Corrective Action Plans

Finding 516933 (2023-003)

Significant Deficiency 2023

MI

Subrecipient Monitoring Period of Performance Significant Deficiency § 200.1 § 200.332 § 200.414

The Agency agrees with the finding. When granting funds as a subaward to a pass-through entity, the Agency will update its master templates for subawards to include the required information. In addition, when the sub agreements are routed for signature and reviewed by the Chief Financial Officer, ...

The Agency agrees with the finding. When granting funds as a subaward to a pass-through entity, the Agency will update its master templates for subawards to include the required information. In addition, when the sub agreements are routed for signature and reviewed by the Chief Financial Officer, they will be double-checked to ensure compliance with this requirement.

View Audit 334839

Finding 516920 (2023-001)

Material Weakness 2023

City of Tacoma

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Material Weakness

The City is fully committed to establishing and maintaining robust internal controls to ensure compliance with federal requirements, particularly in the administration of federal grant programs. Reporting: To meet Federal Funding and Transparency Act (FFATA) reporting requirements, the City will tak...

The City is fully committed to establishing and maintaining robust internal controls to ensure compliance with federal requirements, particularly in the administration of federal grant programs. Reporting: To meet Federal Funding and Transparency Act (FFATA) reporting requirements, the City will take the following actions: Update training material and implement annual training for all Accounting staff and City departments managing federal grants. Update and distribute monthly email to departments to clarify the required information for FFATA filing and require responses with supporting documentation for review. Periodically review federal reporting requirements for any updates and make adjustments as needed, utilizing resources such as the State Auditor’s Office (SAO) Newsletter, conferences, and trainings. Wage Rate Requirement: To meet Davis Bacon Act reporting requirements, the City will incorporate the verbiage from 29 CFR 5.5(a) in full into specifications, as applicable, which will be incorporated into the resulting contracts.

View Audit 334833

Finding 516898 (2023-003)

Significant Deficiency 2023

Comprehensive Community Solutions, INC

IL

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

Finding Number: 2023-003 Finding Name: Data Collection Form Late Submission Finding Synopsis: The organization did not submit the December 31, 2023 data collection form and reporting package to the Federal Audit Clearinghouse in a timely matter. Action Steps: The late submission was due to switching...

Finding Number: 2023-003 Finding Name: Data Collection Form Late Submission Finding Synopsis: The organization did not submit the December 31, 2023 data collection form and reporting package to the Federal Audit Clearinghouse in a timely matter. Action Steps: The late submission was due to switching audit service providers. Systems and procedures are already in place to ensure timely completion of audit and submission of the audit package to the Federal Audit Clearinghouse. Management is now aware that when switching audit firms we will have to allocate more time for the new firm to get familiar with the agency. Contact Person(s): William Chatman, Executive Director/CEO, 815-963-6236 Claudia Seijas, Director of Finance, 815-963-6236 Anticipated Completion Date: Continues

View Audit 334793

Finding 516666 (2023-001)

Significant Deficiency 2023

Philip Health Services, Inc.

SD

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

RE: Audit Finding Corrective Action Plan Philip Health Services recognizes the need for an account to be designated for the loan reserve of $210,564. We will designate a CD in the CDARS Accounts in the amount of $250,000 that is insured by FDIC with a term of 2 years. When this CD is renewed, ...

RE: Audit Finding Corrective Action Plan Philip Health Services recognizes the need for an account to be designated for the loan reserve of $210,564. We will designate a CD in the CDARS Accounts in the amount of $250,000 that is insured by FDIC with a term of 2 years. When this CD is renewed, it will continue to be reserved until the loan reaches an amount that will no longer require the designation. Respectfully, Maureen Cadwell Chief Executive Officer Philip Health Services, Inc.

View Audit 334657

Finding 516587 (2023-002)

Significant Deficiency 2023

Southwestern Wisconsin Community Action Program, Inc.

WI

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

2023-002: Late Audit Submission Auditor's Recommendation: SWCAP should take steps to ensure that its financial records are available in a timely manner to allow the audit to begin sufficiently before the audit due date. SWCAP also should work with their auditing firm to agree upon information that w...

2023-002: Late Audit Submission Auditor's Recommendation: SWCAP should take steps to ensure that its financial records are available in a timely manner to allow the audit to begin sufficiently before the audit due date. SWCAP also should work with their auditing firm to agree upon information that will and will not be prepared by SWCAP so that a proper audit plan can be developed for timely completion. Corrective Action: SWCAP acknowledges the delay in completing the 2023 audit. The unforeseen staffing challenges by our auditing firm in conjunction with our internal turnover significantly impacted our timeline. SWCAP has identified and implemented changes with its personnel and hired an outsourced accounting firm. SWCAP has implemented proactive measures to streamline its audit preparation and submission processes to prevent similar delays in the future. These include enhancing internal review procedures, ensuring clear communication with auditors, and allocating sufficient resources for timely compliance with reporting requirements, federal regulations, and guidelines. Responsible for Corrective Action: Finance Team (Outsourced accounting firm, Operations Manager, Executive Director). Anticipated Completion Date: Completed as of December 2024.

View Audit 334558

Finding 516504 (2023-002)

Significant Deficiency 2023

Housing Authority of the City of Fort Myers

FL

Eligibility HUD Housing Programs Significant Deficiency

The following procedure is put in place to prevent the conditins found during a recent audit review of the LIPH and HCV files: All staff will read HUD requirements for reexamining income and family composition for families in the Public Housing and Housing Voucher Programs. Property managers will ...

The following procedure is put in place to prevent the conditins found during a recent audit review of the LIPH and HCV files: All staff will read HUD requirements for reexamining income and family composition for families in the Public Housing and Housing Voucher Programs. Property managers will be reuqiqred to complete training courses in 2024. Property clerks and leasing specialists will be required to complete Rent Calculation courses that coorelate to their program type. HACFM is actively working on creating operation procedures and process manuals. the Procedure manaul will include the following reuqirements: Annual recertificaton packets will be sent to the resident 120 days from the houshold's annual effective date. Submission of reuqired documentation from resident will be enforced according to the lease agreements. A certification review checklist to support staff in ensuring all documnetation is in the file and all requried signatures are present. The Checklist will ensure that the submitter is verifying the file, the property manager has certified the file prior to finalizing the review in the tenant software program and uploading the file to the records. The property manager is reuqired to conduct 5% audit of the files monthly and correct any deficiencies found. An audit checklist will be created to support this required task. The management analyst position is required to audit 5 random files from each site on a quarterly basis. Ans audit checklist will be createdto support this required task.

View Audit 334417

Finding 516327 (2023-004)

Significant Deficiency 2023

All Nations Health Center, Inc.

MT

Reporting Significant Deficiency § 200.512

The Center intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.

View Audit 334164

Finding 516326 (2023-003)

Significant Deficiency 2023

All Nations Health Center, Inc.

MT

Allowable Costs / Cost Principles Subrecipient Monitoring Significant Deficiency § 200.303

The Business and Finance Department at ANHC has mandated, from all departments at ANHC, an approval form for all “Autopay” transactions to be signed by the ED immediately.

View Audit 334164

Finding 515829 (2023-005)

Significant Deficiency 2023

Isanti County

MN

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Significant Deficiency in ...

Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Recommendation: We recommend the County puts in place the proper procedures to ensure it has proper controls in place to properly document support for all payroll expenditures coded to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will review its procedures and controls over payroll to ensure supporting documentation is retained, reviewed and approved for all employees. Name(s) of the contact person(s) responsible for corrective action: Angie Larson, Auditor-Treasurer / Chief Financial Officer Planned completion date for corrective action plan: December, 31 2024

View Audit 333691 Questioned Costs: $1

Finding 515705 (2003-001)

Significant Deficiency 2023

Biostl

MO

Subrecipient Monitoring Reporting Significant Deficiency

Personnel Responsible For Corrective Action: Mike Higgins, Vice President of Development, Taylor McCabe, Director of Grants Management, and Finance Lead, Tia Newcom Anticipated Completion Date: Expected completion by December 31, 2024Corrective Action Plan: The audit identified that FFATA (Federal F...

Personnel Responsible For Corrective Action: Mike Higgins, Vice President of Development, Taylor McCabe, Director of Grants Management, and Finance Lead, Tia Newcom Anticipated Completion Date: Expected completion by December 31, 2024Corrective Action Plan: The audit identified that FFATA (Federal Funding Accountability and Transparency Act) subaward reports were not submitted properly or on time for first-tier subawards of $30,000 or more. The deficiency was attributed to a lack of awareness of this requirement and the absence of specific internal controls to ensure timely reporting to the Federal Subaward Reporting System (FSRS). To address this finding and establish compliance with 2 CFR Part 170, BioSTL has implemented additional measures and expanded policies and procedures to ensure timely reporting to the FSRS. To ensure the highest compliance, BioSTL has incorporated the standard federal FFATA form as an exhibit within the subawardee contracts, ensuring timely collection of necessary data. This incorporation not only enables the direct gathering of general information within the contract but also includes the requirement for subawardees to complete and sign the standard FFATA form. This approach is paired with additional training and education for both BioSTL’s Grant Management personnel, Program Directors, and the leadership team within subawardee organizations, ensuring that all parties are fully aware of the initial and any ongoing reporting requirements. Through the formalized contractual process, BioSTL has implemented enhanced internal controls by requiring supervisory review and approval at multiple levels. Submitted FFATA documentation will undergo review by the Program Director managing the grant, the Director of Grants Management, and the Vice President of Development, ensuring thorough oversight and compliance at each step. To support this process, BioSTL has implemented an Airtable-based compliance reminder system to automate notifications related to FFATA form submissions. Automated reminders will be sent to both pass-through partners and relevant program staff, reminding them to complete the annual FFATA form submission. Notifications will be issued on September 1st as a 30-day advance notice and again on September 15th, with a final submission deadline to BioSTL set for September 30th of each year. These reminders ensure proactive follow-up and help maintain annual compliance. BioSTL will also ensure that both Program Directors and the Grants Department thoroughly review all submitted FFATA documents, reinforcing accuracy and adherence to reporting timelines.

View Audit 333569

Finding 515609 (2023-001)

Significant Deficiency 2023

Kansas Association of Conservation Districts

KS

Procurement, Suspension & Debarment Significant Deficiency Internal Control / Segregation of Duties § 200.319

Management agrees with the findings and recommendation. The District will update its policies and procedures to ensure they meet the Uniform Guidance Requirements. .

View Audit 333385

Finding 515471 (2023-133)

Significant Deficiency 2023

State of Arizona

AZ

Internal Control / Segregation of Duties Eligibility Reporting

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of B...

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Budget and Finance Anticipated completion date: December 31, 2024 Agency’s Response: Concur AHCCCS concurs with the finding in this audit and would like to note this finding is related to no notice of disenrollment being mailed to a deceased member, and not related to enrollment ineligibility. AHCCCS Division of Member and Provider Services (“DMPS”) will identify the standard process for notification that should have been followed for this case. Once the root cause of the issue has been established, AHCCCS will assess current processes and procedures, as appropriate, to address this issue.

View Audit 333243

Finding 514626 (2023-003)

Significant Deficiency 2023

Rape Crisis Center of Collin County

TX

Allowable Costs / Cost Principles Cash Management Significant Deficiency

Finding Number: 2023-003: Allowable Costs – 1 of the 25 payroll transactions tested, the amount of time charged to the grant did not agree wo the employee’s timesheet. Planned Corrective Action: Turning Point has as an established Grant Activity Reports – Time and Effort Recording policy. We will en...

Finding Number: 2023-003: Allowable Costs – 1 of the 25 payroll transactions tested, the amount of time charged to the grant did not agree wo the employee’s timesheet. Planned Corrective Action: Turning Point has as an established Grant Activity Reports – Time and Effort Recording policy. We will ensure strict adherence to our policy by verifying that all hours charged to grants match employee timesheets. Staff will receive additional training on proper reporting procedures, and monthly audits will be conducted to ensure compliance moving forward. Anticipated Completion Date: October 1, 2024 Responsible Contact Person: Tana Rice, Director of Finance

View Audit 332994

Finding 514624 (2023-001)

Significant Deficiency 2023

Rape Crisis Center of Collin County

TX

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

Finding Number: 2023-001: Allowable Costs – 4 out of the 25 samples tested did not have documented approval from management of the charges on the credit card statement prior to payment. Planned Corrective Action: The Turning Point has an established credit card policy which outlines the appropriate ...

Finding Number: 2023-001: Allowable Costs – 4 out of the 25 samples tested did not have documented approval from management of the charges on the credit card statement prior to payment. Planned Corrective Action: The Turning Point has an established credit card policy which outlines the appropriate approval processes. We have addressed the previous Finance Director’s non-compliance of this policy by providing training on this process to the new Finance Director, have begun implementing regular audits, and ensuring senior leadership has access to all documents needed for approval. Future adherence will be monitored through quarterly reviews and disciplinary action for noncompliance. Anticipated Completion Date: October 1, 2024 Responsible Contact Person: Tana Rice, Director of Finance

View Audit 332994

Finding 514312 (2023-002)

Significant Deficiency 2023

Charlotte Community Health Clinic, Inc.

NC

Significant Deficiency Internal Control / Segregation of Duties Special Tests & Provisions

2023-002 Significant Deficiency in Internal Controls over Compliance Recommendation: CLA recommends that the sliding fee discount program assessment form is reviewed to endure the proper rate is used for each patient. Documentation of the review should be maintained. Action planned in response to ...

2023-002 Significant Deficiency in Internal Controls over Compliance Recommendation: CLA recommends that the sliding fee discount program assessment form is reviewed to endure the proper rate is used for each patient. Documentation of the review should be maintained. Action planned in response to finding: The Front Desk lead will review the sliding fee discount document and verify accuracy of calculation and sign the application.

View Audit 332576

Finding 514240 (2023-001)

Significant Deficiency 2023

Jewish Family Services of Silicon Valley

CA

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

We have received and reviewed the comments in your audit report, which you provided following the audit of our financial statements for the fiscal year ending June 30, 2023. Below is our detailed response to the findings and recommendations: Finding 2023-001: Significant Deficiency in Internal Contr...

We have received and reviewed the comments in your audit report, which you provided following the audit of our financial statements for the fiscal year ending June 30, 2023. Below is our detailed response to the findings and recommendations: Finding 2023-001: Significant Deficiency in Internal Control over compliance related to reporting, specifically the Federal Audit Clearinghouse Data Collection Form - Modified and Repeated Criteria or Specific Requirements: Uniform Guidance 2 CFR 200.512(a) requires recipients expending $750,000 or more in Federal awards during their fiscal year to submit the data collection and reporting package within the earlier 30 calendar days after the receipt of the auditor’s report(s) or nine months after the end of the audit period. Auditor's Recommendation: Harshwal recommends that the Organization (Jewish Family Services of Silicon Valley, JSFSV) evaluate its policies and procedures regarding report submission to ensure the timely submission of all compliance reports. In addition, the Organization should maintain documentation to support the appropriate and timely submission of the single audit (SF-SAC form). Management Response: JFSSV acknowledges the delay in completing the FY23 audit. The unforeseen need for an additional auditor, identified during the FY22 audit process, significantly impacted our timeline. Despite this challenge, JFSSV promptly engaged a new auditing firm to ensure continuity and accuracy in our financial reporting. JFSSV has implemented proactive measures to streamline its audit preparation and submission processes to prevent similar delays in the future. These include enhancing internal review procedures, ensuring clear communication with auditors, and allocating sufficient resources for timely compliance with reporting requirements, federal regulations, and guidelines. JFSSV's progress is as follows: • FY22 audit was completed by June 24, 2023. • FY23 audit is on track for completion by December 2024. • FY24 audit is targeted for completion by March 2025, ensuring compliance with federal reporting timelines. JFSSV is fully committed to maintaining and improving its financial and operational controls. We will continue to monitor corrective actions and adjust our policies and procedures as necessary to prevent similar issues in the future.

View Audit 332447

Finding 514062 (2023-003)

Significant Deficiency 2023

Planned Parenthood Association of Utah

UT

Significant Deficiency Program Income Internal Control / Segregation of Duties § 200.303

Finding 2023-003 Finding Summary: In connection with the audit performed, it was noted that there was an instance where a patient received more federal assistance and another patient received less federal assistance than allowed based on federal poverty guidelines. Responsible Individuals: Kathryn B...

Finding 2023-003 Finding Summary: In connection with the audit performed, it was noted that there was an instance where a patient received more federal assistance and another patient received less federal assistance than allowed based on federal poverty guidelines. Responsible Individuals: Kathryn Boyd, President and CEO Corrective Action Plan: The use of applying slides automatically, without reviewing the account first, has been prohibited by billing staff. In addition, clinic staff are not to apply any payments until the slide has been applied. If there are any issues with the slide, the clinic staff has been instructed to contact the billing staff for review and resolution. The Director of Revenue Cycle will randomly audit staff throughout the year to ensure additional slides are not applied and report out to the Chief Executive Officer. Anticipated Completion Date: 12/02/2024 (disallowing application of slides was previously implemented in 2023)

View Audit 332257

Finding 514022 (2023-003)

Significant Deficiency 2023

Nebraska Domestic Violence Sexual Assault Coalition

NE

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.512

The previous auditors did not submit the required information into the Federal Audit Clearing House at the sooner of nine months after the end of the fiscal year end or 30 days after the completion of the audit. We are communicating with the current audit staff on a frequent basis so this can be com...

The previous auditors did not submit the required information into the Federal Audit Clearing House at the sooner of nine months after the end of the fiscal year end or 30 days after the completion of the audit. We are communicating with the current audit staff on a frequent basis so this can be completed in a timely manner.

View Audit 332223

Finding 513823 (2023-005)

Significant Deficiency 2023

Tulsa Community Foundation

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency § 200.318 § 200.326

Description of Finding: The Foundation and its affiliates did not ensure proper documentation was retained regarding its procurement process. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will adopt a pr...

Description of Finding: The Foundation and its affiliates did not ensure proper documentation was retained regarding its procurement process. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will adopt a procurement policy in accordance with UGG, will collaborate more closely with project partners of federal grants to ensure documentation requirements for the procurement process are adhered to and work to centralize grant documentation for all awards. Name of Contact Person: Kristin Karlin, Controller Projected Completion Date: The Foundation projects the new policy documentation to be complete and centralization of grant documentation to be established by March 31, 2025.

View Audit 331804

Finding 513822 (2023-004)

Significant Deficiency 2023

Tulsa Community Foundation

OK

Subrecipient Monitoring Internal Control / Segregation of Duties Reporting

Description of Finding: The Foundation and its affiliates did not ensure proper performance reporting was completed for individual grants. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will collaborate mo...

Description of Finding: The Foundation and its affiliates did not ensure proper performance reporting was completed for individual grants. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will collaborate more closely with project partners of federal grants to establish reporting deadlines and monitor individual reporting requirements throughout the year. Name of Contact Person: Kristin Karlin, Controller Projected Completion Date: The Foundation projects the new policy documentation to be complete and the process for internal monitoring documentation to be established by March 31, 2025.

View Audit 331804

Finding 513670 (2023-009)

Significant Deficiency 2023

The City of Homewood, Alabama

AL

Reporting Significant Deficiency Internal Control / Segregation of Duties

The City of Homewood, Alabama is in the process of submitting their Project and Expenditure Report to the Department of Treasury that was due on April 30, 2023.

View Audit 331570

Finding 513662 (2023-007)

Significant Deficiency 2023

The City of Homewood, Alabama

AL

Allowable Costs / Cost Principles Reporting Significant Deficiency

The City of Homewood, Alabama will strive to submit its Single Audit Reporting Package to the federal audit clearinghouse no later than nine months after the fiscal year end for all future funds received from the federal government.

View Audit 331570

Finding 513615 (2023-001)

Material Weakness 2023

Weston County Hospital District

WY

Internal Control / Segregation of Duties Material Weakness Reporting

2023-001 Provider Relief Fund Reporting of Lost Revenue Corrective action planned: Management intends to perform an internal recalculation on the information included on the PRF reports. Those recalculated figures will be reconciled to the respective internal and audited financial statements. Antici...

2023-001 Provider Relief Fund Reporting of Lost Revenue Corrective action planned: Management intends to perform an internal recalculation on the information included on the PRF reports. Those recalculated figures will be reconciled to the respective internal and audited financial statements. Anticipated completion date: June 2025 Contact person responsible for corrective action: Tish Miller, Chief Financial Officer

View Audit 331524

Finding 513467 (2023-001)

Material Weakness 2023

Pend Oreille County Public Hospital District No. 1

WA

Material Weakness Reporting Significant Deficiency

2023-001 Provider Relief Fund Reporting of Lost Revenue Corrective action planned: The District moved to a new EHR in the first quarter of 2021. Implementation of the new system put our accounting department behind. When the PRF was reported on, the cost report settlement had not been booked. There...

2023-001 Provider Relief Fund Reporting of Lost Revenue Corrective action planned: The District moved to a new EHR in the first quarter of 2021. Implementation of the new system put our accounting department behind. When the PRF was reported on, the cost report settlement had not been booked. Therefore, the initial gross revenue amount was off. The District expects to have accounting closed much closer to its fiscal year end starting in 2024. Anticipated completion date: January 2024 Contact person responsible for corrective action: Kim Manus, Chief Financial Officer

View Audit 331346

Finding 513427 (2023-006)

Significant Deficiency 2023

Hinds County School District

MS

Allowable Costs / Cost Principles Reporting Significant Deficiency

Finding 2023-006 Corrective Action: The district will ensure that all semi-annuals are signed as stated in the policy manual. The Business Manager will collaborate with Federal Funded directors and obtain copies of semi-annual certifications. Responsible Parties: Avery Johnson, Business Manager Robe...

Finding 2023-006 Corrective Action: The district will ensure that all semi-annuals are signed as stated in the policy manual. The Business Manager will collaborate with Federal Funded directors and obtain copies of semi-annual certifications. Responsible Parties: Avery Johnson, Business Manager Robert Sanders, Superintendent Tiffany Lanier, Federal Programs Director Corrective Action Start Date: October 31, 2024

View Audit 331265

Corrective Action Plans

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