Programs Grant Award: Various Condition/Context: The single audit report was not submitted to the Office Management and Budget in accordance with the reporting requirement. Criteria: COSO/Internal Control Framework defines control activities as ?policies and procedures that help ensures management?s directives are carried out? This would include preparation of the Schedule of Expenditures of Federal Awards and the related Data Collection Form in a timely manner. Uniform Guidance 2 CFR 200.501 states that the audit shall be completed, and the data collection form shall be submitted within the earlier of 30 days after the receipt of the auditor?s report, or nine months after the end of the audit period. Accordingly, audits for fiscal years ending June 30, 2022 would be due on March 31, 2023. Cause: The single audit report was not submitted due to delays in year-end closing entries, schedules, and reconciliations. Effect: As a result of the finding, SMTCCAC did not provide required information to its federal oversight agency in a timely manner. Questioned Costs: None Recommendation: We believe that the year-end closing process could proceed in a timely manner by adhering to a closing schedule and maintaining timely account reconciliations. Progress should be monitored by management to determine that due dates are being met and required reports are submitted to regulatory agencies within the compliance time frame. Views of Responsible Officials and Planned Corrective Actions: See Corrective Action Plans section.

View Audit 32240

Finding 32082 (2022-001)

Significant Deficiency 2022

The Church Home of the Protestant Episcopal Church in the City of Roch

NY

Questioned Costs Reporting Material Weakness

Cause The Home included certain eligible expenses in its Provider Relief Fund reports due to evolving guidance and availability of funding streams at the time the reporting was due for the year ended December 31, 2021, at which time the Home was not pursuing reimbursement for these eligible expenses...

Cause The Home included certain eligible expenses in its Provider Relief Fund reports due to evolving guidance and availability of funding streams at the time the reporting was due for the year ended December 31, 2021, at which time the Home was not pursuing reimbursement for these eligible expenses from the Federal Emergency Management Agency (FEMA). Upon further guidance and clarification of available funds, the Home ultimately pursued reimbursement of these eligible expenses through FEMA. Effect While the Home incurred more than sufficient eligible expenditures and lost revenues to exhibit that the Home?s funds were fully utilized, the expenses claimed for reimbursement through FEMA are, in part, duplicated with expenses claimed for PRF funding. Recommendation We recommend that the Home maintain documentation that ensures they incurred enough eligible expenditures above and beyond amounts claimed for FEMA funding and lost revenue to continue to qualify for the full amount of the PRF funding, even though the expenditures claimed on the PRF reports were also claimed for FEMA funding. Management?s Response If these expenses were not included in the claim for PRF funding, the Home would have been eligible to apply these applicable funds against its lost revenue for the period being reported.

View Audit 31459 Questioned Costs: $1

Finding 32078 (2022-001)

Material Weakness 2022

Hood Canal School District No. 404

WA

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with wage rate requirements. Name, address, and telephone of District contact person: Jeanie Beebe, Director of Finance and Operations 111 N State Rt 106 Shelton, WA 98584 (36...

Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with wage rate requirements. Name, address, and telephone of District contact person: Jeanie Beebe, Director of Finance and Operations 111 N State Rt 106 Shelton, WA 98584 (360) 877-5463 Corrective action the auditee plans to take in response to the finding: The District concurs with the finding. Corrective action will include inserting a prevailing wage rate clause into all federally funded contracts, as well as collecting and reviewing all weekly certified payroll reports in a timely manner from all contractors and subcontractors to verify that prevailing wage was paid. Anticipated date to complete the corrective action: May 17, 2023

View Audit 27938

Corrective Action Plans

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