Corrective Action Plans

Finding 31321 (2022-003)

Material Weakness 2022

Community College District of Monroe County, Michigan

MI

Reporting Material Weakness § 200.502 § 200.510

Condition: During the audit, significant adjustments were identified and proprosed (which were approved and posted by management) to adjust the College's general ledger to the appropriate balances. Planned Corrective Action: A detailed business procedure will be written and implemented that expre...

Condition: During the audit, significant adjustments were identified and proprosed (which were approved and posted by management) to adjust the College's general ledger to the appropriate balances. Planned Corrective Action: A detailed business procedure will be written and implemented that expressly lists how to handle year-end audit as it relates to both the Annual Financial Audit and teh Single Audit. The procedure will include processes for quarterly balancing and review, at a minimum. The procedure will include the creation of the annual SEFA document to be used by auditors in determining what programs the College has been awarded and what expenditures have been made. It will also include who is to handle all pieces of the audit and preparation in the absence of the Director of Financial Services. Contact person responsible for corrective actions: Dana Blair, Director of Financial Services Anticipated Completion Date: January 15, 2023

View Audit 30283

Finding 31320 (2022-002)

Significant Deficiency 2022

Swift County-Benson Hospital

MN

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Finding 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 4 TIN #411670269 Federal Financial Assistance Listing: #93.498 Finding...

Finding 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 4 TIN #411670269 Federal Financial Assistance Listing: #93.498 Finding Summary: The Organization?s expense workbook and special reports submitted to the Department of Health and Human Services for Period 4 were not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Andrea Smart, Vice President of Financial Services and Treasury. Corrective Action Plan: Management will implement a control process which includes a secondary review and approval of any future summarized final expenditure listing used to claim the allowable costs under the federal program. Anticipated Completion Date: September 26, 2023.

View Audit 26844

Finding 31317 (2022-003)

Material Weakness 2022

Madison Community Hospital

SD

Reporting Material Weakness Matching / Level of Effort / Earmarking

Finding 2022-003 Finding Summary: The System does not have an internal control system designed to provide for the preparation of the schedule of expenditures of federal awards (the schedule). As auditors, we were requested to assist with the preparation of the schedule. Responsible Individuals: Te...

Finding 2022-003 Finding Summary: The System does not have an internal control system designed to provide for the preparation of the schedule of expenditures of federal awards (the schedule). As auditors, we were requested to assist with the preparation of the schedule. Responsible Individuals: Teresa Mallett, CFO Corrective Action Plan Madison Regional Health System does not have an internal control designed to provide for the preparation of the schedule and engages Eide Bailly to assist in the preparation of the schedule. This not unusual as the schedule has unique and specialized requirements and preparation is only required when Madison Regional Health System meets a specific threshold of federal expenditures. Madison Regional Health System would most like not be able to draft the schedule without the assistance of Eide Bailly. Management and the Board of Directors is aware of this finding and accepts the risk associated with the finding.

View Audit 31969

Finding 31316 (2022-001)

Material Weakness 2022

Catholic Charities West Virginia,inc.

WV

Material Weakness Reporting Internal Control / Segregation of Duties

2022-001 Grant Revenue Condition: Catholic Charities West Virginia erroneously applied conditional contribution guidance to certain grants which did not meet the criteria for conditional contributions. This caused an overstatement of current year grant revenues and refundable advances, and an unders...

2022-001 Grant Revenue Condition: Catholic Charities West Virginia erroneously applied conditional contribution guidance to certain grants which did not meet the criteria for conditional contributions. This caused an overstatement of current year grant revenues and refundable advances, and an understatement of current year accounts receivable and net assets, along with a restatement of the prior year balances as described in Note 2 to the financial statements. Recommendation: We recommend that management review its policies and procedures surrounding grant revenue accounting to ensure recorded amounts are in accordance with accounting principles generally accepted in the United States of America (GAAP). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have reviewed grant revenue guidance with staff and implemented procedures to ensure that contributions and grants are properly recognized as conditional or unconditional. Name(s) of the contact person(s) responsible for corrective action: Danielle Doerr Planned completion date for corrective action plan: February 3, 2023

View Audit 31968

Finding 31292 (2022-006)

Material Weakness 2022

Lawton Independent School District No. 8

OK

Questioned Costs Reporting § 200.430

This is a repeat finding from FY2021 (2021-004). The finding was identified during our 2021 audit and corrected in March of 2022. It is important to note that, the United States Department of Education?s ?Frequently Asked Questions Elementary and Secondary School Emergency Relief Programs Governor?s...

This is a repeat finding from FY2021 (2021-004). The finding was identified during our 2021 audit and corrected in March of 2022. It is important to note that, the United States Department of Education?s ?Frequently Asked Questions Elementary and Secondary School Emergency Relief Programs Governor?s Emergency Education Relief Programs? dated May 26, 2021 stated on page 19 that ?An LEA must maintain time distribution records (sometimes called ?time and effort? reporting) only if an individual employee is splitting his or her time between activities that may be funded under ESSER or GEER and activities that are not allowable under the applicable program.? After the 2021 was complete and 2022 was significantly underway, the auditor indicated that time-and-effort was required and the auditor stated that SDE agreed. Therefore, the district began obtaining time-and-effort for employees paid with federal funds in March of 2022, regardless of SDE and USDE guidance stating otherwise.

View Audit 35938 Questioned Costs: $1

Finding 31268 (2022-003)

Material Weakness 2022

North Park University

IL

Reporting Student Financial Aid Eligibility

Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: To date all past due enrollment and graduate reports have been filed with the National Student Clearinghouse (NSC). The Registrar?s Office is currently clearing any and all error resolution reports that are...

Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: To date all past due enrollment and graduate reports have been filed with the National Student Clearinghouse (NSC). The Registrar?s Office is currently clearing any and all error resolution reports that are generated for each submission. This week the May 2022 graduates error report was cleared. This leaves the summer and fall terms of 2022 to be corrected. Those should be resolved no later than 5/15/2023. The Registrar?s Office reported the spring 2023 reports and are back on a transmission schedule. Person Responsible for Corrective Action Plan: Ann Marie Vickery ? Interim Registrar Anticipated Date of Completion: 5/15/2023

View Audit 32190

Finding 31264 (2022-003)

Significant Deficiency 2022

Stockton Port District

CA

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

Finding 2022-003 Federal Agency: U.S. Department of Homeland Security Federal Financial Assistance Listing: 97.056 Applicable Federal Award Number: EMW-2019-PU-00447 & EMW-2020-PU-00288 Program Name: Port Security Grants Program Compliance Requirement: Reporting Type of Finding: Significant Deficien...

Finding 2022-003 Federal Agency: U.S. Department of Homeland Security Federal Financial Assistance Listing: 97.056 Applicable Federal Award Number: EMW-2019-PU-00447 & EMW-2020-PU-00288 Program Name: Port Security Grants Program Compliance Requirement: Reporting Type of Finding: Significant Deficiency, Instance of Non-compliance Views of Responsible Officials: We concur. Corrective Action Plan: Update reporting procedures to include documentation of the individual that prepared the semi-annual performance reports Responsible Individual(s): Steve Larson, Grants Manager Jeff Wingfield, Deputy Port Director, Regulatory & Public Affairs Anticipated Completion Date: Procedures to be updated by March 31, 2023.

View Audit 30245

Finding 31249 (2022-003)

Significant Deficiency 2022

Newbury Elderly Housing, Inc.

NH

Allowable Costs / Cost Principles Reporting Significant Deficiency

Finding 2022-003: Plan: Shortages in staffing resulted in incomplete implementation of con-ective action plan in 2021. Documentation and differentiation of job duties for Director of Housing and Project Manager will continue to be developed and implemented. Documentation of non-site-based housing st...

Finding 2022-003: Plan: Shortages in staffing resulted in incomplete implementation of con-ective action plan in 2021. Documentation and differentiation of job duties for Director of Housing and Project Manager will continue to be developed and implemented. Documentation of non-site-based housing staff members allocation of time to a prope1iy will continue to be implemented and refined. Anticipated Completion: December 31, 2022 ( ongoing) Contact: Jill Lesmerises, Chief Fiscal Officer Michael Tabory, Chief Operating Officer

View Audit 26553

Finding 31248 (2022-002)

None 2022

Newbury Elderly Housing, Inc.

NH

HUD Housing Programs Reporting

Finding 2022-002: Plan: Director of Housing will monitor/review a 10% sample of all recertifications. Program staff will proactively ask for peer review or program director review of any recertifications with complex income and rent calculations. Ongoing training will continue for all program staff....

Finding 2022-002: Plan: Director of Housing will monitor/review a 10% sample of all recertifications. Program staff will proactively ask for peer review or program director review of any recertifications with complex income and rent calculations. Ongoing training will continue for all program staff. Anticipated Completion: December 31 , 2022 ( ongoing) Contact: Jill Lesmerises, Chief Fiscal Officer Michael Tabory, Chief Operating Officer 35

View Audit 26553

Finding 31247 (2022-001)

None 2022

Newbury Elderly Housing, Inc.

NH

HUD Housing Programs Reporting Internal Control / Segregation of Duties

No corrective action necessary, completed prior to year end. See finding.

View Audit 26553

Finding 31246 (2022-001)

Significant Deficiency 2022

City of Middletown

OH

Subrecipient Monitoring Reporting

CORRECTIVE ACTION PLAN June 30, 2023 City of Middletown, Ohio respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Clark Schaefer Hackett One East Fourth St, Suite 1200 Cincinnati, Ohio 45202 Audit p...

CORRECTIVE ACTION PLAN June 30, 2023 City of Middletown, Ohio respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Clark Schaefer Hackett One East Fourth St, Suite 1200 Cincinnati, Ohio 45202 Audit period: December 31, 2022 The finding from the December 31, 2022 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Findings-Financial Statement Audit None noted Findings-Federal Award Programs Audits Significant Deficiency 2022-001 Reporting - Coronavirus State and Local Fiscal Recovery Funds Recommendation: It was recommended the City improve controls over reporting requirements associated with this program. Action Taken: We concur with the recommendation, and it will be implemented effective 4/30/23 If the there are any questions regarding this plan, please call Samantha Zimmerman, Finance Director, at 513- 425-7872.

View Audit 26943

Finding 31235 (2022-002)

Material Weakness 2022

Benton Harbor Area Schools

MI

Reporting Material Weakness § 200.303 § 200.510

Department: Grants & Finance Condition: The District did not record expenditures to the 2020-21 or 2021-22 grants in a timely manner, and internal controls over expenditures charged were not in place throughout the period during which such charges were incurred. Expenditures reported for the Title ...

Department: Grants & Finance Condition: The District did not record expenditures to the 2020-21 or 2021-22 grants in a timely manner, and internal controls over expenditures charged were not in place throughout the period during which such charges were incurred. Expenditures reported for the Title II, Part A grant in their submission to the Michigan Department of Education?s Financial Information Database (FID) did not agree with expenditures reported in the schedule of expenditures of Federal awards (SEFA) for the same period, as the District did not provide accurate information to the auditors nor did they prepare an accurate SEFA. Corrective Action: Internal controls have been implemented over the purchasing process, all grant expenditures are approved by the Grant Coordinator and Teaching and Learning Department. Grant Coordinator meets on a regular basis with the finance department to ensure that all grant related expenditures are being processed with the correct code and in the correct manner. Any discrepancies that arise are addressed immediately. Person(s) Responsible for Executing Corrective Action: ? Grant Coordinator ? Grant Accountant ? Chief of Teaching and Learning ? Finance Office Designee Anticipated Completion Date: 12/31/22

View Audit 30731

Finding 31214 (2022-001)

None 2022

Town of Winchendon, Massachusetts

MA

Subrecipient Monitoring Period of Performance Reporting § 200.344

Condition: Final financial reports were not filed in a timely manner for a Special Education Cluster grant. Corrective Action Planned: To date all grants required to be closed out have been completed. Anticipated Completion Date: 2022-2023 school year Contact: Thad King, Superintendent of Schools

View Audit 33701

Finding 31213 (2022-002)

None 2022

Nauset Regional School District

MA

Questioned Costs Reporting Subrecipient Monitoring

The District will enhance the documentation surrounding aspects of Grant compliance and formalize the documentation for approval by the School Committee. The District will adhere to the recommendation that all documentation related to the audit, including preparation of the SEFA, is prepared in a ti...

The District will enhance the documentation surrounding aspects of Grant compliance and formalize the documentation for approval by the School Committee. The District will adhere to the recommendation that all documentation related to the audit, including preparation of the SEFA, is prepared in a timely manner in order to ensure required deadlines are met.

View Audit 31438 Questioned Costs: $1

Finding 31209 (2022-001)

Significant Deficiency 2022

Puerto Rico Department of Justice

PR

Allowable Costs / Cost Principles Reporting Significant Deficiency

Below we break down the Action Plan to address finding 2022-001. We must begin our comments by informing that, on December 28, 2022, the PRDOJ formalized a professional services contract number 2023-000067 with the company Aquino, De Cordova, Alfaro & Co., LLP (Independent Auditors) to carry out th...

Below we break down the Action Plan to address finding 2022-001. We must begin our comments by informing that, on December 28, 2022, the PRDOJ formalized a professional services contract number 2023-000067 with the company Aquino, De Cordova, Alfaro & Co., LLP (Independent Auditors) to carry out the Agency financial audit process for fiscal year 2021-2022. The clause number six of the contract required that the Independent Auditors submitted on or before March 31, 2023, the final Single Audit Report required as part of the audit process. However, the PRDOJ was obliged to extend the term of the contract because the Independent Auditors could not complete the contracted services and render the Single Audit Report within the stipulated term. The Independent Auditors indicated that the delay in the delivery of the Single Audit Report was since the audit process could not be started until the contract was signed and that the information was not received in a timely manner. Despite the reasons stated by the Independent Auditors, the reality is that the Independent Auditors undertook the contractual clauses agreed in the contract and between them, the agreement to submit the final Single Audit on or before March 31, 2023. Pursuant to the provisions of contract number 2023-000067, the administration of the PRDOJ was under the understanding that the Independent Auditors would comply with the delivery term of the SingleAudit Report within the agreed term. In this way, we ensured that we hired a firm that complied with the term to submit the Single Audit Report to the Federal Audit Clearinghouse provided in federal statute 45 CFR sec. 75.512. However, it is not until the end of the month of March that we become aware that the Independent Auditors could not meet the deadline of submitting the Single Audit Report. As a result of this, the PRDOJ had to extend the contract so that the Independent Auditors could complete the Single Audit Report, take internal measures to alleviate and address the delay, and submit the PRDOJ's Single Audit Report for fiscal year 2021 to the Federal Audit Clearinghouse. Under the contextual framework outlined above, we inform our corrective action plan to finding number 2022-01 presented in the Single Audit Report. First, the PRDOJ requested in June several proposals from Independent Auditors to carry out the Agency?s financial audit process for the 2022-2023 fiscal year. Consequently, a firm of Independent Auditors was selected, and we requested all the information and documentation required at the federal and state level to contract with the government. The contract was drafted in July and will soon be signed. In addition, the new contract provides that the Independent Auditor must submit the Single Audit Report to the PRDOJ on or before March 1, 2024. In this way, the PRDOJ will have the Single Audit Report in advance and, in this way, ensure that the document is submitted before March 31, 2024, to the Federal Audit Clearinghouse.This initiative goes hand in hand with the elaboration of a rigorous and meticulous work plan between the PRDOJ and the Independent Auditors with the delivery dates and exchange of information for the preparation of the Single Audit Report. The work plan provides that the audit process will begin as soon as the contract is signed in early August. For its part, the PRDOJ must submit all the required information to the Independent Auditors before the end of December. ? Regarding the internal administrative aspects of the PRDOJ to comply with this corrective action plan, we inform that we have designated an employee of the Agency to ensure that all our dependencies and their directors submit all the information required to the Independent Auditors on time on the stipulated dates. This includes, but is not limited to, all information in the preliminary PBC and any additional information that is required by the Independent Auditors. ? Likewise, this PRDOJ employee will serve as a link between the firm of Independent Auditors and the agencies of the agency that request information and documentation. Lastly, the PRDOJ official will ensure that the Independent Auditors firm submits the Single Audit Report to the Federal Audit Clearinghouse before March 31, 2024.This is a comprehensive corrective action plan that we have prepared in coordination with all the dependencies of the PRDOJ to guarantee faithful compliance with federal statutes.

View Audit 31223

Finding 31195 (2022-002)

Significant Deficiency 2022

Housing Authority of Kansas City, Missouri

MO

HUD Housing Programs Reporting Significant Deficiency

Finding 2022 ? 002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Housing Voucher Cluster Assistance Listing Number: 14.871/14.879 Federal Award Identification Number and Year: MO002VO - 2022 Award Period: January 1, 2022 ? December 31, 2022 Compliance Require...

Finding 2022 ? 002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Housing Voucher Cluster Assistance Listing Number: 14.871/14.879 Federal Award Identification Number and Year: MO002VO - 2022 Award Period: January 1, 2022 ? December 31, 2022 Compliance Requirement: Reporting ? PIH Information Center (PIC) Reporting Type of Finding: ? Significant Deficiency in Internal Control over Compliance ? Other Matters Condition: The Authority did not satisfy PIC reporting requirements in accordance with 24 CFR Part 908. Exceptions were noted in 4 out of 40 recertifications. In each of the four instances, the HUD-50058 was unable to be located within the PIC system. Cause: The Authority did not identify recertifications that failed to upload to the PIC system. Auditor?s Recommendations: Recommend that the Authority implement controls to ensure HUD-50058 recertifications are uploaded to PIC. Response to Finding 2022-002 The Authority generally concurs with the auditor?s findings and recommendations. The 2022 Audit included the review of 40 Recertifications and identified four instances where the HUD- 50058 was not located within the PIC system. Action Taken: A Corrective Action Plan has been developed to ensure HUD-50058 recertifications are uploaded to PIC. Implementation began on August 1, 2023. To provide consistency, the plan is to upload the HUD-50058 sixty days in advance of the recertification date. HAKC will upload the HUD-50058 every week to ensure recertifications are registered in PIC. In addition, we will increase quality control file reviews and conduct such reviews on a more frequent basis to identify errors sooner and address the cause of errors quickly to prevent systemic errors. Errors will be identified by error type and the person who made the error. Patterns of errors will be monitored, and additional training provided for similar error types that are frequently repeated and persons who are identified as frequently making errors. Name of the contact person responsible for corrective action: Edwin Lowndes Executive Director. Planned completion date for corrective action plan: March 1, 2024.

View Audit 28025

Finding 31190 (2022-001)

Significant Deficiency 2022

Peoria Housing Authority

IL

HUD Housing Programs Reporting Significant Deficiency

Finding 2022-001 ? Internal Control over Cash Reconciliations ? Significant Deficiency ? Noncompliance and Qualified at Single Audit Level PHA Response: The Peoria Housing Authority (PHA) has a policy to provide reasonable assurance that the Financial Statements are prepared in accordance with acc...

Finding 2022-001 ? Internal Control over Cash Reconciliations ? Significant Deficiency ? Noncompliance and Qualified at Single Audit Level PHA Response: The Peoria Housing Authority (PHA) has a policy to provide reasonable assurance that the Financial Statements are prepared in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP). Subsequent to December 31, 2022, the PHA procured the services of Bedrock Housing Consultants who have addressed the timeliness and accuracy of bank reconciliations as well as the monitoring of interfund accounts to ensure they are balanced. The PHA will resolve this issue during the 2023 calendar year. Corrective Action Plan: The Peoria Housing Authority (PHA) will continue to ensure timely and accurate financial reports. Bedrock Housing Consultants will continue to work with the Finance Department to ensure timely and accurate bank reconciliations are being performed. Staff will continue to participate in training in Housing Authority financial management to understand better the industry?s policies, procedures, and practices. The PHA will reconcile monthly all accounts, including accurate reconciliation of all bank accounts as well as balancing interfunds, and when possible reimbursing the amounts due. Any audit adjustments will be made in the proper period and in the accounts detailed per the auditor?s adjusting journal entry report. This will be addressed during the 2023 calendar year. Person Responsible: Armeca Crawford, Chief Executive Officer Bedrock Housing Consultants in coordination with the PHA Finance Department. Anticipated Completion Date: December 31, 2023

View Audit 25746

Finding 31188 (2022-002)

Significant Deficiency 2022

Alabama Nursing Home Association Education Foundation

AL

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.329

Finding 2022-002 ?Internal Control Over Reporting Status: Completed. Planned Corrective Action: Management will retain documentation of review of reports. Person(s) Responsible: John Matson, Acting Executive Director Completion Date: September 26, 2023

View Audit 25745

Finding 31181 (2022-001)

Significant Deficiency 2022

Wisconsin Illinois Senior Housing, Inc. and Affiliate

CO

Reporting

Management agrees with and will implement the recommended review as outlined by our auditors to include a review of all program reporting to verify accuracy and appropriateness of information, including comparing all information to source documentation to ensure correct data has been utilized, in ac...

Management agrees with and will implement the recommended review as outlined by our auditors to include a review of all program reporting to verify accuracy and appropriateness of information, including comparing all information to source documentation to ensure correct data has been utilized, in accordance of the terms and conditions of the program. All substantiating documentation for the amounts reported and the correct amounts will be maintained by management.

View Audit 30416

Finding 31178 (2022-003)

Material Weakness 2022

Young Womens Christian Association of Greater Lafayette

IN

HUD Housing Programs Reporting Internal Control / Segregation of Duties

2022-003: REPORTING--STOP Recommendation: Internal controls and procedures should be established and documentation maintained to support all program metrics surrounding each grant reporting. Corrective Actions: YWCA acknowledges discrepancies in data metrics reported. Recommendations in the Correc...

2022-003: REPORTING--STOP Recommendation: Internal controls and procedures should be established and documentation maintained to support all program metrics surrounding each grant reporting. Corrective Actions: YWCA acknowledges discrepancies in data metrics reported. Recommendations in the Corrective Action Plan were adopted and phased in beginning September 2023. Those recommendations were: ? Confirm best practice approaches with other victim service providers on data collection process and program reports. ? The Chief Executive Officer, Chief Financial Officer and Director are reviewing data collection and program report processes to ensure accuracy and compliance. ? The Director of DVIPP and Client Services Specialist are building a detailed process manual to provide clear guidance on program report process (including, but not limited to, data collection/entry, how to write the narratives and collect numbers for program reports). The detailed process manual will streamline procedures and clarify roles and responsibilities to all involved in program reports.

View Audit 37339

Finding 31175 (2022-002)

Material Weakness 2022

Young Womens Christian Association of Greater Lafayette

IN

HUD Housing Programs Reporting Internal Control / Segregation of Duties

2022-002: REPORTING--VOCA Recommendation: Internal controls and procedures should be established and documentation maintained to support all program metrics surrounding each grant reporting. Corrective Actions: YWCA acknowledges discrepancies in data metrics reported. Recommendations in the prio...

2022-002: REPORTING--VOCA Recommendation: Internal controls and procedures should be established and documentation maintained to support all program metrics surrounding each grant reporting. Corrective Actions: YWCA acknowledges discrepancies in data metrics reported. Recommendations in the prior Corrective Action Plans were adopted and phased in beginning September 2023. Those recommendations were: ? Additional staff have been trained to review data entered into the client database monthly for quality assurance prior to running the reports used to complete program reports for grants. Three staff members complete this review monthly. ? Data is being entered into the client database and monitored regularly. ? Standardized reports from the database are used to compile program reports and backup documentation is saved. ? Program reports are reviewed and approved by the Chief Program Officer or the Chief Executive Officer prior to submission to granting agency. ? Program staff are entering client data into the client database in a timely manner. All client data must be entered before monthly reports are compiled. This data is also compiled in a Google doc which the Senior Director compares to output from the database. ? Client bed nights are being tracked in the client database rather than on a paper residential log. ? YWCA has requested an additional field be added to the client database to allow more detailed and accurate reporting. ? The Senior Director has conducted trainings for all staff related to accurate and timely collection and entry of client data into the database. YWCA continues to follow the preceding recommendations and has implemented the following additional internal controls and procedures to ensure data quality: ? Confirm best practice approaches with other victim service providers on data collection process and program reports. ? The Chief Executive Officer, Chief Financial Officer and Director are reviewing data collection and program report processes to ensure accuracy and compliance. ? The Director of DVIPP and Client Services Specialist are building a detailed process manual to provide clear guidance on program report process (including, but not limited to, data collection/entry, how to write the narratives and collect numbers for program reports). The detailed process manual will streamline procedures and clarify roles and responsibilities to all involved in program reports.

View Audit 37339

Finding 31174 (2022-001)

Material Weakness 2022

St. Claire Regional Medical Center, Inc.

KY

Cash Management Material Weakness Reporting

CORRECTIVE ACTION PLAN September 8, 2023 U.S. Department of Health and Human Services St. Claire Regional Medical Center, Inc. respectively submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Blue & Co., LLC 2650 East...

CORRECTIVE ACTION PLAN September 8, 2023 U.S. Department of Health and Human Services St. Claire Regional Medical Center, Inc. respectively submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Blue & Co., LLC 2650 Eastpoint Parkway, Suite 300 Louisville, Kentucky 40223 Audit Period: Year ended June 30, 2022 The findings from the Schedule of Findings and Questioned Costs for the year ended June 30, 2022, are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. FINDINGS ? FEDERAL AWARD PROGRAM AUDITS 2022-001 Condition: Untimely disbursement of federal grant funds received: When receiving federal grant funds for the HHS Rural Health Care Services Outreach, Rural Health Network Development, and Small Health Care Provider Quality Improvement Plan Program, the Hospital did not disburse federal grant funds received within 3 working days. Action: Management will implement internal control procedures by December 31, 2023 to ensure proper and timely disbursements of federal grant funds to ensure proper cash management of any future HHS Rural Health Care Services Outreach, Rural Health Network Development, and Small Health Care Provider Quality Improvement Plan Program funds. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Chris McClurg, CFO, at (606) 783-6587. Sincerely, Chris McClurg Chief Financial Officer

View Audit 36989

Finding 31173 (2022-002)

Material Weakness 2022

Riverview Hospital

IN

Questioned Costs Allowable Costs / Cost Principles Reporting

Findings Reported by Uniform Guidance ? The following steps have been taken or will be taken to address Finding 2022-002: ? Riverview Hospital plans to monitor controls related to reporting to ensure amounts are appropriately stated. ? Riverview Hospital will prepare internal documentation supporti...

Findings Reported by Uniform Guidance ? The following steps have been taken or will be taken to address Finding 2022-002: ? Riverview Hospital plans to monitor controls related to reporting to ensure amounts are appropriately stated. ? Riverview Hospital will prepare internal documentation supporting reconciled expense amounts which should be retained for a minimum of three (3) years from the date of the final report in accordance with payment terms and conditions.

View Audit 36798 Questioned Costs: $1

Finding 31164 (2022-002)

Significant Deficiency 2022

Housing Authority of St. Louis County

MO

HUD Housing Programs Reporting Significant Deficiency

2022-002 Housing Voucher Cluster ? Assistance Listing No. 14.871/14.879 ? PIC Reporting Recommendation: The Authority should implement processes to ensure HUD-50058 submissions are submitted into the PIC system timely and accurately. Explanation of disagreement with audit finding: There is no disagr...

2022-002 Housing Voucher Cluster ? Assistance Listing No. 14.871/14.879 ? PIC Reporting Recommendation: The Authority should implement processes to ensure HUD-50058 submissions are submitted into the PIC system timely and accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Since 2022, the Authority has sought comprehensive PIC training from its HUD Field Supervisor, PIC Couch, and EIV Coordinator. During these training events our Authority-HUD team addressed errors dating to 2021 and staff learned to make required corrections in a timely manner. The Authority also has included PIC reporting review as a responsibility for its recently created Housing Choice Voucher (HCV) Floater position. With the assistance of the HCV Floater and oversight by the HCV Director, the Authority addresses any PIC reporting errors effectively and immediately upon receipt. Name(s) of the contact person(s) responsible for corrective action: Nicole O?Dell/Katrina Sommer Planned completion date for corrective action plan: On-going

View Audit 35864

Finding 31154 (2022-001)

None 2022

Tolleson Elementary School District No. 17

AZ

Reporting

Finding Number: 2022-001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: Dr. Myriam Roa, Executive Director of Business Services (through June 30, 2023) Anita Percell, Executive Director of Business Services (as of July 1, 2023) A...

Finding Number: 2022-001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: Dr. Myriam Roa, Executive Director of Business Services (through June 30, 2023) Anita Percell, Executive Director of Business Services (as of July 1, 2023) Anticipated Completion Date: July 31, 2023 Planned Corrective Action: The District has prepared and submitted the ESSER III application to the Arizona Department of Education in May of 2023 and will make any revisions if necessary, in a timely manner. The District has hired new key finance positions with grants management experience to complete all future revisions and submissions.

View Audit 33624

Corrective Action Plans

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