Corrective Action Plans

Finding 1162168 (2021-007)

Material Weakness 2021

CA

Reporting Significant Deficiency Internal Control / Segregation of Duties

JCFHD experienced substantial leadership and staff turnover in key financial roles over multiple years, including the CEO, CFO, and finance team. As a result, the individuals who originally prepared the lost revenues calculation were no longer employed at the facility when the Uniform Guidance audit...

JCFHD experienced substantial leadership and staff turnover in key financial roles over multiple years, including the CEO, CFO, and finance team. As a result, the individuals who originally prepared the lost revenues calculation were no longer employed at the facility when the Uniform Guidance audit was conducted. This led to challenges in locating complete supporting documentation for the original calculation, resulting in additional calculations being necessary. Under new leadership, JCFHD has prioritized the development and implementation of robust policies and procedures to ensure that all relevant financial documentation is readily accessible for future Uniform Guidance audits. These measures are intended to strengthen internal controls and improve audit readiness. Corrective Action: 1. Provide additional training to finance staff on GAAP financial reporting and disclosure requirements to strengthen internal review and oversight. 2. Implement a documented review process for financial statements and footnotes prepared by external auditors, including CFO and Board-level approval prior to issuance. Completion Date: Within 120 days.

View Audit 371977

Finding 1162167 (2021-006)

Material Weakness 2021

JOHN C. FREMONT HEALTHCARE DISTRICT

CA

Reporting Significant Deficiency

JCFHD experienced significant turnover in CEO, CFO, and finance positions over multiple years resulting in delays in completing the Uniform Guidance audit. JCFHD is under new leadership and has prioritized implementing policies and procedures to ensure future uniform guidance audits are completed an...

JCFHD experienced significant turnover in CEO, CFO, and finance positions over multiple years resulting in delays in completing the Uniform Guidance audit. JCFHD is under new leadership and has prioritized implementing policies and procedures to ensure future uniform guidance audits are completed and filed timely. Corrective Action: 1. Develop and implement written accounting policies and procedures aligned with GAAP and COSO principles. 2. Establish a monthly reconciliation calendar for all significant balance sheet accounts, with supervisory review and sign-off. 3. Provide training to accounting staff on new policies, reconciliation standards, and documentation requirements. 4. Assign the Accountant to monitor compliance and report quarterly to the CFO on reconciliation status and control improvements. Completion Date: Target completion within 90 days.

View Audit 371977

Finding 1161633 (2021-001)

Material Weakness 2021

L.b.s.h. Housing Corporation

NY

Reporting

Management will work with their independent auditor to ensure that a proper data collection form will be submitted on a timely basis for the 2021 audit.

View Audit 371523

Finding 1161494 (2021-005)

Material Weakness 2021

Bristow Housing Authority

OK

HUD Housing Programs Reporting

Corrective Action Plan Finding: Finding 2021-005-Board Minutes-Reporting Condition: We do not have access to any board minutes between the minutes of the January 28, 2022 and December 26, 2023. Current management represents that they are not aware of any board minutes for that period, or if the boar...

Corrective Action Plan Finding: Finding 2021-005-Board Minutes-Reporting Condition: We do not have access to any board minutes between the minutes of the January 28, 2022 and December 26, 2023. Current management represents that they are not aware of any board minutes for that period, or if the board met. Corrective Action Planned As noted above, the Authority now holds regular board meetings and the minutes are generated. Person responsible for corrective action: Diane Adams, Executive Director Telephone: (918) 367-5558 Housing Authority of Bristow, Oklahoma Fax: (918) 367-2341 1110 S. Chestnut Bristow, OK 74010 Anticipated Completion Date- June 30, 2026

View Audit 371390

Finding 1161150 (2021-003)

Material Weakness 2021

Pulaski Memorial Hospital

IN

Reporting

Corrective action: Management has implemented internal controls over compliance in place to assist with the timely preparation of the SEFA.

View Audit 371159

Finding 1161149 (2021-002)

Material Weakness 2021

Pulaski Memorial Hospital

IN

Allowable Costs / Cost Principles Reporting

Corrective action: Management understands the due date for single audit reporting package submission to the Federal Audit Clearinghouse and filed as soon as possible

View Audit 371159

Finding 1161064 (2021-004)

Material Weakness 2021

Coal County Healthcare Authority

OK

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

Condition - Expenditures reported to HRSA were not in accordance with Pub. L. No. 116-136, 134 Stat. 563 Plan of Corrective Action Much research was performed by the Authority's leadership to identify guidance from HRSA including reviewing FAQs, Fact Sheets, consulting attorneys, auditors, consultan...

Condition - Expenditures reported to HRSA were not in accordance with Pub. L. No. 116-136, 134 Stat. 563 Plan of Corrective Action Much research was performed by the Authority's leadership to identify guidance from HRSA including reviewing FAQs, Fact Sheets, consulting attorneys, auditors, consultants and other parties. The complexity of the reporting requirements, including changing FAQ's and our inability to gain a definite approval of the use of our funds, resulted in the Authority filing the its submission based on the best available information at the time. The Authority's position is that the Provider Relief Funds were appropriately expensed using additional expenses and lost revenues not initially submitted to the portal. The Authority will continue to monitor the guidance for use of funds provided by HRSA and will strive to appropriately utilize all funds in the future. The Authority will review the most recently distributed Provider Relief Fund FAQ's which provide details on requirements related to the program Contact person: Chris Martin, CEO cmartin@ccghospital.com (580)927-2327 Expected implementation:2024 - 2025

View Audit 371035 Questioned Costs: $1

Finding 1159993 (2021-003)

Material Weakness 2021

Native Village of Tyonek

AK

Reporting § 200.328 § 200.329 § 200.501

Management has contracted with a contract accountant who has already started audit preparation services for future audits. The 2022 has been started and will be completed shortly. The 2023 audit will be started shortly. The Native Village expects to be fully caught up by their fiscal year 2025 audit...

Management has contracted with a contract accountant who has already started audit preparation services for future audits. The 2022 has been started and will be completed shortly. The 2023 audit will be started shortly. The Native Village expects to be fully caught up by their fiscal year 2025 audit.

View Audit 370455

Finding 1159992 (2021-002)

Material Weakness 2021

Native Village of Tyonek

AK

Reporting § 200.328 § 200.329

Management will ensure that all required grant reporting, both financial and/or narrative/programmatic will be prepared and submitted timely. The final reporting for the Treasury CARES ACT has been completed and submitted subsequent to year end.

View Audit 370455

Finding 1159785 (2021-010)

Material Weakness 2021

Program of Academic Exchange

NY

Reporting § 200.512

PAX will establish appropriate policies, procedures, and controls to ensure that future submissions of Uniform Guidance reports are filed timely. The primary deliverable will be timely audit completion and submission. Dije Kucana, Comptroller, and Bradley Smith, CEO, effective immediately

View Audit 370334

Finding 1155786 (2021-005)

Material Weakness 2021

Medstar, Inc.

MI

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Condition: The Organization was unable to provide supporting documentation to substantiate the allowability and accuracy of the expenses and lost revenue submitted in the portal. Planned Corrective Action: Company is an emergency services (ambulance, first responder, and was instrumental in the admi...

Condition: The Organization was unable to provide supporting documentation to substantiate the allowability and accuracy of the expenses and lost revenue submitted in the portal. Planned Corrective Action: Company is an emergency services (ambulance, first responder, and was instrumental in the administration of the monoclonal antibodies) - healthcare company and was during the pandemic. Company was able to provide general ledger information by personnel classification in aggregate monthly with percentages related to the Covid pandemic, Company changed payroll companies in June, 2022 from Trion to DM Payroll -where we were unable to access the payroll registers by personnel name. Medstar has full access to payroll registers through DM Payroll. Contact person responsible for corrective action: Lalainia Budyznowski Anticipated Completion Date: 06/30/2022 - Completed

View Audit 368173 Questioned Costs: $1

Finding 1154804 (2021-001)

Material Weakness 2021

New York State Housing Finance Agency

NY

Reporting § 200.303 § 200.502 § 200.510

Finding 2021‐001 Federal Agency: United States Department of Housing and Urban Development (HUD) Planned Corrective Actions: Responsible Official – Darryl Johnson, Deputy CFO Anticipated completion date – October 2025 Management will review its controls and update standard work documentation to ensu...

Finding 2021‐001 Federal Agency: United States Department of Housing and Urban Development (HUD) Planned Corrective Actions: Responsible Official – Darryl Johnson, Deputy CFO Anticipated completion date – October 2025 Management will review its controls and update standard work documentation to ensure that all loans and expenditures related to the Housing Trust Fund are appropriately accumulated and reported in the schedule of expenditures of federal awards (SEFA) for the period covered by the New York State Housing Finance Agency’s financial statements in accordance with Uniform Guidance 2 CFR section 200.502. All staff working on SEFA preparation and review, will receive additional education in reporting for federal programs.

View Audit 367167

Finding 576256 (2021-009)

Material Weakness 2021

Community Homeless Solutions

CA

Questioned Costs Allowable Costs / Cost Principles Material Weakness

The agency will implement a formal voucher and approval system to correctly record grant expenses

View Audit 366162 Questioned Costs: $1

Finding 575378 (2021-002)

None 2021

National Center for the Advancement of Stem

PA

Reporting § 200.512

Agency: National Center for the Advancement of STEM Education, Inc. (nCASE) Person Responsible for Corrective Action: Name: Nancy Priselac Title: Executive Director Anticipated Completion Date: December 8, 2023 Response to Finding: Management does not concur with audit recommendation. Correction Act...

Agency: National Center for the Advancement of STEM Education, Inc. (nCASE) Person Responsible for Corrective Action: Name: Nancy Priselac Title: Executive Director Anticipated Completion Date: December 8, 2023 Response to Finding: Management does not concur with audit recommendation. Correction Action to be Taken: Original audit was scheduled on time and completed in a timely manner with complete cooperation from nCASE. Audit results were shared with nCASE with no findings at that time. DoD has reviewed the matters covered in the audit report thoroughly, and the grant was closed out without any repayment of funds to DoD. Upon subsequent review and reconciliation, amounts were not overcharged.

View Audit 365412

Finding 575370 (2021-005)

Material Weakness 2021

McKenzie County Healthcare Systems, Inc. and Subsidiary

ND

Internal Control / Segregation of Duties Material Weakness Reporting § 200.303

Finding 2021-005 Federal Agency Name: Program Name: Finding Summary: Corrective Action Plan: Responsible Individual: Department of Health and Human Services COVID-19: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year Period 1 TIN #770637...

Finding 2021-005 Federal Agency Name: Program Name: Finding Summary: Corrective Action Plan: Responsible Individual: Department of Health and Human Services COVID-19: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year Period 1 TIN #770637498 Federal Assistance Listing #93.498 The Health System failed to provide an expense listing that supported the expenses included within the HHS Special Report - Period 1 (Report). In addition, the Health System's lost revenue report did not reconcile to the Report and there was no evidence of review by someone other than the preparer. We will implement internal control policies to ensure all amounts reported and submitted to the federal agency are adequately documented and supported We will also implement internal control policies to ensure that the required reports are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Scott Merkel, CFO Anticipated Completion Date: Ongoing

View Audit 365407

Finding 575368 (2021-004)

Material Weakness 2021

McKenzie County Healthcare Systems, Inc. and Subsidiary

ND

Reporting Material Weakness

Finding 2021-004 Federal Agency Name: Program Name: Finding Summary: Corrective Action Plan: Responsible Individual: Department of Health and Human Services COVID-19: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 1 TIN #77063...

Finding 2021-004 Federal Agency Name: Program Name: Finding Summary: Corrective Action Plan: Responsible Individual: Department of Health and Human Services COVID-19: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 1 TIN #770637498 Federal Assistance Listing #93.498 Department of Health and Human Services COVID 19: Disaster Grants - Public Assistance (Presidentially Declared Disasters) (FEMA) Federal Assistance Listing #97.036 The Health System does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. We requested that our auditors, Eide Bailly LLP, to draft the Schedule and accompanying notes to the Schedule. It is not cost effective to have an internal control system designed to provide for the preparation of the Schedule and accompanying notes to the Schedule. We requested that our auditors, Eide Bailly LLP, prepare the Schedule and accompanying notes to the Schedule as part of their annual audit. We have designated a member of management to review the drafted Schedule and accompanying notes to the Schedule. Scott Merkel, CFO Anticipated Completion Date: Ongoing

View Audit 365407

Finding 574878 (2021-012)

Material Weakness 2021

City of East St. Louis, Illinois

IL

Reporting

The City partially disagrees with the finding. The classification approach used by the City was based on guidance provided by the U.S. Department of the Treasury under SLFRF. Specifically, the City elected to treat up to $10 million in ARPA funds as revenue replacement and allocated these across two...

The City partially disagrees with the finding. The classification approach used by the City was based on guidance provided by the U.S. Department of the Treasury under SLFRF. Specifically, the City elected to treat up to $10 million in ARPA funds as revenue replacement and allocated these across two fiscal years to track usage of restricted vs. unrestricted portions. However, we acknowledge that SEFA preparation should reflect expenditures as reported under Uniform Guidance regardless of internal fund classifications. In response, we are: • Updating our SEFA preparation procedures to ensure full alignment with 2 CFR §200 Subpart F; • Implementing a review and sign-off process by both Finance and Grants Management prior to submission; • Providing training to our accounting team on federal expenditure classification and SEFA reporting standards. We will also consult with our external auditors during the next reporting cycle to validate fund treatment and ensure that reporting is accurate and consistent with federal expectations.

View Audit 365135

Finding 574877 (2021-011)

Material Weakness 2021

City of East St. Louis, Illinois

IL

Allowable Costs / Cost Principles Reporting

The City partially agrees with this finding. The ARPA funds in question were received and recorded by the Treasurer's Office, and documentation of the receipt was submitted to the auditors. However, due to technical limitations stemming from a system upgrade during the fiscal year, the transaction w...

The City partially agrees with this finding. The ARPA funds in question were received and recorded by the Treasurer's Office, and documentation of the receipt was submitted to the auditors. However, due to technical limitations stemming from a system upgrade during the fiscal year, the transaction was not interfaced properly with the general ledger side of the City's accounting system. To address this issue, the City is: • Working with the current software provider to resolve the integration problem; • Performing a full reconciliation of Treasurer records and general ledger entries for all ARPA funds; • Exploring the implementation of a more robust and user-friendly financial system to ensure proper recording and reporting in the future. Additionally, we are developing standard operating procedures to ensure manual entries are logged and reconciled during system outages or migration periods.

View Audit 365135

Finding 574737 (2021-010)

Material Weakness 2021

Claremont School District

NH

Questioned Costs Subrecipient Monitoring Material Weakness § 200.303 § 200.334

The District did not provide a corrective action plan

View Audit 365056 Questioned Costs: $1

Finding 574736 (2021-009)

Material Weakness 2021

Claremont School District

NH

Questioned Costs Subrecipient Monitoring Material Weakness § 200.303 § 200.334

The District did not provide a corrective action plan

View Audit 365056 Questioned Costs: $1

Finding 574658 (2021-011)

Material Weakness 2021

Virgin Islands Port Authority

VI

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.303

The Authority will continue to make progress in meeting required review processes and submission timelines. For the reports where the necessity of submission is in question, the Authority will consult with its federal partner to obtain a determination.

View Audit 364929

Finding 574653 (2021-009)

Material Weakness 2021

Virgin Islands Port Authority

VI

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.303

The Director of Engineering will sign reports submitted to the FAA as validation that the items have been reviewed. The Senior Compliance Officer serves as the record-keeper for documents filed between VIPA, the FAA, and other institutions, ensuring that VIPA submits the required filings and maintai...

The Director of Engineering will sign reports submitted to the FAA as validation that the items have been reviewed. The Senior Compliance Officer serves as the record-keeper for documents filed between VIPA, the FAA, and other institutions, ensuring that VIPA submits the required filings and maintains a working spreadsheet of items sent. Additionally, a tickler system has been implemented in accounting to serve as a reminder to submit financial reports to Engineering or the grantor.

View Audit 364929

Finding 574651 (2021-006)

Material Weakness 2021

Virgin Islands Port Authority

VI

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

The Authority will ensure that when a federal report is prepared by Director, it will be reviewed by another Director or member of the management team.

View Audit 364929

Finding 573946 (2021-005)

Significant Deficiency 2021

Bemidji Regional Airport Authority

MN

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Corrective Action Plan Actions Planned in Response to Finding Authority will implement a monitoring procedure over reporting forms. Official Responsible for Ensuring CAP Implementation Kyle Christiansen, Executive Director Planned Completion of CAP December 31, 2023.

View Audit 364568

Finding 573941 (2021-004)

Material Weakness 2021

Bemidji Regional Airport Authority

MN

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Corrective Action Plan Actions Planned in Response to Finding Authority staff will work with a third-part accountant on reconciling the balances and posting the proper year-end adjustments. The Authority will implement monitoring procedures over year-end accrual adjustments. Official Respons...

Corrective Action Plan Actions Planned in Response to Finding Authority staff will work with a third-part accountant on reconciling the balances and posting the proper year-end adjustments. The Authority will implement monitoring procedures over year-end accrual adjustments. Official Responsible for Ensuring CAP Implementation Kyle Christiansen, Executive Director Planned Completion of CAP December 31, 2024.

View Audit 364568

Corrective Action Plans

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