Corrective Action Plans

Finding 7744 (2021-008)

Material Weakness 2021

PA

Questioned Costs Reporting Allowable Costs / Cost Principles

U.S. Department of Health and Human Services 2021-008 Immunization Cooperation Agreements – Assistance Listing No. 93.268 Condition and Context: While testing allowable costs relating to payroll expenditures, transactions were identified that could not be appropriately re-calculated per the amount t...

U.S. Department of Health and Human Services 2021-008 Immunization Cooperation Agreements – Assistance Listing No. 93.268 Condition and Context: While testing allowable costs relating to payroll expenditures, transactions were identified that could not be appropriately re-calculated per the amount that was charged to the grant. The County was not able to provide support for payroll expenditure amounts charged to the grant on an individual employee basis. Recommendation: We recommend management should review the process of timekeeping for grant eligible employees for daily time input, as well as grant authorized wages. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will develop a written process for time tracking for grant-eligible employees and will provide training to grant-funded departments in order to ensure that all payroll expenditures charged to the grant are eligible, authorized, and charged on an individual employee basis. Project codes in Infor will allow salary distribution and personnel information to be assigned to each grant. Where possible, this function will be used to assist in supporting the amounts charged to the grant program. The general accounting department will work with departments to ensure they are properly using Labor Allocations to keep track of individuals assigned to particular grants along with documentation of time worked and pay received. Name(s) of the contact person(s) responsible for corrective action: Thomas Landauer Planned completion date for corrective action plan: March 2024

View Audit 10111 Questioned Costs: $1

Finding 7724 (2021-007)

Significant Deficiency 2021

County of Montgomery

PA

Reporting Significant Deficiency

U.S. Department of Housing and Urban Development 2021-007 Community Development Block Grant – Assistance Listing No. 14.218 Condition and Context: While testing the reporting requirements, CLA noted one of the two quarterly 'Cash on Hand' reports was submitted more than 10 days after the quarter end...

U.S. Department of Housing and Urban Development 2021-007 Community Development Block Grant – Assistance Listing No. 14.218 Condition and Context: While testing the reporting requirements, CLA noted one of the two quarterly 'Cash on Hand' reports was submitted more than 10 days after the quarter end. The U.S. Department of Housing and Urban Development expects that the PR29, CDBG-CV Cash on Hand Quarterly Report will meet this ongoing reporting requirement which are due no later than 10 days after the end of each calendar quarter. The report due 7/10/2021 was submitted on 8/30/2021. Recommendation: We recommend management should review the process for submitting CDBG reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Deputy Controller of Grant Accounting will provide training to grant funded-departments to stress the importance of compliance with grant requirements including reporting requirements. The Grant Accountant will regular reviews of each department to ensure required reporting is County of Montgomery November 27, 2023 submitted on time and will work with non-compliant departments to establish a corrective action plan for late reporting. Name(s) of the contact person(s) responsible for corrective action: Thomas Landauer Planned completion date for corrective action plan: January 2024

View Audit 10111

Finding 7723 (2021-006)

Significant Deficiency 2021

County of Montgomery

PA

Reporting Significant Deficiency

U.S. Department of Housing and Urban Development 2021-006 Community Development Block Grant – Assistance Listing No. 14.218 Condition and Context: The expense detail provided was based on the cash basis instead of the accrual basis. As a result, the SEFA did not capture expense during the year corre...

U.S. Department of Housing and Urban Development 2021-006 Community Development Block Grant – Assistance Listing No. 14.218 Condition and Context: The expense detail provided was based on the cash basis instead of the accrual basis. As a result, the SEFA did not capture expense during the year correctly. While performing the SEFA tie out of the CDBG grants, it was noted that federal expenditures were reported on the cash basis, based on the program year instead of the county's fiscal year. Recommendation: We recommend management reviews the process of recording federal expenditures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A Deputy Controller of Grant Accounting was hired in February 2023 and is responsible for establishing processes, providing training, and working with grant-funded departments to ensure the proper recording of federal expenditures. The County is reviewing and updating the post-award Grant Accounting Policies including the treatment of grant expenditures and revenues to ensure a consistent grant accounting process. The process for recording federal expenditures will be formalized and regular training and oversight will be provided to County grant staff to ensure that federal grant expenditures reported on the SEFA are reported on the accrual basis. Continued utilization of the Infor Grant Management System, including the assignment of individual Project Codes to each grant, will allow department grant staff to identify and isolate federal expenditures in Infor. Name(s) of the contact person(s) responsible for corrective action: Thomas Landauer Planned completion date for corrective action plan: January 2024

View Audit 10111

Finding 7722 (2021-004)

Significant Deficiency 2021

County of Montgomery

PA

Reporting Significant Deficiency Internal Control / Segregation of Duties

U.S. Department of the Treasury, U.S. Department of Labor, U.S. Department of Transportation, U.S. Department of Health and Human Services 2021-004 Various Federal Programs – Assistance Listing Nos. 14.218, 21.019, 21.023, 93.268, 93.323, 93.563, 93.658 Condition and Context: The County’s single aud...

U.S. Department of the Treasury, U.S. Department of Labor, U.S. Department of Transportation, U.S. Department of Health and Human Services 2021-004 Various Federal Programs – Assistance Listing Nos. 14.218, 21.019, 21.023, 93.268, 93.323, 93.563, 93.658 Condition and Context: The County’s single audit and reporting package was delayed for the year ended December 31, 2021, beyond the due date. Recommendation: The County should evaluate its procedures around timely submission of the single audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County is implementing best practices in grant administration to ensure the timely submission of the Single Audit. A Deputy Controller, Grant Accounting was hired in February 2023. This position provides oversight, training, communications and regular review of grant receivables and expenditures, along with their inclusion in the General Ledger. Additionally, continued use of Infor’s grant management system and Project codes will increase efficiency in accurately completing the SEFA and providing documentation as requested for programs being audited. The County began implementing a grant accounting system as part of our implementation of Infor in mid-2021 and will continue to roll out this system to departments who receive grants but not yet utilizing the system to track their grants. Immediately upon completion of the 2021 SEFA in May 2023, the County invested in additional temporary accounting staff to assist with preparation of the 2022 SEFA, which is complete as of November 2023. We will work with CLA to ensure the 2022 Single Audit can be completed timely with a submission goal of mid-2023. County staff will begin preparation of the 2023 SEFA in early 2024 and will work with CLA toward an on-time submission of the 2023 Single Audit by September 30, 2024. Name(s) of the contact person(s) responsible for corrective action: Thomas Landauer and Dean Dortone Planned completion date for corrective action plan: January 2024

View Audit 10111

Finding 7717 (2021-001)

Material Weakness 2021

Breathitt County Fiscal Court

KY

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.303

County Judge/Executive’s Response: The Breathitt County Fiscal Court has hired a new County Treasurer since the completion of the 2021 audit who will ensure stronger internal controls are maintained in her official capacity and will be working with additional staff members, such as the Finance Offic...

County Judge/Executive’s Response: The Breathitt County Fiscal Court has hired a new County Treasurer since the completion of the 2021 audit who will ensure stronger internal controls are maintained in her official capacity and will be working with additional staff members, such as the Finance Officer and Occupational Tax Administrator, to segregate duties in a more controlled method. The newly hired County Treasurer will work to resolve the following issues by the end of the calendar year in the following manner. Failure to perform accurate reconciliations - the new Treasurer has already begun to perform accurate reconciliations at the end of each month. Tax obligations not paid timely - the new Treasurer has already implemented a system for paying obligations by the deadline. Failure to maintain accounting records - the Former Treasurer began the process of reporting & record maintenance for the Justice Center Corporation Fund and the new Treasurer is continuing with this reporting method. This was implemented at the end of 2022. Failure to prepare financial statements timely - the new Treasurer will complete the annual statement in accordance with KRS 68.020 in a timely manner. Failure to prepare an accurate Schedule of Expenditures of Federal Awards (SEFA) - the new Treasurer will complete SEFA's accurately. Disbursements issues: o Segregation of duties is currently being reviewed and the new Treasurer is establishing a process for review and approval of disbursements that will allow for stronger internal controls. New system will be in place by the end of the calendar year. The Breathitt County Fiscal Court has also begun utilizing [software name redacted] as the primary accounting software which will allow for more consistent tracking of purchase orders and permit better tracking of obligated expenses. Supporting documentation will be kept for all transactions, including credit card transactions. Invoices will be paid in a timely manner - great strides have already been made in this area with the hiring of the new Treasurer but will continue to improve during the remainder of the calendar year 2023. The Breathitt County Fiscal Court adopted the KY Model Procurement code in August 2023. With the hiring of a new Applicant Agent in January 2023 and a new Treasurer in July 2023 proper bid documentation is already being maintained and procurement policies are being followed. An encumbrance list will be maintained by the new Treasurer. Payroll issues: o Annual pay rate lists will be maintained & approved at the first regular meeting of the Breathitt County Fiscal Court each January. New County Treasurer will ensure that payments moving forward do not exceed statutory maximums. All lump sum payments made to employees will be issued using W2's, moving forward, beginning in November 2023.

View Audit 10097

Finding 7626 (2021-008)

Material Weakness 2021

Memorial Hospital of Texas County Authority

OK

Material Weakness Reporting

In the future, we will develop a spreadsheet to calculate lost revenues as necessary based on applicable guidance. We will be sure to include this calculation in the reporting submission even if we feel expenditures are adequate to cover the federal award received.

View Audit 10000

Finding 7624 (2021-006)

Material Weakness 2021

Memorial Hospital of Texas County Authority

OK

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment

In the future, we will only use actual amounts for items that have been purchased. In addition, amounts will be reviewed against the funding guidance to make sure they are within the period of availability.

View Audit 10000 Questioned Costs: $1

Finding 7623 (2021-005)

Material Weakness 2021

Memorial Hospital of Texas County Authority

OK

Questioned Costs Allowable Costs / Cost Principles Material Weakness

We used the initial PRF reporting guidelines that indicated that the PRFs could be used to maintain health care service delivery. Due to limited staff, including staff turnover, and the need to focus our efforts on maintaining health care delivery including caring for COVID‐19 patients, we were not ...

We used the initial PRF reporting guidelines that indicated that the PRFs could be used to maintain health care service delivery. Due to limited staff, including staff turnover, and the need to focus our efforts on maintaining health care delivery including caring for COVID‐19 patients, we were not able to keep up with the continuously changing guidance pertaining to the use of the PRF. For future federal funding, we plan to more closely monitor the guidelines surrounding the funding and work with outside consultants for new federal programs or those programs that have constantly changing guidance.

View Audit 10000 Questioned Costs: $1

Finding 7622 (2021-004)

Significant Deficiency 2021

Memorial Hospital of Texas County Authority

OK

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

See corrective action plan for finding 2021‐002 and 2021‐003. 2021-002 In FY 2020, the Authority implemented procedures requiring a payment request form approval form be included with all cash disbursements documenting the levels of approval required for each invoice, which must be attached and ke...

See corrective action plan for finding 2021‐002 and 2021‐003. 2021-002 In FY 2020, the Authority implemented procedures requiring a payment request form approval form be included with all cash disbursements documenting the levels of approval required for each invoice, which must be attached and kept with the invoice and check stub. No payments should be processed by Accounts Payable without the properly completed payment request form. Action: 1) Written policy will be created by accounting department and communicated to both leadership team and accounting department. 2021-003 It is not cost effective for the Authority to justify staffing the number of positions necessary to have proper segregation of duties over cash disbursements. The Authority is aware of the lack of segregation of duties. The Board of Trustees and management will keep close supervision and review of accounting information as best means of preventing and detecting errors and irregularities.

View Audit 10000

Finding 7490 (2021-001)

None 2021

Air Force Retired Officers Community – Washington, D.c. Dba Falcons Landing

VA

Subrecipient Monitoring Reporting § 200.512

Corrective Action Plan Finding 2021-001 – Reporting - Submission of the Data Collection Form Air Force Retired Officers Community – Washington, D.C. DBA Falcons Landing (the Organization) hereby acknowledges the Organization’s audit reporting package was not submitted by the filing deadline of Se...

Corrective Action Plan Finding 2021-001 – Reporting - Submission of the Data Collection Form Air Force Retired Officers Community – Washington, D.C. DBA Falcons Landing (the Organization) hereby acknowledges the Organization’s audit reporting package was not submitted by the filing deadline of September 30, 2022. The Organization will file the reporting package shortly after issuance and ensure that any future audits are completed and filed timely, by working closely with our audit partner and frequently accessing the substantive status, stage of completion or any other pertinent aspect of the audit necessary to meet the filing deadline. Anticipated Completion Date The Organization anticipates submission of the audit and data collection form immediately upon completion. Individual Responsible for Corrective Action Plan Hardy Lister, Chief Financial Officer

View Audit 9678

Finding 7170 (2021-006)

Significant Deficiency 2021

Commonwealth of Puerto Rico - Department of the Family

PR

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Cash Management

There were multiple lockdowns executiver orders that impacted business, no school or day care and ADSEF case managers were called to work on a gradual basis on February 2021. Only essential workers were active. At the time of the Pandemic, the cases were evaluated in the regional offices based on th...

There were multiple lockdowns executiver orders that impacted business, no school or day care and ADSEF case managers were called to work on a gradual basis on February 2021. Only essential workers were active. At the time of the Pandemic, the cases were evaluated in the regional offices based on the minimum citeria, then they were sent to the Central Level offices to the Medical Board for evaluation. Given to this situation Single Audits started latre since it depends on the personnel to be present at the local and regional offices.

View Audit 9287

Finding 7168 (2021-001)

Material Weakness 2021

Commonwealth of Puerto Rico - Department of the Family

PR

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.327 § 200.328

A Financial System Enterprise Resource Planning (ERP) has been selected for implementation which will connect financial processes between the Puerto Rico Treasury Department and ADSEF fo facilitate the compliance with the required time frame. The training started on January 2023, and will continue u...

A Financial System Enterprise Resource Planning (ERP) has been selected for implementation which will connect financial processes between the Puerto Rico Treasury Department and ADSEF fo facilitate the compliance with the required time frame. The training started on January 2023, and will continue until implementation in 2024. (ERP SYSTEM) Achieve the centralization of the fiscal and accounting systems of the agencies, instrumentalities, and public corporations to facilitate access to financial information for the Government of Puerto Rico. The ERP will lead the government to prepare and publish audited financial statements in a timely manner, and therefore, ensure that PR has access to financial markets again. During these sessions of work ADSEF has participated in several trainings with new and updated information. Centralize Government financial systems Integrate finance, buy, human capital management and payroll modules into a single platform.

View Audit 9287

Finding 7092 (2021-007)

Significant Deficiency 2021

Plaza Nursing Home Company, Inc.

NY

Reporting

In May 2022, a new CFO was hired and new procedures put in place. Both the CFO and Accounting Manager ensured all calculations are dual reviewed. Based on this process, it is well documented internally that the entity does indeed qualify for the full amount of funding received.

View Audit 9116

Finding 7091 (2021-006)

Significant Deficiency 2021

Plaza Nursing Home Company, Inc.

NY

Reporting Allowable Costs / Cost Principles § 200.303

In May 2022, a new CFO was hired and new procedures put in place. Both the CFO and Accounting Manager ensured all calculations are dual reviewed. Based on this process, it is well documented internally that the entity does indeed qualify for the full amount of funding received.

View Audit 9116

Finding 7090 (2021-005)

Significant Deficiency 2021

Plaza Nursing Home Company, Inc.

NY

Reporting Period of Performance

In May 2022, a new CFO was hired and new procedures put in place. Both the CFO and Accounting Manager both have reviewed eligible expenditures and loss revenue to ensure entity does indeed qualify for the full amount of funding, regardless of the information that was submitted on the respective repo...

In May 2022, a new CFO was hired and new procedures put in place. Both the CFO and Accounting Manager both have reviewed eligible expenditures and loss revenue to ensure entity does indeed qualify for the full amount of funding, regardless of the information that was submitted on the respective reports.

View Audit 9116

Finding 7089 (2021-004)

Significant Deficiency 2021

Plaza Nursing Home Company, Inc.

NY

Subrecipient Monitoring Reporting § 200.512

In May 2022, a new CFO was hired and new procedures put in place. All reporting requirements are tracked by both the CFO as well as the Accounting Manager and reviewed on a monthly basis.

View Audit 9116

Finding 7088 (2021-006)

Significant Deficiency 2021

Iroquois Nursing Home, Inc.

NY

Reporting Allowable Costs / Cost Principles § 200.303

In May 2022, a new CFO was hired and new procedures put in place. Both the CFO and Accounting Manager ensured all calculations are dual reviewed. Based on this process, it is well documented internally that the entity does indeed qualify for the full amount of funding received.

View Audit 9115

Finding 7087 (2021-005)

Significant Deficiency 2021

Iroquois Nursing Home, Inc.

NY

Reporting Period of Performance

In May 2022, a new CFO was hired and new procedures put in place. Both the CFO and Accounting Manager both have reviewed eligible expenditures and loss revenue to ensure entity does indeed qualify for the full amount of funding, regardless of the information that was submitted on the respective repo...

In May 2022, a new CFO was hired and new procedures put in place. Both the CFO and Accounting Manager both have reviewed eligible expenditures and loss revenue to ensure entity does indeed qualify for the full amount of funding, regardless of the information that was submitted on the respective reports.

View Audit 9115

Finding 7086 (2021-004)

Significant Deficiency 2021

Iroquois Nursing Home, Inc.

NY

Subrecipient Monitoring Reporting § 200.512

In May 2022, a new CFO was hired and new procedures put in place. All reporting requirements are tracked by both the CFO as well as the Accounting Manager and reviewed on a monthly basis.

View Audit 9115

Finding 6624 (2021-007)

Significant Deficiency 2021

Sunny Vista Living Center

CO

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

We recommend that management review all expenditures for federal awards for accuracy under the criteria provided by the U.S. Department of Health and Human Services to ensure all supporting documentation is properly maintained and all errors are identified and corrected timely. The Organization co...

We recommend that management review all expenditures for federal awards for accuracy under the criteria provided by the U.S. Department of Health and Human Services to ensure all supporting documentation is properly maintained and all errors are identified and corrected timely. The Organization concurs with this recommendation. Management will review calculations and supporting documentation for all expenditures for federal awards to ensure accuracy in future reporting.

View Audit 8554

Finding 6623 (2021-006)

Significant Deficiency 2021

Sunny Vista Living Center

CO

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles

We recommend the Organization put processes in place to ensure accurate portal reporting under the grant. We also recommend monitoring future reporting within the portal to ensure the allocation of expenses attributable to coronavirus and lost revenues are accurately updated. The Organization con...

We recommend the Organization put processes in place to ensure accurate portal reporting under the grant. We also recommend monitoring future reporting within the portal to ensure the allocation of expenses attributable to coronavirus and lost revenues are accurately updated. The Organization concurs with this recommendation. Management will implement a control over the preparation and review over the completion and submission of the special reports to the government website. The submission will be prepared and documented and will be reviewed by another experienced individual. Any comments will be documented and followed up by staff documenting and evidencing the review.

View Audit 8554

Finding 6622 (2021-005)

Significant Deficiency 2021

Sunny Vista Living Center

CO

Reporting Significant Deficiency Internal Control / Segregation of Duties

We recommend the Organization put processes in place over reporting to ensure timely submission of the audit report. The Organization concurs with this recommendation. Management will put processes into place to ensure timely submission of the audit report prior to the reporting deadline.

View Audit 8554

Finding 6572 (2021-001)

None 2021

Winnebago Housing Development Commission, INC

NE

Reporting Special Tests & Provisions

WINNEBAGO HOUSING AND DEVELOPMENT COMMISSION 100 South Elm Circle, P.O. Box 671 Winnebago, NE 68071 402-878-2241 CORRECTIVE ACTION PLAN September 15, 2023 U.S. Department of Treasury Winnebago Housing and Development Commission respectfully submits the following corrective action plan for the year ...

WINNEBAGO HOUSING AND DEVELOPMENT COMMISSION 100 South Elm Circle, P.O. Box 671 Winnebago, NE 68071 402-878-2241 CORRECTIVE ACTION PLAN September 15, 2023 U.S. Department of Treasury Winnebago Housing and Development Commission respectfully submits the following corrective action plan for the year ended December 31, 2021. Name and address of independent public accounting firm: Midwest Professionals, PLLC 215 South Court Avenue Gaylord, MI 49735 Audit period: January 1, 2021 – December 31, 2021 The findings from the 2021 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Major Federal Program Audit 2021-001 Late Single Audit Submission Condition: The Development Commission’s audit was not completed and the data collection form and reporting package were not submitted within nine months after the end of the audit period. Recommendation: Obtain the services of a new Finance Manager who will coordinate the close out of the year end financials with the fee accountant so the books are closed prior to the start of the FY2023 audit. Action Taken: The Commission has sought to employ additional personnel in the finance department to assume the past finance manager’s responsibilities. The Commission is hopeful that the additional personnel is able to provide the fee accountant sufficient information to allow for timely financials to be produced and thus facilitate the submission of a timely audit reports in the future. If you should have any questions regarding the plan, please call Dana Zagurski at (402) 878- 2241. Sincerely, Dana Zagurski, Executive Director 100 S. Elm Circle Winnebago, NE 68071 Tel. (775) 964-6020

View Audit 8509

Finding 6220 (2021-006)

Material Weakness 2021

District of Columbia Housing Authority

MD

HUD Housing Programs Material Weakness Reporting

Recommendation: We recommend the Authority implements controls to ensure that recertifications are uploaded to PIC in accordance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken/planned in response to finding: ...

Recommendation: We recommend the Authority implements controls to ensure that recertifications are uploaded to PIC in accordance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken/planned in response to finding: HCVP continues to transmit all 50058 transactions to PIC on a weekly basis and review PIC error reports for corrections needed. Any identified errors are assigned to specific staff for correction within 5 business days. The PIC coordinator will confirm corrections are submitted and accepted in PIC. A monthly report will be provided to the Senior VP summarizing the number of transmissions, errors, and status of corrections. Name of the contact person responsible for corrective action: Khaliah Payne Planned completion date for corrective action plan: Ongoing until all PIC errors are addressed/resolved as needed.

View Audit 8175

Finding 6210 (2021-005)

Material Weakness 2021

District of Columbia Housing Authority

MD

HUD Housing Programs Material Weakness Reporting

Recommendation: We recommend the Authority implements controls to ensure that recertifications are uploaded to PIC in accordance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken/planned in response to finding: ...

Recommendation: We recommend the Authority implements controls to ensure that recertifications are uploaded to PIC in accordance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken/planned in response to finding: HCVP continues to transmit all 50058 transactions to PIC on a weekly basis and review PIC error reports for corrections needed. Any identified errors are assigned to specific staff for correction within 5 business days. The PIC coordinator will confirm corrections are submitted and accepted in PIC. A monthly report will be provided to the Senior VP summarizing the number of transmissions, errors, and status of corrections. Name of the contact person responsible for corrective action: Khaliah Payne Planned completion date for corrective action plan: Ongoing until all PIC errors are addressed/resolved as needed.

View Audit 8175

Corrective Action Plans

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