Corrective Action Plans

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

Finding 572446 (2021-005)

Significant Deficiency 2021

City of Ithaca

NY

Reporting

Condition Reporting is performed by the City Controller, who has many years of experience in reporting under Uniform Guidance and is capable and has not had any findings in the past regarding this requirement. The reports are lightly reviewed by the Deputy Controller and City Manager. However, n...

Condition Reporting is performed by the City Controller, who has many years of experience in reporting under Uniform Guidance and is capable and has not had any findings in the past regarding this requirement. The reports are lightly reviewed by the Deputy Controller and City Manager. However, no formal process is in place to document such approval. Therefore, there is no control that can be tested to verify this review. Corrective Action Plan The City will implement a formal review and sign-off by the Deputy Controller and City Manager.

View Audit 363568

Finding 571920 (2021-004)

Significant Deficiency 2021

Choctaw County

OK

Reporting Allowable Costs / Cost Principles § 200.303 § 200.502 § 200.508 § 200.510

We will adopt procedures and implement to ensure accurate reporting of expenditures on the SEFA and to ensure compliance with federal requirements.

View Audit 362988

Finding 571780 (2021-004)

Significant Deficiency 2021

Gunnison Valley Hospital Special Service District

UT

Reporting Significant Deficiency

Assistance Listing Number: #93.498 Program Name: Provider Relief Fund and American Rescue Plan {ARP} Rural Distribution Compliance Requirement: Other Finding Summary: The District does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of f...

Assistance Listing Number: #93.498 Program Name: Provider Relief Fund and American Rescue Plan {ARP} Rural Distribution Compliance Requirement: Other Finding Summary: The District does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. We were requested to draft the schedule of expenditures of federal awards Responsible Individuals: Brian Murray, Chief Financial Officer Corrective Action Plan: GVH will review its' internal controls related to grant tracking. It also assign a project or grant account number to each grant and code all expenditures to that account code. The items in this account will be logged and the appropriate back identified and maintained.

View Audit 362800

Finding 571779 (2021-003)

Material Weakness 2021

Gunnison Valley Hospital Special Service District

UT

Material Weakness Reporting Internal Control / Segregation of Duties

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: Provider Relief Fund and American Rescue Plan {ARP} Rural Distribution Compliance Requirement: Reporting Finding Summary: The District did not have adequate internal controls policy in plac...

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: Provider Relief Fund and American Rescue Plan {ARP} Rural Distribution Compliance Requirement: Reporting Finding Summary: The District did not have adequate internal controls policy in place to ensure lost revenue reported were accurate and based upon underlying. Responsible Individuals: Brian Murray, Chief Financial Officer Corrective Action Plan: GVH will review its internal controls related to lost revenue calculations to ensure the lost revenue calculations reconciles to the supporting and audited accounting records.

View Audit 362800

Finding 571476 (2021-001)

Material Weakness 2021

Native American Lifelines, INC

MD

Reporting

Management has been in contact with their funders regarding the late submission and no action is expected. Management will arrange for future audits and submissions to be performed timely

View Audit 362387

Finding 570632 (2020-001)

Material Weakness 2021

Village of Shungopavi

AZ

Material Weakness Reporting

December 20, 2023 Harshwal & Company, LLP 6565 Americas Parkway NE, Suite 800 As required by Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), we have provided below our respons...

December 20, 2023 Harshwal & Company, LLP 6565 Americas Parkway NE, Suite 800 As required by Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), we have provided below our response and corrective action plan addressing the finding noted in the Village of Shungopavi's single audit reporting package for the fiscal year ended December 31, 2020. 1. Finding 2020-001 Compliance with Reporting Requirements of Single Audit Corrective Action Plan: Yes, management agrees with the finding. As the new manager coming on the job in October of 2022, I am aware of this requirement and for the future years the Village will comply with meeting the required deadline for submitting the SF-SAC single audit data collection form to the Federal Audit Clearinghouse. Anticipated completion date: May 3, 2024 This being the first time Village of Shungopavi is doing a single audit, it will take time to set up an account and input the information required on the form. Responsible person: Gene Kuwanquaftewa, Community Services Administrator Gene Kuwanquaftewa P om unity Services Administrator Village of Shungopavi

View Audit 361660

Finding 570097 (2021-002)

Material Weakness 2021

County of Belknap, New Hampshire

NH

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

Planned Corrective Action: Finance Director will review quarterly report prior to submission. Planned Implementation Date of Corrective Action: Immediately upon notification, June 09, 2025. Person Responsible for Corrective Action: County Administrator and Finance Director

View Audit 361369

Finding 570042 (2021-004)

Material Weakness 2021

Local Redevelopment Authority of the Lands and Facilities of Naval Station Roosevelt Roads

PR

Procurement, Suspension & Debarment Reporting Matching / Level of Effort / Earmarking § 200.512

2021-004 Late Single Audit Submissions Category: Material weakness in Internal Control and Material Noncompliance Condition: The Authority has not timely submitted the Single Audit Reporting Packages for the years ended June 30, 2021, and 2022. Management’s Response: Starting in FY 2024-2025, the Fi...

2021-004 Late Single Audit Submissions Category: Material weakness in Internal Control and Material Noncompliance Condition: The Authority has not timely submitted the Single Audit Reporting Packages for the years ended June 30, 2021, and 2022. Management’s Response: Starting in FY 2024-2025, the Finance Department will maintain detailed records of all payments made, deposits received, and the reimbursement and transfer processes. This approach ensures that all reports are completed in a timely manner. To strengthen internal control over accounts, disbursements, and fund entries, the LRA’s Finance Department will hire additional personnel. These new team members are responsible for updating and managing accounting records. Together, they have established a strict timeline for completing important tasks to ensure a clear and concise flow of funds. The workloads will be divided among the team, with specific responsibilities assigned for Accounts Receivable, Accounts Payable, Bank Reconciliation, and Bookkeeping. Some responsibilities are interlinked, allowing team members to support one another in the event of absence or the need for assistance and providing documents to the external audits for the Single Audits. Person in charge: Juan C. Rodriguez Rivera Accounting Official 787-705-7188 Juan.rodriguez@lra.pr.gov Implementation Date: FY 2024-2025

View Audit 361347

Finding 570041 (2021-003)

Material Weakness 2021

Local Redevelopment Authority of the Lands and Facilities of Naval Station Roosevelt Roads

PR

Reporting Procurement, Suspension & Debarment Period of Performance

2021-003 Performance and Financial Reports Submissions Category: Material weakness in Internal Control and Material Noncompliance Condition: The Authority did not comply with the submission due dates of the Performance Reports and Federal Financial Reports established by the OEA in their Notice of A...

2021-003 Performance and Financial Reports Submissions Category: Material weakness in Internal Control and Material Noncompliance Condition: The Authority did not comply with the submission due dates of the Performance Reports and Federal Financial Reports established by the OEA in their Notice of Award granted on June 6, 2020. In addition, from five reports examined to test compliance with due dates, the submission date could not be verified in four instances, including the Federal Financial Report. Management’s Response: Starting in FY 2024-2025, the Finance Department will maintain detailed records of all payments made, as well as the reimbursement and transfer processes. The LRA’s Finance Department will hire additional personnel to strengthen the internal control of its accounts, disbursements, and fund entries. The new team members will be task with updating and managing accounting records. Together, they have will develop a strict timeline for completing important tasks to ensure a concise and transparent flow of funds. Workloads will be divided, with specific responsibilities assigned to individual team members, including Accounts Receivable, Accounts Payable, Bank Reconciliation, and Bookkeeping. Some responsibilities are interconnected, allowing team members to support each other in case of absence or when assistance is needed. Person in charge: Juan C. Rodriguez Rivera Accounting Official 787-705-7188 Juan.rodriguez@lra.pr.gov Implementation Date: FY 2024-2025

View Audit 361347

Finding 568040 (2021-007)

Material Weakness 2021

City of Cortland

NY

Reporting § 200.502

Corrective Action Plan Finding 2021-006 and 2021-007 Identification of Federal Awards and Preparation of a Complete and Accurate Schedule of Expenditures of Federal Awards (SEFA) Criteria: The Uniform Guidance requires the auditee to prepare a SEFA for the period covered by the auditee's financia...

Corrective Action Plan Finding 2021-006 and 2021-007 Identification of Federal Awards and Preparation of a Complete and Accurate Schedule of Expenditures of Federal Awards (SEFA) Criteria: The Uniform Guidance requires the auditee to prepare a SEFA for the period covered by the auditee's financial statement. It is the responsibility of the auditee's management to design and implement internal controls that provide reasonable assurance over the completeness and accuracy of the SEFA. The SEFA is the basis for the auditor's identification of major programs. Condition: The City's initial SEFA provided for the audit was incomplete and contained inaccurate program expenditure amounts. In particular, there were multiple federal programs that were materially misstated; including the following major federal program for the year under audit: ALN 14.228 Community Development Block Grants/State's Program and Non-Entitlement Grants in Hawaii In addition, there were multiple federal programs that were not identified, or had inaccurate amounts reported, on the initial SEFA for the year under audit: ALN 10.664 Cooperative Forestry Assistance - not identified ALN 97.036 Disaster Grants - Public Assistance (Presidentially Declared Disasters) - inaccurate amounts reported ALN 21.027 (COVID-19) Coronavirus State and Local Fiscal Recovery Funds - inaccurate amounts reported Cause: The City does not have a method to accurately track the related expenditures for reporting. Effect or Potential Effect: A Uniform Guidance compliance audit is based on the premise that management must comply with federal statutes, regulations and the terms and conditions of the federal awards it received. Without identifying the funds as federal, the auditee may not have complied with those requirements. In addition, there is increased risk regarding the accurate reporting of grant expenditures and noncompliance with policies and procedures surrounding the recording of federal awards. Questioned Costs: None Context: The City was aware of the requirement to prepare a SEFA prior to the audit; however, they were not able to accumulate the appropriate records to correctly identify the source of funding for all ongoing projects. In addition, management was unable to accurately determine the amounts to be reported on the SEFA in accordance with 2 CFR §200.502. The adjustments to the SEFA amounted to an increase in Total Federal Expenditures reported of $366,330. Repeat Finding: This is not a repeat finding. Recommendation: We recommend the City develop and implement procedures to ensure that information related to all federal awards is accumulated to assist in the preparation of the SEFA. In addition, we recommend management of the City verify the completeness and accuracy of the amounts reported on the SEFA. Response: The City agrees with the finding, and will develop a method for accurately tracking federal expenditures. Anticipated Completed Date: June 30, 2025 Responsible Contact Person: Elizabeth Greenwood, Director of Administration & Finance City of Cortland, 25 Court Street, Cortland, NY 13045 (607) 758-8373

View Audit 360421

Corrective Action Plans

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