Corrective Action Plans

Finding 32511 (2022-002)

Material Weakness 2022

OH

Questioned Costs Allowable Costs / Cost Principles Reporting

Corrective Action Plan Federal Award Findings and Questioned Costs For the Years Ended December 31, 2020 and 2021 Finding 2022-002 ? A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles; L. Reporting Federal program information: Federal Program: 93.948, COVID-19 Provider Relief ...

Corrective Action Plan Federal Award Findings and Questioned Costs For the Years Ended December 31, 2020 and 2021 Finding 2022-002 ? A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles; L. Reporting Federal program information: Federal Program: 93.948, COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Locations: Various Award Numbers: Various Award Period: January 1, 2020 through June 30, 2022 Summary of finding: UC Health did not have effective internal controls in place to ensure expenses and lost revenues reported in the Portal were not duplicated. This resulted in the overstatements of expenses and lost revenues reported in the Portal. Planned corrective action: Management will establish processes for reviews of the reporting guidelines to better interpret and comply with the guidelines for future reporting. Anticipated completion date: Prior to next filing due September 30, 2023 Responsible contact person: Michael Wiedeman, Vice President and Controller

View Audit 29116 Questioned Costs: $1

Finding 32489 (2022-013)

Significant Deficiency 2022

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Reporting § 200.1 § 200.332

DHS: The Office of Children, Youth, and Families (OCYF) is sending out a Restrictions and Requirements document with each tentative and final allocation letter. This document lists all OCYF?s grants, the federal agency granting the fund and where to find the rules and regulations guiding the usage o...

DHS: The Office of Children, Youth, and Families (OCYF) is sending out a Restrictions and Requirements document with each tentative and final allocation letter. This document lists all OCYF?s grants, the federal agency granting the fund and where to find the rules and regulations guiding the usage of the funds. For the State fiscal year 2021-2022, Tentative Allocation Letters were sent out on April 1, 2021, with Federal Award Identification Numbers (FAIN) and funding amounts. Final Allocation Letters were sent out August 12, 2021, with the Amount, FAIN and Name. OCYF has a risk assessment process in place for Title IV-E and TANF awards. During the Quality Assurance reviews, which occur twice a year at a minimum, OCYF reviews a sample of Title IV-E eligible foster care cases, Title IV-E ineligible foster care cases, Title IV-E eligible adoption assistance cases, and TANF eligible cases. Depending on the number of eligibility and claiming errors identified during the review, OCYF schedules more frequent visits as the risk of repeated and continued errors in these County Children and Youth Agencies (CCYAs) is higher. Inaccurate eligibility determinations lead to inaccurate federal claiming, so basing the review schedule on a CCYA?s eligibility review outcome allows OCYF to target those CCYAs where inaccurate claiming is a higher risk. However, to further address this finding, the risk assessment now includes documentation. Anticipated Completion Date: Completed Contact Person and Title: TinaMarie Petrovitz, Director of County Support DOH: The Department plans to develop and implement a robust subrecipient monitoring program which includes establishing a new section within the Budget Office pending enacted budget funds and complement to support the creation of the section. Initiative goals/milestones include: - Assessment: Comprehensive assessment of all current federal grants and subawards and their processes. This assessment will document best practices and identify gaps within the agency?s processes. It will also provide an evaluation of current operational and technological resources that can be leveraged to facilitate compliance. Target start date: February 27, 2023. Target completion date: June 30, 2023. - Educate Department: Budget Office is developing a bulletin that will outline the subrecipient monitoring requirements with links to State and Federal Sources. The bulletin will be shared with all program office staff. The Budget Office will develop the following templates and provide to all program offices: - Determination of vendor status: Subrecipient or Contractor - Risk Assessment Form - Internal Control Self-Assessment for Subrecipient Template - Subrecipient Monitoring Template All materials will be updated with any additional information gained during the assessment. Start date: February 3, 2023. Target Completion Date: June 30, 2023 - Implementation of full compliance initiative: Recommendations provided in the assessment will be used to develop and implement comprehensive policies and procedures led by a new section in the Budget Office. Target start date July 1, 2023. Target fully operational date: June 30, 2024. Anticipated Completion Date: 06/30/2024 Contact Person and Title: Andrea Race, CFO

View Audit 27724 Questioned Costs: $1

Finding 32463 (2022-004)

Significant Deficiency 2022

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Reporting § 200.303

PDE uses its eGrants system to collect all LEA required records under ESSER I and ESSER II. The eGrants system is designed to allow licensed educational agencies and certain community-based programs within the Commonwealth, access to PDE grants. Through this system, the LEA can submit applications f...

PDE uses its eGrants system to collect all LEA required records under ESSER I and ESSER II. The eGrants system is designed to allow licensed educational agencies and certain community-based programs within the Commonwealth, access to PDE grants. Through this system, the LEA can submit applications for funding, e-sign contracting documents, upload back-up documentation, submit program quarterly reports, and file final expenditure reports. PDE Division of Federal Programs also utilizes Pennsylvania's Information Management System (PIMS) to collect and verify LEA data. PIMS has business rules built in to ensure valid data collection. The eGrants system makes it possible for records pertaining to the ESSER awards to be retained separately from other grant funds, including funds that an SEA or LEA receives under the CARES Act and CRRSA. This follows the requirements under 2 C.F.R. ? 200.334 and 34 C.F.R. ? 76.730, including financial records related to the use of grant funds. Through quarterly financial reporting, LEAs are required to report the amount of cash received, expended, and on hand. If the amount of cash-on-hand reported is determined to be too high, or the quarterly report is not submitted, monthly payments will be suspended until the next quarterly report is due. Current monitoring to verify data and ensure compliance with existing federal guidelines, typically occurs from January through May. LEAs receive a unique username and password to access Fedmonitor and complete an online self-assessment. Beginning in October 2022, all LEAs were placed on a four-year monitoring cycle and were monitored in the 2021?22 fiscal year and will be monitored again in the 2024?25 fiscal year. Data collected in eGrants, PIMS and Fedmonitor is verified during these monitoring visits. Anticipated Completion Date: Completed Contact Person and Title: Susan McCrone, Division Manager, Federal Programs; Brian Campbell, Director, Bureau of Curriculum, Assessment, and Instruction

View Audit 27724 Questioned Costs: $1

Finding 32457 (2022-011)

Significant Deficiency 2022

Commonwealth of Pennsylvania

PA

Subrecipient Monitoring Reporting Significant Deficiency

While the Governor?s Budget Office agrees with the fact cited in finding, it is not possible to correct the situation and the error had no impact on the implementation of the federal program. No corrective action is necessary, nor would it have any discernable impact. The Interim Report was a one-...

While the Governor?s Budget Office agrees with the fact cited in finding, it is not possible to correct the situation and the error had no impact on the implementation of the federal program. No corrective action is necessary, nor would it have any discernable impact. The Interim Report was a one-time progress report required by U.S. Treasury to document our state?s progress in spending State and Local Fiscal Recovery Funds and distributing, on the behalf of the U.S. Treasury, payments from the Treasury to Non-Entitlement Units (NEU) of local government as of July 31, 2021. The Interim Report also required states to provide revenue replacement calculations for calendar year 2020. This report was due on August 31, 2021. There were no follow up reports using the same format as the Interim Report. The figures reported as transfers to NEUs in the Interim Report accurately reflected the total dollars that had been electronically transferred to local governments as of July 31, 2021, as that was how we interpreted the federal guidance at the time. It was our interpretation that U.S. Treasury wanted information on how much had been distributed and received by NEUs as of July 31, 2021, rather than how many payments we had approved in our accounting system and were in the process of being paid. After filing the Interim Report, the Office of the Budget continued to report updates of distributions to NEUs both using a U.S. Treasury portal, and ultimately by exchanging spreadsheets of NEU data with the US Treasury to painstakingly ensure the data the U.S. Treasury had was correct. The Office of the Budget will continue to file compliance reports in accordance with U.S. Treasury?s guidance. At no time did the U.S. Treasury indicate there were issues with the composition or acceptability of our filed Interim Report. At this time, all NEU funds received from the federal government have been either distributed to NEUs or have been returned to the U.S. Treasury and this program is complete. Therefore, we are currently not required to, nor do we have plans to report on the progress of NEU distributions to the federal government in the future. Anticipated Completion Date: N/A Contact Person and Title: Mike Wood, Bureau Director, Bureau of Performance, Revenue, and Program Analysis; Colleen Kling, Division Manager, Division of Program Analysis and Performance Improvement

View Audit 27724

Finding 32455 (2022-007)

Significant Deficiency 2022

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Reporting § 200.303

Similar to other DHS programs, DHS has implemented an after-action review of information submitted, using a contracted vendor. DHS faced challenges implementing a program with 67 counties and no central eligibility determination system. DHS has learned that implementing the supportive services and m...

Similar to other DHS programs, DHS has implemented an after-action review of information submitted, using a contracted vendor. DHS faced challenges implementing a program with 67 counties and no central eligibility determination system. DHS has learned that implementing the supportive services and multi-sector partnerships was challenging in the context of the global pandemic and workforce shortages. This made DHS dependent on local county reports to maintain program oversight and compile statewide data for submission to US Treasury. DHS plans to strengthen this control as we plan for future emergency or pandemic programs related to rental assistance. Anticipated Completion Date: 06/30/2023 Contact Person and Title: Joel O?Donnell, Director, Bureau of Program Support, OIM

View Audit 27724 Questioned Costs: $1

Finding 32431 (2022-014)

Material Weakness 2022

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Reporting § 200.208 § 200.332 § 200.339 § 200.501 § 200.505

PDE: Audits retrieved from the Federal Audit Clearinghouse are now reviewed after entry into PDE?s SharePoint website, to ensure PDE remains compliant with federal guidelines to respond to any and all findings pertaining to federal dollars it passes to subrecipients. Likewise, PDE Audit Section cont...

PDE: Audits retrieved from the Federal Audit Clearinghouse are now reviewed after entry into PDE?s SharePoint website, to ensure PDE remains compliant with federal guidelines to respond to any and all findings pertaining to federal dollars it passes to subrecipients. Likewise, PDE Audit Section continues to improve upon its processes for timely determinations of those single audits with findings by multiple means, including periodic SharePoint enhancements designed to aid in timely review of single audit packages, working closely with PDE program areas to assist in timely responses and quickly addressing SharePoint access issues as they arise. Anticipated Completion Date: 06/30/2023 Contact Person and Title: Clayton P. Carroll, II, Audit Coordinator; Jessica Sites, Director, Bur. of Budget and Fiscal Mgmt DEP: BAFM now provides agencies with single audit reporting packages that have findings each week that have been accepted by the Federal Audit Clearinghouse (FAC). This allows for us to start our management decision process in a timelier manner and meet the six-month deadline for issuing our decision. This information first appeared in our notifications starting April 30, 2021. In addition, the DEP program that had been previously identifying agreements as contracts rather than subrecipient agreements has corrected this issue and all subrecipients have been notified in writing of this correction and provided the information for submitting their single audits (if necessary). The letters were sent to subrecipients on approximately May 31, 2022. DEP Fiscal Management staff will continue to monitor the BAFM SharePoint site and FAC for additional filings to attempt to avoid this issue in the future. DEP is also hiring additional staff for the oversight and monitoring of the subrecipient single audits to ensure compliance with all requirements. These positions are currently in the filing process, and we are hopeful that they will be filled, and staff trained by September 30, 2023. Anticipated Completion Date: 09/30/2023 Contact Person and Title: Jennifer L. Brandt, Senior Fiscal Management Specialist, Federal Grants and Audits DOH: NORTH Inc.?s Single Audit report for the period ending 9/30/2020 was officially submitted and showing on the FAC on 2/9/2023. Bureau of WIC staff reached out to the Director and CFO of NORTH Inc. by phone and email. Emails were sent with instructions on how to submit the report as well as the importance of submitting the report timely per their grant agreement. Each follow-up phone call included discussion on the importance of submitting their single audit as soon as possible. Moving forward the Bureau of WIC will implement the following procedure: 1 .Three months after the end of the audit period (Federal Fiscal Year), Project Officers will send an email that outlines the process for submitting a single audit reporting package to the FAC to their respective WIC local agencies. This email will provide a date that the single audit is due to be submitted to the FAC in order to stay in compliance with their current WIC grant agreement. 2. Six months after the end of the audit period (three months from the due date of the single audit reporting package) an official letter from the Bureau Director will go out to the WIC local agencies that are due to submit a single audit. The letters will include instructions on how to submit the single audit in FAC and the Audit Requirements link referenced in their grant agreement. 3. If the WIC local agency notifies the Bureau of WIC that their auditor will not be able to submit their agency?s single audit by the due date, then the Project Officer will work with the local agency to get a projected date of completion and a timeline on when the local agency?s auditor is able to finalize the audit and submit it to the FAC. The Bureau of WIC will then notify DOH?s Audit Coordinator and OB-BAFM of this information, so they are able to track it. 4. If the WIC local agency does not submit the report by the due date and fails to notify their project officer; a notice to cure letter will be sent to the agency. Concerning NORTH Inc.?s Single Audit report for the period ending September 30, 2021: 1. The Bureau of WIC will contact NORTH Inc. and request a meeting with their auditor. 2. Following the meeting with NORTH Inc.?s auditor, the Bureau Director will send an official letter to NORTH Inc. The letter will include the instructions on how to submit the single audit in the FAC and the Audit Requirements link referenced in their grant agreement. They will also be made aware of the actions that could result from them not submitting this audit by the agreed upon date. 3. If the single audit is not received by the agreed upon date, then the Bureau of WIC will send a notice to cure letter. Anticipated Completion Date: 03/24/2023 Contact Person and Title: Sally Zubairu-Cofield, Director, Bureau of WIC DHS: Regarding the timeliness of finding resolution and procedures related to the SEFA reviews, the Audit Resolution Section (ARS) hired an additional staff member in August 2021 and hired two additional staff members in February 2022, and an additional staff member in January 2023. Finally, the ARS worked with Office of the Budget, Bureau of Accounting and Financial Management to develop a risk-based approach for single audit reviews, which will greatly streamline the process of single audit reviews to gain substantial efficiencies. Regarding late audit report submissions, we will continue to follow the requirements of 2 CFR ?200.339 and Commonwealth Management Directive 325.8. We will continue to work with counties and their independent auditors to obtain any late Single Audit reports. Anticipated Completion Date: 06/30/2023 Contact Person and Title: David Bryan, Manager, ARS; Alexander Matolyak, Director, Division of Audit & Review

View Audit 27724 Questioned Costs: $1

Finding 32430 (2022-010)

Significant Deficiency 2022

Commonwealth of Pennsylvania

PA

Reporting School Nutrition Programs Equipment & Real Property Management

IT - PDA?s PA Meals team will incorporate appropriate migration strategies within the policy of ITP_INF000, along with providing a migration audit plan checklist for any future data migrations. Additionally, the INF000 will be incorporated into the Delivery Center?s development framework, where a...

IT - PDA?s PA Meals team will incorporate appropriate migration strategies within the policy of ITP_INF000, along with providing a migration audit plan checklist for any future data migrations. Additionally, the INF000 will be incorporated into the Delivery Center?s development framework, where appropriate. PDA added a Business Analyst to the team for assisting with future application testing and documentation. This individual will be directly involved in helping develop and orchestrate a testing strategy based on delivery center standards to include, but not limited to: - Determine appropriate criteria to be tested. - Assist in establishing a test group of qualified testers. - Coordinate with technical team on pass/fail criteria. - Utilize standard testing tasks/checklists ensuring consistency. - Assist the team, key business users and the technical team in reviewing testing results. The reports were reviewed electronically (100s of report pages) checking for various scenarios. As a result, these complete reports are similar and difficult to distinguish between without an associated checklist and specific report criteria. In the future, full test plans and execution results capturing pass/fail of the defined tests will be retained in pdf (or similar) format. The team will continue with best practices and delivery center standards, utilizing a Business Analyst as part of the testing and review process. The SEFA report had extensive testing, however, there is a timing issue that will always exist if the expectation is to provide the data in both January and September. The January report will be accurate for when it is run, along with what transactions were sent by the warehouse vendor. Subsequently, changes can and will occur to those commodities being reported on over the next 6 months. Additionally, it is reliant upon the warehouse vendor to report all transactions timely. As a result, running the same report after June 30th will consistently vary due to a physical inventory review in June, along with additional transactions being updated as part of the inventory review. PDA is recommending a one-time annual report in September, which will include all the adjustments from a June physical inventory and updated transactions. A January report is fine to run but should not be considered a fully accurate assessment due to the timing and missing data. Program - PDA strives to maintain accurate and complete records with respect to the receipt, distribution, and inventory of USDA donated foods, including end products processed from donated food. To that end, PDA has already or will put the following steps in place to strengthen procedures for future periods to ensure errors identified during the reconciliation process are corrected timely in the system: 1) All findings noted with regards to the Commodity Processors Inventory Report have been corrected and no known issues remain. 2) No further inventory balances remain on record with inactive distributors, as all product was previously transferred to active distributors. 3) Processor monthly performance reports (MPRs) will be completed and filed in accordance with USDA?s prescribed schedule (90 days after completion of month). 4) BFA will work with the Commodity Distributors and USDA to mutually resolve discrepancies and achieve reconciliation with USDA receipts. 5) Moving forward, all Commodity Distributor Inventory Reports will be reconciled by the beginning of a new federal fiscal year (October 1), and inventory balances at commodity distributors will agree with year-end physical inventory counts. Anticipated Completion Date: IT - 09/30/2023; Program 1-Completed; 2-Completed; 3-09/30/2023; 4-09/30/2023; 5-09/30/2023 Contact Person and Title: Caryn Long Earl, PDA, Director, Bureau of Food Assistance (BFA)

View Audit 27724

Finding 32418 (2022-003)

Significant Deficiency 2022

Crawford County Community School Corporation

IN

Subrecipient Monitoring Reporting Significant Deficiency § 200.302 § 200.303 § 200.328

Finding 2022-003 Information on the federal program: Subject: Education Stabilization Fund ? Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Entity: Indiana Departmen...

Finding 2022-003 Information on the federal program: Subject: Education Stabilization Fund ? Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) to meet federal reporting requirements for ESSER grant awards and the GEER grant award. The first report was for the period of March 13, 2020 to September 30, 2020 and was due by January 21, 2021. The second report was for the period of October 1, 2020 to June 30, 2021 and was due by May 13, 2022. We noted for both reports that were submitted, there was no documented review by someone other than the preparer of the report to ensure the information submitted was complete and accurate. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. Crawford County Community School Corporation will continue submission of required data to the IDOE on federal spending with at least two people completing the curation. However, final drafts will be reviewed and then final reports will be signed by the at least two people who reviewed the final draft. This signed copy, if not required to be submitting to the IDOE, will be kept locally. Responsible party and timeline for completion: 1) Amy Belcher, Program Administrator, will ensure all final reports have been reviewed and signed by at least two people before submission to the IDOE immediately.

View Audit 27913

Finding 32402 (2022-001)

Material Weakness 2022

Enumclaw School District No. 216

WA

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

SUMMARY SCHEDULE OF PRIOR AUDIT FINDINGS Enumclaw School District No. 216 September 1, 2021 through August 31, 2022 This schedule presents the status of findings reported in prior audit periods. Audit Period: September 1, 2020 ? August 31, 2021 Report Ref. No.: 1030921 Finding Ref. No.: 2021-001 Ass...

SUMMARY SCHEDULE OF PRIOR AUDIT FINDINGS Enumclaw School District No. 216 September 1, 2021 through August 31, 2022 This schedule presents the status of findings reported in prior audit periods. Audit Period: September 1, 2020 ? August 31, 2021 Report Ref. No.: 1030921 Finding Ref. No.: 2021-001 Assistance Listing Number(s): 84.425 Federal Program Name and Granting Agency: COVID-19 Education Stabilization Fund, U.S. Department of Education Pass-Through Agency Name: Office of Superintendent of Public Instruction Finding Caption: The District did not have adequate internal controls for ensuring compliance with Davis-Bacon Act (prevailing wage rate) requirements. Background: During the 2020-2021 school year, the District paid $658,502 from its ESSER II award to 11 contractors to repair and replace the roof at two schools, update HVAC controls in seven schools, and replace wet and rotting insulation to improve air quality and circulation to prevent the spread of COVID-19. Additionally, the District used its ESSER II award to replace faulty and broken bathroom sinks to allow for safe and consistent use of sinks for hand washing. Our audit found the District did not have adequate internal controls for ensuring compliance with federal prevailing wage rate requirements. Specifically, the District did not collect weekly certified payroll reports from the contractors to confirm they paid laborers proper prevailing wages. We consider this deficiency in internal controls to be a material weakness, which led to material noncompliance. The issue was not reported as a finding in the prior audit.

View Audit 27599

Finding 32396 (2022-001)

Material Weakness 2022

Leap Charities, Inc.

ID

Reporting Internal Control / Segregation of Duties § 200.512

The Organization started its remediation of its accounting closing processes during 2021. As a part of the Organization?s remediation they hired an external consultant to provide chief financial officer/controller level services over the Organization?s accounting and financial processes. Timely and ...

The Organization started its remediation of its accounting closing processes during 2021. As a part of the Organization?s remediation they hired an external consultant to provide chief financial officer/controller level services over the Organization?s accounting and financial processes. Timely and accurate accounting records will ensure the timely completion of future reporting requirements for the Organization.

View Audit 27380

Finding 32391 (2022-002)

Significant Deficiency 2022

Cabrini University

PA

Reporting Student Financial Aid Significant Deficiency

2022-002 Student Financial Assistance Cluster ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University review its policies and procedures to ensure accurate e...

2022-002 Student Financial Assistance Cluster ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University review its policies and procedures to ensure accurate effective dates are reported in both the campus and program level records submitted to the NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Registrar?s Office will review National Student Clearinghouse (NSC) information following transmission, particularly for effective dates of completely withdrawn students. The NSC reports enrollments to NSLDS for the University. Name(s) of the contact person(s) responsible for corrective action: Gerard J. Donahue, Registrar Planned completion date for corrective action plan: June 30, 2023

View Audit 27062

Finding 32390 (2022-002)

Material Weakness 2022

Christian Housing of St. Joseph, INC Chilton Place Apts.

MO

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2022 Name of Audit: Christian Housing of St. Joseph, Inc. HUD Project Number: 084-11148 Name of Audit Firm: Welch & Associates, LLC Period Covered by Audit: Year Ended March 31, 2022 Corrective Action Plan Prepared by: Name: Tamara Wallace Position...

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2022 Name of Audit: Christian Housing of St. Joseph, Inc. HUD Project Number: 084-11148 Name of Audit Firm: Welch & Associates, LLC Period Covered by Audit: Year Ended March 31, 2022 Corrective Action Plan Prepared by: Name: Tamara Wallace Position: Executive Director ? Management Agent Telephone Number: 816-233-4250 Finding 2022-002 Comments on Findings and Each Recommendation: The Organization agrees with the auditors? finding. Action(s) Taken or Planned on the Finding: The Organization is in the process of selling its assets pending HUD approval and expects to dissolve within the next 12 months (see Note 11).

View Audit 27889

Finding 32389 (2022-001)

Material Weakness 2022

Christian Housing of St. Joseph, INC Chilton Place Apts.

MO

HUD Housing Programs Procurement, Suspension & Debarment Reporting

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2022 Name of Audit: Christian Housing of St. Joseph, Inc. HUD Project Number: 084-11148 Name of Audit Firm: Welch & Associates, LLC Period Covered by Audit: Year Ended March 31, 2022 Corrective Action Plan Prepared by: Name: Tamara Wallace Position...

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2022 Name of Audit: Christian Housing of St. Joseph, Inc. HUD Project Number: 084-11148 Name of Audit Firm: Welch & Associates, LLC Period Covered by Audit: Year Ended March 31, 2022 Corrective Action Plan Prepared by: Name: Tamara Wallace Position: Executive Director ? Management Agent Telephone Number: 816-233-4250 Findings-Financial Statement Audit None Findings-Federal Award Program Audit Federal Agency: Department of Housing and Urban Development Major Program: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects Section 207/223f Assistance Listing Number: 14.155 Finding 2022-001 Comments on Findings and Each Recommendation: The Organization agrees with the auditors? finding. Action(s) Taken or Planned on the Finding: Management will ensure that the accounts reconcile to source documents, including report from the software used to process tenant rental activities. Management expects to establish the process by September 30, 2022.

View Audit 27889

Finding 32385 (2022-001)

Significant Deficiency 2022

Elder Care Services, Inc.

FL

Matching / Level of Effort / Earmarking Reporting § 200.303

Beginning October 2023, prior to submission of required reports, clinical directors, Zoila Huston (Leon County) and Mariposa Wilson (Gadsden & Wakulla counties) will ensure the reports are reviewed and approval is documented through signature of the CEO, Jocelyne Fliger. Additionally, documentation ...

Beginning October 2023, prior to submission of required reports, clinical directors, Zoila Huston (Leon County) and Mariposa Wilson (Gadsden & Wakulla counties) will ensure the reports are reviewed and approval is documented through signature of the CEO, Jocelyne Fliger. Additionally, documentation of submission of those reports will be obtained through either appropriate signature, electronic confirmation or equivalent.

View Audit 28092

Finding 32372 (2022-001)

Material Weakness 2022

School District of Haveford Township

PA

School Nutrition Programs Internal Control / Segregation of Duties Subrecipient Monitoring

Management?s Response: Management will implement safeguards to ensure responsible business office employees are held accountable for following procedures to ensure timely and complete monthly and annual financial reporting.

View Audit 28232

Finding 32370 (2022-003)

Significant Deficiency 2022

Inova Health System

VA

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking

Recommendation: The System?s policy and procedures should be designed to ensure accurate reporting as required by the Uniform Guidance. View of Responsible Officials: There is no disagreement with the audit finding. Corrective Action Planned: Management will design and ensure written policies and pr...

Recommendation: The System?s policy and procedures should be designed to ensure accurate reporting as required by the Uniform Guidance. View of Responsible Officials: There is no disagreement with the audit finding. Corrective Action Planned: Management will design and ensure written policies and procedures will be created outlining processes and control activities to ensure reporting to federal awarding agencies and pass-through entities are complete and accurate. During the current fiscal year, Inova began implementing enhancements to Oracle?s Grants Accounting module. Once completed, this will assist management to automate certain processes and procedures that were not available after the initial implementation. The enhanced reporting capabilities will include automated reporting that will identify grants that expended federal awards. Grants Accounting will schedule quarterly meetings with Finance and GMO leadership present. The purpose of these meetings will be to review federal funding received that will ultimately be used in the preparation of financial reports submitted to the appropriate governing agencies. The Director of Grants Accounting will guide the meetings and obtain approvals from department leaders confirming amounts to be reported for federal grant awards. In preparation of the meetings, the Director of Grants Accounting will prepare an agenda to guide discussions of grant terms and conditions and applicable FAQs, more explicitly for awards received outside of Inova?s normal course of business (i.e., COVID-19). These meetings will also provide an opportunity for Finance, GMO, and Grants Accounting leaders to review the unique characteristics of the federal grant award programs on at least a quarterly basis. Meeting minutes will be maintained to document discussions and actions to be taken. The minutes will also serve as support for accounting memos related to special awards received that document Inova?s understanding of the award and related reporting requirements. All accounting memos will be prepared by the Director of Grants Accounting and reviewed by the Senior Director of Financial Reporting. Name(s) of the Contact Person(s) Responsible for Corrective Action: Christopher T. Smith, Vice President of Finance and Corporate Controller, 571-472-8122. Christopher Trump, Senior Director of Financial Reporting, 571-373-2868. Michael H. Lowen, Director, Grant Accounting, 571-472-8108. Planned completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2023.

View Audit 27876

Finding 32367 (2022-001)

Material Weakness 2022

Vermont State Colleges

VT

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Finding number: 2022-001 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster CFDA #: 84.007, 84.033, 84.038, 84.063, 84.268 Award year:2022 Corrective Action Plan: An external consultant (Higher Education Assistance Group) was contracted to bring current ...

Finding number: 2022-001 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster CFDA #: 84.007, 84.033, 84.038, 84.063, 84.268 Award year:2022 Corrective Action Plan: An external consultant (Higher Education Assistance Group) was contracted to bring current NVU?s required reporting for enrollment and student program status changes through the Spring 2022 term. This work was complete September 9. Letters/Notifications were issued to United Educators (August 10) and impacted students (week of September 5). Ongoing, NVU has received support from the registrar at our sister institution Community College of Vermont (CCV). CCV?s registrar has coordinated with the National Student Clearinghouse and submitted the first of term enrollment file for Fall 2022 on 10/3/22. NVU plans to hire a registrar soon and ongoing enrollment reporting will fall within the responsibilities of this new hire. Additionally, the Vermont State Colleges System registrar team will perform monthly checks to confirm that enrollment reporting for NVU has been completed. Timeline for Implementation of Corrective Action Plan: September 2022 Contact Person Sharron Scott, CFO

View Audit 28359

Finding 32365 (2022-003)

Significant Deficiency 2022

Beaufort County

NC

Eligibility Reporting

Finding 2022-003 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: "Staff will be trained on state communications as it relates to applicants' benefits and the importance of sharing information with all areas which the pa...

Finding 2022-003 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: "Staff will be trained on state communications as it relates to applicants' benefits and the importance of sharing information with all areas which the participant receives benefits. Currently the lead worker manages the notifications received to ensure timely processing of SSI terminations. Agency processes have been reviewed to monitor SSI terminations to prevent recertifications from becoming overdue. " Proposed completion date: "Training will be provided the week of November 7, 2022, to review findings and corrective action items. State communications will continue to be monitored. One (1) technical error cited for an untimely SSI Exparte Review was for a prior fiscal year. "

View Audit 27610

Finding 32355 (2022-001)

Significant Deficiency 2022

Thomas Health System, Inc.

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

Corrective Action Plans

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