Corrective Action Plans

Finding 386626 (2021-003)

Significant Deficiency 2021

CA

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring

Management Response and Corrective Action Plan City’s Response: The City concurs with the finding. Staff responsible for this control during FY 2021 are no longer employed by the City. Corrective Action Plan: Current City Finance staff in conjunction with Police Department staff are monitoring ESAC ...

Management Response and Corrective Action Plan City’s Response: The City concurs with the finding. Staff responsible for this control during FY 2021 are no longer employed by the City. Corrective Action Plan: Current City Finance staff in conjunction with Police Department staff are monitoring ESAC reporting processes. Planned Implementation Date: started in Q4 FY 2023 and has continued into FY 2024 Responsible Person: Finance Department staff

View Audit 298952

Finding 384265 (2021-006)

Significant Deficiency 2021

City of Davis

CA

Period of Performance Reporting Matching / Level of Effort / Earmarking

Finding Reference Number: SA 2021-006 Timely Reporting and Return of Unspent Grant Advance AL Number: 21.019 Assistance Listing Title: COVID-19 – Coronavirus Relief Fund Federal Agency: Department of Treasury Pass Through Entity: Yolo County, California Department of Finance Federal Award Ide...

Finding Reference Number: SA 2021-006 Timely Reporting and Return of Unspent Grant Advance AL Number: 21.019 Assistance Listing Title: COVID-19 – Coronavirus Relief Fund Federal Agency: Department of Treasury Pass Through Entity: Yolo County, California Department of Finance Federal Award Identification Number: Unavailable (Yolo County) and 607 (California Department of Finance) • Fiscal Year of Initial Finding: 2021 • Name(s) of the contact person: Kelly Stachowicz, Assistant City Manager • Corrective Action Plan: City notified Yolo County of unspent funds in January 2021. City returned unspent funds to Yolo County in January ($222) and March ($27,617) of 2021, with reporting submitted to County in March of 2021. For future short-notice and unexpected grants provided to the City, the City will designate a lead staff person with bandwidth to manage said grant and clarify timelines with the granting agency. • Anticipated Completion Date: Completed in March 2021.

View Audit 297401

Finding 384254 (2021-004)

Material Weakness 2021

City of Davis

CA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Finding Reference Number: SA 2021-004 Federal Funding Accountability and Transparency Act (FFATA) Reporting AL Number: 14.218 Assistance Listing Title: COVID-19 - Community Development Block Grants/Entitlement Grants (CDBG) Federal Agency: Department of Housing and Urban Development Federal Aw...

Finding Reference Number: SA 2021-004 Federal Funding Accountability and Transparency Act (FFATA) Reporting AL Number: 14.218 Assistance Listing Title: COVID-19 - Community Development Block Grants/Entitlement Grants (CDBG) Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-14-MC-06-0037, B-18-MC-06-0037, B-19-MC-06-0037, B-20-MC-06-0037, B-20-MW-06-0037 • Fiscal Year of Initial Finding: 2021 • Name(s) of the contact person: Jennifer Block, Management Analyst • Corrective Action Plan: The City has an existing FFATA Procedure. All relevant staff (those working with federal funds) will receive training on the procedure to ensure familiarity with it and understanding of the requirements to complete FFATA reporting. The City filed the missing report in March 2024. • Anticipated Completion Date: March 10, 2024

View Audit 297401

Finding 384252 (2021-002)

Material Weakness 2021

City of Davis

CA

Reporting Cash Management Program Income

Finding reference number: SA 2021-002 Accurate Financial Reporting in the Annual PR26 Report Assistance Listing Number: 14.218 Assistance Listing Title: COVID-19 - Community Development Block Grants/Entitlement Grants (CDBG) Name of Federal Agency: Department of Housing and Urban Development Federa...

Finding reference number: SA 2021-002 Accurate Financial Reporting in the Annual PR26 Report Assistance Listing Number: 14.218 Assistance Listing Title: COVID-19 - Community Development Block Grants/Entitlement Grants (CDBG) Name of Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-14-MC-06-0037, B-18-MC-06-0037, B-19-MC-06-0037, B-20-MC-06-0037, B-20-MW-06-0037 • Fiscal Year of Initial Finding: 2021 • Name(s) of the contact person: Jennifer Block, Management Analyst • Corrective Action Plan: Since FY 2021, the City has reviewed its organizational structure and processes for management of the CDBG grant program. At the end of FY 2023, the City brought the program back in-house to the newly-created Department of Social Services and Housing (SSH). In FY 2024, staff developed a process to ensure timely and consistent draws, with reconciliation to the general ledger at the point of each draw. SSH staff have developed a timeline of required actions for the program to ensure compliance with deadlines. • Anticipated Completion Date: June 30, 2024

View Audit 297401

Finding 383644 (2021-004)

Material Weakness 2021

Daviess Community Hospital

IN

Allowable Costs / Cost Principles Reporting

Management continues to evaluate the current controls related to reporting to ensure amounts are appropriately stated. Under a revised calculation, utilizing detailed listings of expenses and updated lost revenue calculations, we have adequate expenses and lost revenues to support funding reported ...

Management continues to evaluate the current controls related to reporting to ensure amounts are appropriately stated. Under a revised calculation, utilizing detailed listings of expenses and updated lost revenue calculations, we have adequate expenses and lost revenues to support funding reported for Periods 1 and 2.

View Audit 296677

Finding 383643 (2021-003)

Material Weakness 2021

Daviess Community Hospital

IN

Allowable Costs / Cost Principles Reporting

Management continues to evaluate the current controls related to reporting to ensure amounts are appropriately stated. Though the decrease was significant, we have adequate expenses and lost revenues to support funding reported for Periods 1 and 2.

View Audit 296677

Finding 382374 (2021-008)

Significant Deficiency 2021

Children's Home of Kingston

NY

Reporting Internal Control / Segregation of Duties

2021-008 – Submission to Federal Audit Clearinghouse; Beginning March 2024, the Agency will establish and implement internal controls over financial reporting sufficient to ensure Single Audits are completed and submitted in a timely manner. The Board of Directors will request a review of Financial ...

2021-008 – Submission to Federal Audit Clearinghouse; Beginning March 2024, the Agency will establish and implement internal controls over financial reporting sufficient to ensure Single Audits are completed and submitted in a timely manner. The Board of Directors will request a review of Financial Audits annually. This will ensure Single Audits are completed and submitted in a timely manner. The Chief Executive Officer [CEO, Executive Director], Marianne Gribbon will meet with the Controller (Jarri Melton) weekly to ensure timely financial reporting. Reports will be provided to the board of Directors monthly. The Agency plans to adhere to the following timeline: •June 2024: completion of 21-22 (2022) audit •December 2024: completion of 22-23 (2023) audit •March 2025: completion of 23-24 (2024) audit •December 2025: completion of 24-25 (2025) audit Additionally, the Board of Directors will meet with the auditors during the December Board of Directors meeting to review the findings of the previous year’s audit (i.e., in December 2025, the auditors will review the 2024-2025 audit.) This will be a standing meeting between the Board of Directors and the auditors. Considering the significant delay in reporting, the Board of Directors will review the audit within one month of finalizing the audit. The timeline for outstanding audits is as follows: •21-22 (2022) audit will be reviewed no later than July 2024 •22-23 (2023) audit will be reviewed no later than January 2025 •23-24 (2024) audit will be reviewed no later than April 2025 •24-25 (2025) audit will be reviewed no later than January 2026 The Board is aware of the significant reporting delay. The CAP, presented here, will be shared with the Board during March 2024 to ensure compliance and timely reporting.

View Audit 296079

Finding 382372 (2021-007)

Significant Deficiency 2021

Children's Home of Kingston

NY

Reporting

2021-007 Financial and Performance Reporting; Beginning March 2024, the Agency will conduct a review of timely submission of reporting is performed as part of the audit procedures. The Agency will implement a procedure that includes establishing reoccurring due dates on the Agency’s Microsoft 365 Ou...

2021-007 Financial and Performance Reporting; Beginning March 2024, the Agency will conduct a review of timely submission of reporting is performed as part of the audit procedures. The Agency will implement a procedure that includes establishing reoccurring due dates on the Agency’s Microsoft 365 Outlook Calendar with the following positions included on the calendar invite: •Chief Program Officer – Mackenzie Anson, •Program Director – Catherine Cruz, •Controller – Jarri Melton, and Chief Executive Officer – Marianne Gribbon. This will ensure the required reports are completed and submitted by the required due dates. The Controller (Jarri Melton) will develop monthly and quarterly closing procedures to aid in the timely closing and filing of reports required by CFDA No. 93.676. Furthermore, the Board of Directors Executive Committee will be notified of all upcoming audits at the beginning of each fiscal year. The Board will be kept informed of the audit process and the CEO, Marianne Gribbon, will provide monthly updates during Executive Committee meetings.

View Audit 296079

Finding 380908 (2021-009)

Material Weakness 2021

Love County Health Center D/b/a Mercy Health Love County

OK

Reporting Material Weakness

Finding 2021-009 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital does not have an internal control system designed to provide for a complete and accurate sche...

Finding 2021-009 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. Responsible Individuals: Scott Callender Corrective Action Plan : Due to the small accounting staff there was little internal review of the schedule of federal expenditures resulting in errors. The Hospital will adopt a policy where the schedule of expenditures will be reviewed by a qualified individual. Anticipated Completion Date: Ongoing

View Audit 295601

Finding 380907 (2021-008)

Material Weakness 2021

Love County Health Center D/b/a Mercy Health Love County

OK

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Finding 2021-008 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy to ensure reported amounts agreed with under...

Finding 2021-008 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy to ensure reported amounts agreed with underlying supporting documentation. In addition the underlying supporting documentation contained errors. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process to a ensure the report agrees with the under lying supporting documentation. Anticipated Completion Date: Ongoing

View Audit 295601

Finding 380906 (2021-007)

Material Weakness 2021

Love County Health Center D/b/a Mercy Health Love County

OK

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

Finding 2021-007 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were bei...

Finding 2021-007 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were being reduced by Medicare's reimbursement or claimed on other grants. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process to ensure amounts claimed for this program are reduced by amounts reimbursed or obligated by another source and include a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission Anticipated Completion Date: Ongoing

View Audit 295601

Finding 380905 (2021-006)

Material Weakness 2021

Love County Health Center D/b/a Mercy Health Love County

OK

Allowable Costs / Cost Principles Reporting Procurement, Suspension & Debarment § 200.303

Finding 2021-006 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA# 93.498 Finding Summary: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were...

Finding 2021-006 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA# 93.498 Finding Summary: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were being in the proper period. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. Anticipated Completion Date: Ongoing

View Audit 295601

Finding 380904 (2021-005)

Material Weakness 2021

Love County Health Center D/b/a Mercy Health Love County

OK

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues ...

Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues was reviewed and approved. Accordingly, the errors in the lost revenue calculation spreadsheet were not identified by management. In addition, the Hospital did not have an internal control process in place to ensure a review and approval of the Period 1 Report was performed by someone other than the preparer of the report. Responsible Individuals: Scott Callender Corrective Action Plan : The Hospital will implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. Anticipated Completion Date: Ongoing

View Audit 295601

Finding 380734 (2021-002)

None 2021

Housing Authority of Crisfield

MD

HUD Housing Programs Reporting

Data Collection Form and Financial Data Schedule (Non Compliance) Recommendation: We recommended that the Authority develop procedures to ensure that future reporting packages and FDS reports are submitted by the respective deadlines. Explanation of disagreement with audit finding: There is no disag...

Data Collection Form and Financial Data Schedule (Non Compliance) Recommendation: We recommended that the Authority develop procedures to ensure that future reporting packages and FDS reports are submitted by the respective deadlines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will review and enhance our policies and procedures over year end close, to ensure all adjustments are made timely to allow for timely audit facilitation to ensure we are meeting the DCF and FDS deadlines. Name(s) of the contact person(s) responsible for corrective action: Don Bibb, Executive Director Planned completion date for corrective action plan: December 31, 2023

View Audit 295401

Finding 380731 (2021-001)

Material Weakness 2021

Housing Authority of Crisfield

MD

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Financial Reporting (Material Weakness) Recommendation: The Authority must implement processes and controls to ensure accurate interim and year-end financial statements. Adequate and accurate financial information is vital to make management decisions that impact the Authority. This information must...

Financial Reporting (Material Weakness) Recommendation: The Authority must implement processes and controls to ensure accurate interim and year-end financial statements. Adequate and accurate financial information is vital to make management decisions that impact the Authority. This information must be shared timely and discussed to make the necessary changes that are needed and to prepare the proper cash flow projections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will review and enhance our policies and procedures over year end close, to ensure all adjustments are made timely to allow for timely audit facilitation to ensure we are meeting the DCF and FDS deadlines; Name(s) of the contact person(s) responsible for corrective action: Don Bibb, Executive Director Planned completion date for corrective action plan: December 31, 2023

View Audit 295401

Finding 380615 (2021-002)

None 2021

Housing Commission of Talbot

MD

HUD Housing Programs Reporting

Data Collection Form and Financial Data Schedule (Non Compliance) Recommendation: We recommended that the Commission develop procedures to ensure that future reporting packages and FDS reports are submitted by the respective deadlines. EQ\JALHOUSIIIG OPPORTUNITY Explanation of disagreement ...

Data Collection Form and Financial Data Schedule (Non Compliance) Recommendation: We recommended that the Commission develop procedures to ensure that future reporting packages and FDS reports are submitted by the respective deadlines. EQ\JALHOUSIIIG OPPORTUNITY Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will review and enhance our policies and procedures over year end close, to ensure all adjustments are made timely to allow for timely audit facilitation to ensure we are meeting the DCF and FDS deadlines. Name(s) of the contact person(s) responsible for corrective action: Don Bibb, Executive Director Planned completion date for corrective action plan: December 31, 2023

View Audit 295388

Finding 380614 (2021-001)

Material Weakness 2021

Housing Commission of Talbot

MD

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Financial Reporting (Material Weakness) Recommendation: The Commission must implement processes and controls to ensure accurate interim and year-end financial statements. Adequate and accurate financial information is vital to make management decisions that impact the Commission. This information mu...

Financial Reporting (Material Weakness) Recommendation: The Commission must implement processes and controls to ensure accurate interim and year-end financial statements. Adequate and accurate financial information is vital to make management decisions that impact the Commission. This information must be shared timely and discussed to make the necessary changes that are needed and to prepare the proper cash flow projections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Commission will review and enhance our policies and procedures over year end close, to ensure all adjustments are made timely. In addition, we create policy and procedures to perform an assessment for component unit determination of any new legally separate organization that is established. Name(s) of the contact person(s) responsible for corrective action: Don Bibb, Executive Director Planned completion date for corrective action plan: December 31, 2023

View Audit 295388

Finding 377354 (2022-002)

Material Weakness 2021

Red Wind Consulting INC

CO

Subrecipient Monitoring Material Weakness Reporting

Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of reporting. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document in wri...

Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of reporting. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document in writing, the process and review it with department leaders. Additionally, staff members working in areas concerning this process will be trained to ensure process adherence.

View Audit 295151

Finding 375950 (2021-005)

Material Weakness 2021

Hogar Fortaleza Del Caido, Inc.

PR

Reporting Material Weakness § 200.512

See the Corrective Action Plan for chart/table.

View Audit 295003

Finding 375831 (2021-001)

Material Weakness 2021

California Asian Pacific Chamber of Commerce

CA

Reporting Subrecipient Monitoring Material Weakness

Description of Finding: Untimely audit submission in accordance with OMB Uniform Guidance Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian understands the seriousness of this deficiency an...

Description of Finding: Untimely audit submission in accordance with OMB Uniform Guidance Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian understands the seriousness of this deficiency and the need for strict adherence to timely audit submissions per the OMB Uniform Guidance. Additional staff have been hired to assist in accounting processes; and an Interim Controller has been hired to review all accounting processes and procedures with the Director of Finance, provide best practice recommendations and month-end closing schedule. Monthly reviews of the financial data, including reconciliations of all accounts will be performed and reviewed by the Controller and Director of Finance. Implementation of these recommendations will help to mitigate the risk of untimely submissions in future years. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: July 2024

View Audit 294918

Finding 375495 (2021-014)

Material Weakness 2021

Okmulgee County

OK

Reporting Internal Control / Segregation of Duties § 200.303 § 200.502 § 200.508 § 200.510

Management will work together to design and implement a system of internal controls to ensure an accurate reporting of revenues and expenditures on the SEFA, that the notes to the SEFA are prepared, and compliance with all applicable federal requirements.

View Audit 294536

Finding 375454 (2021-003)

Material Weakness 2021

Hale County Hospital

AL

Reporting Cash Management Eligibility

We are implementing policies to address the audit finding 2021-003 as follows: We have implemented a policy to ensure that all future Provider Relief Fund reporting is reviewed prior to filing. Anticipated completion date: September 30, 2024

View Audit 294509

Finding 375452 (2021-004)

Significant Deficiency 2021

Hale County Hospital

AL

Reporting Internal Control / Segregation of Duties

We are implementing policies to address the audit finding 2021-004 as follows: We are continuing to institute processes and procedures to complete timely reconciliations to allow for future filings to be made prior to the deadline. Anticipated completion date: September 30, 2024

View Audit 294509

Finding 375451 (2021-001)

Material Weakness 2021

On the Road Lending

TX

Reporting Matching / Level of Effort / Earmarking

We agree with the recommendation and will implement procedures to oversee the timely filing of the federal single audit or program specific audit reporting package.

View Audit 294504

Finding 375421 (2021-005)

Significant Deficiency 2021

Municipality of Morovis

PR

Reporting

We concur with the finding. The pandemic caused by the outbreak of COVID-19 disrupted and delayed many accounting and reporting processes during the fiscal year 2020 since the Municipality had to shut down operations for various months. Consequently, several projects and tasks calendarized were post...

We concur with the finding. The pandemic caused by the outbreak of COVID-19 disrupted and delayed many accounting and reporting processes during the fiscal year 2020 since the Municipality had to shut down operations for various months. Consequently, several projects and tasks calendarized were postponed or delayed, including certain reports required by Federal Regulations and Uniform Guidance. As disclosed in Comments and Corrective Actions of Finding #2021-001, the Municipality hired an Accounting Firm which is already working with the necessary adjustments, conversions entries and details and subsidiaries to prepare the Municipality’s financial statements for the fiscal year ended June 30, 2022. Expected Implementation Date: a) The financial statements for the fiscal year 2021-2022 are currently in process. We expect to submit a draft for audit during July 2024. b) The Municipality signed with the external accounting firm a professional services contract for the preparation of the financial statements for the fiscal year 2021-2022. The time schedule includes submission to the external auditors of a draft of the financial statements during July 2024 to a final audit report issued on or before September 2024. c) Related to the audit reports for the fiscal years 2022-2023 and 2023-2024, we are planning to complete and submit them in compliance with the Uniform Guidance on or before March 2025. With this schedule the Municipality will be following the Uniform Guidance. Responsible Person: Finance Department Director.

View Audit 294483

Corrective Action Plans

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