Corrective Action Plans

Finding 479063 (2023-001)

Significant Deficiency 2023

MI

Eligibility HUD Housing Programs Significant Deficiency

The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" t...

The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" to be served. The Corporation contacted three staff in the regional HUD office, including the staff that had been our representative for annually renewed operation and support service grants for the two projects. Regional HUD staff were not able to provide a copy of the original grant agreements which would indicate the number of persons to be served by each project. HUD staff stated that they do not keep copies of grant agreements longer than seven years. Corporation management will continue to work with HUD personnel to determine the continuing compliance requirements of the Continuum of Care funding received for initial construction or rehabilitation. Corporation management will continue to serve individuals meeting the definition of homelessness at its two projects and document evidence in the file.

View Audit 315585

Finding 479054 (2023-001)

Significant Deficiency 2023

Evergreen Youth & Family Services, Inc.

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that clients meet eligibility requirements before being enrolled in the program. This could include verifying age at the time of enrollment and ...

Transitional Living for Homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to ensure that clients meet eligibility requirements before being enrolled in the program. This could include verifying age at the time of enrollment and periodically re-verifying eligibility for on-going clients. Additionally, the Organization should review its policies and procedures to ensure that they are in compliance with program requirements and make any necessary updates. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Clearly define eligibility requirements for staff conducting intakes, along with the intake process. Staff and Program Director will reverify eligibility when doing check requests. Two opportunities will be provided for staff each year to revisit eligibility requirements and to provide staff with refresher training. Intake Process: At the time of intake into the program, client’s will be asked for their driver’s license, state ID, permit, tribal ID, or birth certificate. If the client doesn't have any Identification, staff will calculate the client's age using the client's reported date of birth. Staff will then attempt to help the client secure personal vital documents and add copies to the client file for verification. The Program Director will also verify eligibility. Training: Staff to be trained in the spring and fall of each year to revisit eligibility requirements, intake processes, along with agency core values, mission and vision. Name(s) of the contact person(s) responsible for corrective action: Elena Guerra, EYS Program Director Planned completion date for corrective action plan: • Clearly define eligibility requirements for staff by July 1, 2024. • Host trainings by September 30, 2024, and March 31, 2025. • Verify eligibility for new clients and current clients on an ongoing basis.

View Audit 315565

Finding 479025 (2023-003)

Significant Deficiency 2023

Catholic Social Services

NE

Reporting Internal Control / Segregation of Duties Significant Deficiency

CSS management will improve its system of internal controls in order to actively track and adhere to reporting requirements outlined in its award agreements.

View Audit 315529

Finding 479024 (2023-002)

Significant Deficiency 2023

Catholic Social Services

NE

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.512

CSS management will improve staffing and internal controls to ensure compliance with the timely reporting requirements stated in 2 CFR §200.512.

View Audit 315529

Finding 479014 (2023-002)

Significant Deficiency 2023

Arapahoe County, Colorado

CO

Special Tests & Provisions HUD Housing Programs Significant Deficiency

HOME Investment Partnerships Program and COVID-19 HOME Investment Partnerships Program - Significant Deficiency Condition: The County did not conduct the required inspections of the HOMEassisted rental housing units during the year ended December 31, 2023. Recommendation: We recommend the County con...

HOME Investment Partnerships Program and COVID-19 HOME Investment Partnerships Program - Significant Deficiency Condition: The County did not conduct the required inspections of the HOMEassisted rental housing units during the year ended December 31, 2023. Recommendation: We recommend the County continue to train personnel so that the inspections are completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In 2023, performance issues with the administration of the HOME program were discovered, to include the absence of required inspections. With significant turnover of tenured leadership and employees within the Community Resources Department, Arapahoe County Community Resources took proactive measures in 2023 for review of the Community Development Housing and Homeless Services (CDHHS) programs by recognized consultants within the field. Community Resources has contracted with two consultants, to assist in a full review and re-development of policies and procedures (Civitas) for the CDBG and HOME programs as well as a full review of all case files (Affordable Housing Consultants). Included with this response are the contracts with both Civitas and Affordable Housing Consultants for verification purposes. The County anticipates their work to be completed and an implementation of updated policies and procedures for these programs by fall of 2024. The role of Program Administrator over the HOME program was not filled until April of 2024. This role will be responsible for all future HOME program inspections. Community Resources CDHHS employees will be taking part in a two-day training in June 2024 (June 11th and 12th, 2024) for the following:  Davis Bacon & Related Acts (Applicability, wage determinations, payroll review, interviews, common errors and how to correct)  Section 3 (Applicability, Safe Harbor benchmarks, documenting compliance, qualitative efforts)  TBRA Inspections (National Standards for the Physical Inspection of Real Estate (NSPIRE) administrative procedures)  HOME Program - Implementation and Best Practices - Arapahoe County, CO - June 12, 2024  This HOME training is an introductory course focusing on underwriting and subsidy layering requirements.  Eligible Activities (Homeowner rehab programs, Homebuyer programs, Rental housing)  Underwriting (Subsidy layering and underwriting requirements and best practices)  Community Housing Development Organization (CHDO) (Requirements, best practices, management, etc)  Long-term Compliance (HOME Match, eligible beneficiaries, income limits, subsidy layering & limits, affordability, written agreements, etc)  IDIS and Reporting Arapahoe County staff will be conducting monitoring of the two Tenant Based Rental Assistance (TBRA) programs and projects within in the affordability period (20-year span) between mid-June to mid-August of 2024. The remaining HOME program projects, within the affordability period (20-year span) will have audits completed by the end of our 2023 grant cycle, September 30th, 2024. Name of the contact person responsible for corrective action: Katherine Smith Planned completion date for corrective action plan: September 30, 2024

View Audit 315527

Finding 478994 (2023-035)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

Reporting Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment § 200.303

DEPARTMENT OF PUBLIC HEALTH 2023-035 Opioid – STR - Assistance Listing No. 93.788 Action taken in response to the finding: Reporting - GRPA Submission evidence: Per recommendations of the auditing team the Project PI will review all data provided to them by the project staff before submitting to SP...

DEPARTMENT OF PUBLIC HEALTH 2023-035 Opioid – STR - Assistance Listing No. 93.788 Action taken in response to the finding: Reporting - GRPA Submission evidence: Per recommendations of the auditing team the Project PI will review all data provided to them by the project staff before submitting to SPARS. When review is finalized the PI will submit the reports to SPARS. At this time the PI will screenshot an image of each report submission page to SPARS for each GPRA report and save the file as a pdf. (This will need to be done as the reporting system does not return a confirmation report for filings.) Any subsequent updates of data will similarly be reviewed, compared to previous submissions to ensure accuracy, and logged. The same documentation will be recorded and stored with the previous submission data to keep accurate record of any changes. Data to create/compile the report (back up, supporting documentation to match the report) process. These pdf records documenting the time and date of initial report submissions and any edits will be kept on file with both the PI in their Teams program file, and with the BSAS Grant Teams SOR grant file for the corresponding grant year for future reference. Our internal Fiscal Compliance Auditor will review batches of these submission quarterly to ensure compliance. Evidence of Review & Approval process: These records will be reviewed both by the Grant PI and the BSAS Grants specialist to ensure accuracy, in particular where changes are being made. If changes have been made to data that may require future explanation the cause of the variances will be noted by the PI and documentation will be include with the submission records. Reporting – Programmatic Progress Reports Submission evidence: Per recommendations of the auditing team the Project PI will review all data provided to them by the project staff before submitting to eRA Commons. When review is finalized the PI will submit the reports to eRA Commons. At this time the PI will screenshot an image of each report submission page to eRA Commons for each PPR and save the file as a pdf. (This will need to be done as the reporting system does not return a confirmation report for filings.) Any subsequent updates of data will similarly be reviewed, compared to previous submissions to ensure accuracy, and logged. The same documentation will be recorded and stored with the previous submission data to keep accurate record of any changes. Data to create/compile the report (back up, supporting documentation to match the report) process. These pdf records documenting the time and date of initial report submissions and any edits will be kept on file with both the PI in their Teams program file, and with the BSAS Grant Teams SOR grant file for the corresponding grant year for future reference. Our internal Fiscal Compliance Auditor will review batches of these submission quarterly to ensure compliance. Evidence of Review & Approval process: These records will be reviewed both by the Grant PI and the BSAS Grants specialist to ensure accuracy, in particular where changes are being made. If changes have been made to data that may require future explanation the cause of the variances will be noted by the PI and documentation will be included with the submission records. Name of the contact person responsible for corrective action: Shannon McEneaney-Farron, BSAS Fiscal Director, Nicole Schmitt, Director of the Office of Strategy and Innovation (Grant PI) Planned completion date for corrective action plan: Ongoing. This process will commence as of July 1, 2024.

View Audit 315520

Finding 478987 (2023-032)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

Questioned Costs Special Tests & Provisions Significant Deficiency § 200.303

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2023-032 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Action taken in response to the finding: In response to the finding, MassHealth will • Implement corrective measures to ensure workbooks are revamped ...

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2023-032 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Action taken in response to the finding: In response to the finding, MassHealth will • Implement corrective measures to ensure workbooks are revamped and that processes are implemented to automate and improve the importation of data and to allow more time for quality control review. • Work with staff to develop additional checks to ensure the correct federal share is reported and returned. • Return the identified federal share in the QE 03.2024 CMS 64. Name of the contact person responsible for corrective action: Janet Chin, Director Federal Revenue Claiming, Title XIX & XXI Planned completion date for corrective action plan: Immediate and ongoing

View Audit 315520 Questioned Costs: $1

Finding 478982 (2023-031)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

Special Tests & Provisions Reporting Significant Deficiency § 200.303

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2023-031 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Action taken in response to the finding: The Executive Office of Health and Human Services (EOHHS) has reviewed the required elements of reports submi...

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2023-031 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Action taken in response to the finding: The Executive Office of Health and Human Services (EOHHS) has reviewed the required elements of reports submitted by managed care providers with EOHHS staff and reviewed the steps that EOHHS staff should take when any element of those reports is missing. Name of the contact person responsible for corrective action: Robert Roche, FP&A Analyst Planned completion date for corrective action plan: May 2, 2024

View Audit 315520

Finding 478972 (2023-029)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

Questioned Costs Eligibility Special Tests & Provisions § 200.303

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2023-029 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Action taken in response to the finding: Dental: In response to the finding MassHealth required DentaQuest to: • Implement a corrective action plan to...

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2023-029 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Action taken in response to the finding: Dental: In response to the finding MassHealth required DentaQuest to: • Implement a corrective action plan to review and improve internal controls for the retention of provider enrollment documentation. • Ensure that all required documents are obtained and retained during validation and revalidation (i.e., “provider eligibility recertification”) processes for both individual dental providers and dental group practices. • Provide additional training to its provider enrollment staff on document retention. DentaQuest has implemented the above requirements to ensure provider license and revalidation dates are verified and maintained in MassHealth’s Medicaid Management Information System (MMIS) upon enrollment and subsequent revalidation. However, MassHealth anticipates that due to a backlog in the dental group practice revalidation process, dental group practice revalidation will not be complete January 2025. In the event that a MassHealth-enrolled provider or group practice does not timely respond to MassHealth revalidation requests, MassHealth initiates the process of terminating the provider’s MassHealth contract. BSS: For the one out of state provider that MassHealth did not revalidate, once identified, the provider was immediately put into a revalidation process. The provider did not respond to requests from MassHealth to revalidate and the provider’s MassHealth contract was terminated effective 1/21/2024 for failure to revalidate. MassHealth and BSS will continue to review and ensure that all providers who are required to revalidate are completed within the CMS required timeframes. Name of the contact person responsible for corrective action: Tuyen Vu, Deputy Director, Dental Janice Wadsworth, Director of Provider Operations Planned completion date for corrective action plan: Dental: January 1, 2025 BSS: January 21, 2024

View Audit 315520 Questioned Costs: $1

Finding 478932 (2023-018)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION 2023-018 COVID-19 – Elementary and Secondary School Emergency Relief Fund (ESSER), COVID-19 – American Rescue Plan – Elementary and Secondary School Emergency Relief (ARP ESSER) – Assistance Listing No. 84.425D, 84.425U Action taken in response to the...

DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION 2023-018 COVID-19 – Elementary and Secondary School Emergency Relief Fund (ESSER), COVID-19 – American Rescue Plan – Elementary and Secondary School Emergency Relief (ARP ESSER) – Assistance Listing No. 84.425D, 84.425U Action taken in response to the finding: In FY24, internal controls and procedures were implemented to ensure that all required subawards are reported timely to FSRS no later than the end of the month following the month of issuance. Name of the contact person responsible for corrective action: Robert Curtain, Chief Officer for Data and Accountability Planned completion date for corrective action plan: July 1, 2023

View Audit 315520

Finding 478931 (2023-017)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION 2023-017 Title I Grants to Local Educational Agencies – Assistance Listing No. 84.010 Action taken in response to the finding: In FY24, internal controls and procedures were implemented to ensure that all required subawards are reported timely to FSR...

DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION 2023-017 Title I Grants to Local Educational Agencies – Assistance Listing No. 84.010 Action taken in response to the finding: In FY24, internal controls and procedures were implemented to ensure that all required subawards are reported timely to FSRS no later than the end of the month following the month of issuance. Name of the contact person responsible for corrective action: Robert Curtain, Chief Officer for Data and Accountability Planned completion date for corrective action plan: July 1, 2023

View Audit 315520

Finding 478930 (2023-016)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

Questioned Costs Eligibility Significant Deficiency § 200.303

EXECUTIVE OFFICE OF HOUSING AND LIVABLE COMMUNITIES 2023-016 COVID-19 – Emergency Rental Assistance Program – Assistance Listing No. 21.023 Action taken in response to the finding: EOHLC has notified Nan McKay of the income ineligibility. Nan McKay and EOHLC agreed with the finding. In February 202...

EXECUTIVE OFFICE OF HOUSING AND LIVABLE COMMUNITIES 2023-016 COVID-19 – Emergency Rental Assistance Program – Assistance Listing No. 21.023 Action taken in response to the finding: EOHLC has notified Nan McKay of the income ineligibility. Nan McKay and EOHLC agreed with the finding. In February 2024 Nan McKay sent payment recoupment letters to the landlord and the utility company to attempt to recoup the funds paid on behalf of an ineligible household. EOHLC met with Nan McKay leadership staff on 04/18/2024 to review income eligibility steps for emergency rental assistance programs. Name of the contact person responsible for corrective action: Amy Mullen Planned completion date for corrective action plan: April 18, 2024

View Audit 315520 Questioned Costs: $1

Finding 478913 (2023-011)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2023-011 WIOA Cluster, Employment Service Cluster – Assistance Listing No. 17.258, 17.259, 17.278, 17.207, 17.801 Action taken in response to the finding: In FY 2023, a Corrective Action Plan (CAP) was drafted and implemented to address prior aud...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2023-011 WIOA Cluster, Employment Service Cluster – Assistance Listing No. 17.258, 17.259, 17.278, 17.207, 17.801 Action taken in response to the finding: In FY 2023, a Corrective Action Plan (CAP) was drafted and implemented to address prior audit findings related to Federal Financial Reports (FFR). Prior audit findings were a result of extraordinary turnover within EOLWD’s Finance Office, which resulted in having no staff who were fully dedicated to filing Federal Financial Reports (FFR). The CAP included: (1) filling vacant positions; (2) training new staff in the federal reporting process and requirements; (3) automating business practices; and (4) drafting and implementing an FFR Standard Operating Procedure (SOP). The first three corrective actions identified in the CAP were implemented throughout FY 2023. The SOP for Federal Financial Reporting was developed throughout FY 2023 and implemented in FY 2024. The necessary controls for ensuring that ETA 9130 reports reflect earmarking requirements and are accurately supported by documentation that support reported balances were implemented with the implementation of the FFR SOP in FY 2024. In addition, the automated business practices cited in the CAP were refined throughout FY 2023 to ensure data in supporting documentation correlates to what is reported on an ETA 9130 report. Name of the contact person responsible for corrective action: Malachy Rice, Director of Federal Grants Management Planned completion date for corrective action plan: October 1, 2023

View Audit 315520

Finding 478900 (2023-006)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2023-006 Unemployment Insurance, COVID-19 – Unemployment Insurance – Assistance Listing No. 17.225 Action taken in response to the finding: While Massachusetts BAM unit (MBAM) had been making progress in meeting timeliness deadlines, it began suff...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2023-006 Unemployment Insurance, COVID-19 – Unemployment Insurance – Assistance Listing No. 17.225 Action taken in response to the finding: While Massachusetts BAM unit (MBAM) had been making progress in meeting timeliness deadlines, it began suffering setbacks in or around July 2022. MBAM was experiencing difficulties with the SUN server not accepting data and the system adding additional edits that should not have existed. Consistent work with the USDOL Hotline resolved the issues and/or created workarounds. Ultimately the SUN server failed after degrading for a year. The server was unavailable for use sporadically through the year and for four full separate weeks in May, June, and July 2023. Not only were staff unable to submit DCI data but it took additional organizational work of handling unentered cases, additional time to work with the Hotline and test fixes, while needing additional steps to implement work arounds for items that could not be fixed. MBAM continues to utilize work arounds for BAM data entry. Since SWA’s SUN server has become functional again, MBAM has been improving timeliness. MBAM also continues to work with ETA Hotline to report and resolve defects within the SUN system. MBAM management also developed an organizational strategy for the unit to provide its investigators with weekly updates on what cases should be worked on based on batch due dates. A case status report has been developed to provide unit supervisors with the status of each case assigned, expected date of completion, work completed to date on case, and cause for delay. Additionally, MBAM management has developed in-house reporting to track individual investigators. The reports track each investigator, telling management the number of cases closed each week and tracking the aging of Investigations. The manager uses these reports to identify cases to be prioritized based on aging and to quickly identify if a specific investigator is lagging in their case closure. Based on performance, the Manager has coaching sessions with individual investigators a minimum of every two weeks where work prioritization, organization, and any other additional necessary issues are reviewed and discussed. A meeting with all investigators is held weekly to provide education, discuss change to policy/procedure, and provide an open forum for BAM program implementation questions. Monitoring also occurs at the end of each quarter. Based on outcome, discussion of weaknesses and development of new levels of support are discussed and implemented. Name of the contact person responsible for corrective action: Susan Saulnier, Director of UI Performs Planned completion date for corrective action plan: September 30, 2024

View Audit 315520

Finding 478896 (2023-003)

Significant Deficiency 2023

Commonwealth of Massachusetts

MA

Allowable Costs / Cost Principles Subrecipient Monitoring Period of Performance § 200.303 § 200.308 § 200.309 § 200.403

DEPARTMENT OF ELEMENTARY PUBLIC HEALTH 2023-003 WIC Special Supplemental Nutrition Program for Women, Infants, and Children – Assistance Listing No. 10.557 Action taken in response to the finding: The Department and the WIC Nutrition Program will have all fiscal staff review the Operating Procedur...

DEPARTMENT OF ELEMENTARY PUBLIC HEALTH 2023-003 WIC Special Supplemental Nutrition Program for Women, Infants, and Children – Assistance Listing No. 10.557 Action taken in response to the finding: The Department and the WIC Nutrition Program will have all fiscal staff review the Operating Procedures to refresh themselves of the procedures surrounding Purchase Orders and Expenditures. (Excerpt from Operating Procedures) All Staff should complete a “Request for Purchase” form with all pertinent information such as quotes, renewal notices, conference registration, etc. and submit it to supervisor or Director for initial approval. Once the request is approved, the form is given to a fiscal staff to start the process of encumbering funds through MMARS and preparing a PURCHASE ORDER. At the very least, staff will identify that the service performed is correct and that funds are available and already encumbered to process the payment. All federal payments require a Program Code, and so the fiscal staff need to be sure the appropriate one is entered based on the dates of service or the date of the Purchase Order. Once all documents have been uploaded and submitted, then either the WIC State Director or the Fiscal Director will need to electronically approve the transaction in the Tracking System. The Fiscal Director and the State Director will more thoroughly review the assignment of Program Codes as they pertain to the Federal grant award dates before approving payment documents. This review will involve verifying: • The type of service • Date of service or receipt of item • Date of Purchase Order • Program Codes Name of the contact person responsible for corrective action: Beverly Andrew and Rachel Colchamiro Planned completion date for corrective action plan: April 30, 2024

View Audit 315520

Finding 478873 (2023-003)

Significant Deficiency 2023

Harvest Against Hunger

WA

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking

Federal Agency: U.S. Department of the Treasury Federal Program Name: Coronavirus State and Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: K3422 & K3724 - 2021 Pass-Through Agency: Washington State Department of Agriculture Pass-Through Number(s...

Federal Agency: U.S. Department of the Treasury Federal Program Name: Coronavirus State and Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: K3422 & K3724 - 2021 Pass-Through Agency: Washington State Department of Agriculture Pass-Through Number(s): E128H7X5KWX5 Award Period: 7/1/21-6/30/23; 11/19/21-6/30/23 Type of Finding: • Significant Deficiency in Internal Control over Compliance Section III – Findings and Questioned Costs – Major Federal Programs Condition: Harvest Against Hunger allocates costs to the program based on the available funding and number of employees working on the project. They do not use the timesheet to record the operating hours for the program, but rather management makes a judgmental decision based on their understanding of program operations during the payroll period. Questioned costs: None Cause: The Organization lacks documentation supporting the allocation determination used to determine payroll amounts charged to the major program. Views of responsible officials: There is no disagreement with the finding. Criteria or specific requirement: Per §200.303, non-Federal entities must "establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non- Federal entity is managing the Federal award in compliance with Federal statues, regulations, and the terms and conditions of the Federal awards." Additionally, non-Federal entities must charge salaries and wages "based on records that accurately reflect the work performed" (§200.430(i)). Effect: Without proper documentation of the payroll allocation used, the Organization could charge time to a federal program that does not reflect true expenditures incurred by that program. Repeat Finding: This is not a repeated finding. Recommendation: The Organization should implement policies for consistently determining time allocation to the federal program, and ensure internal controls help to ensure this allocation is correct and consistently documented

View Audit 315495

Finding 478779 (2023-010)

Significant Deficiency 2023

Alameda Health System, A Public Hospital Authority

CA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will review, modify, and implement policies and procedures over the program to ensure that required reports are prepared and reviewed by separate individuals. Documentation will be mai...

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will review, modify, and implement policies and procedures over the program to ensure that required reports are prepared and reviewed by separate individuals. Documentation will be maintained by the program to evidence preparation and review processes and timely filing of required reports.

View Audit 315421

Finding 478778 (2023-009)

Significant Deficiency 2023

Alameda Health System, A Public Hospital Authority

CA

Cash Management Period of Performance Subrecipient Monitoring § 200.305

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will review, modify, and implement policies and procedures over the program to ensure funds are disbursed for expenditures incurred prior to requesting reimbursement and that expenditu...

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will review, modify, and implement policies and procedures over the program to ensure funds are disbursed for expenditures incurred prior to requesting reimbursement and that expenditures are incurred within the contract’s performance period.

View Audit 315421

Finding 478774 (2023-005)

Significant Deficiency 2023

Alameda Health System, A Public Hospital Authority

CA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will review, modify, and implement policies and procedures over the program to ensure that required reports are prepared and reviewed by separate individuals. Documentation will be mai...

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will review, modify, and implement policies and procedures over the program to ensure that required reports are prepared and reviewed by separate individuals. Documentation will be maintained by the program to evidence preparation and review processes and timely filing of required reports.

View Audit 315421

Finding 478772 (2023-003)

Significant Deficiency 2023

Alameda Health System, A Public Hospital Authority

CA

HUD Housing Programs Reporting Significant Deficiency § 200.303

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will review, modify, and implement policies and procedures over the program to ensure that performance reports are prepared and reviewed by separate individuals. Documentation will be ...

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will review, modify, and implement policies and procedures over the program to ensure that performance reports are prepared and reviewed by separate individuals. Documentation will be maintained by the program to evidence preparation and review processes and timely filing of annual report.

View Audit 315421

Finding 478723 (2023-009)

Significant Deficiency 2023

Hyde County

NC

Eligibility Significant Deficiency

Finding: 2023-009 Inadequate Request for information New Medicaid Supervisor started 6/1/23 & has put new procedures in place & training of staff to eliminate the errors that occurred during the audit. All cases are reviewed before being processed to make sure the worker has worked the case properly...

Finding: 2023-009 Inadequate Request for information New Medicaid Supervisor started 6/1/23 & has put new procedures in place & training of staff to eliminate the errors that occurred during the audit. All cases are reviewed before being processed to make sure the worker has worked the case properly & if not immediate feedback, staffing & 2nd party review form is provided to the worker. Due to COVID & the State continuing cases this resulted in 15 of 35 of our errors. Of the 20 left, one is from 2018 due to the claim being paid in 2023 for a date of service of 2018. The other 19 relate to a current recert, however, review shows these were still worked prior to new supervisor & new procedures put into place. New staff has been brought in & are being trained one-on-one. It is anticipated that it will take 6 months - 1 year to get the new workers completely trained in their program. Team also has a pending new hire. Staffing cases & 2nd party reviews will continue indefinitely. Lots of errors came from the worker not running TWN. New process includes when the recert is started the workers is to run OVS, AVS & TWN. This is checked during 2nd party that all were started the same day. Workers are being taught that they are to upload their documents in NCFast at review/app & hard copy files are being eliminated to risk being lost.

View Audit 315389

Finding 478722 (2023-008)

Significant Deficiency 2023

Hyde County

NC

Eligibility Significant Deficiency

Finding: 2023-008 Inaccurate Resource Calculation New Medicaid Supervisor started 6/1/23 & has put new procedures in place & training of staff to eliminate the errors that occurred during the audit. All cases are reviewed before being processed to make sure the worker has worked the case properly & ...

Finding: 2023-008 Inaccurate Resource Calculation New Medicaid Supervisor started 6/1/23 & has put new procedures in place & training of staff to eliminate the errors that occurred during the audit. All cases are reviewed before being processed to make sure the worker has worked the case properly & if not immediate feedback, staffing & 2nd party review form is provided to the worker. Due to COVID & the State continuing cases this resulted in 15 of 35 of our errors. Of the 20 left, one is from 2018 due to the claim being paid in 2023 for a date of service of 2018. The other 19 relate to a current recert, however, review shows these were still worked prior to new supervisor & new procedures put into place. New staff has been brought in & are being trained one-on-one. It is anticipated that it will take 6 months - 1 year to get the new workers completely trained in their program. Team also has a pending new hire. Staffing cases & 2nd party reviews will continue indefinitely. For cases related to property resource entered incorrectly, previous supervisor instructed staff to enter the replacement value & not the tax value. This is being fixed as cases are being touched by the worker. New workers are being taught to review eligibility check to make sure income/resources are calcuating properly before processing.

View Audit 315389

Finding 478721 (2023-007)

Significant Deficiency 2023

Hyde County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding: 2023-007 New Medicaid Supervisor started 6/1/23 & has put new procedures in place & training of staff to eliminate the errors that occurred during the audit. All cases are reviewed before being processed to make sure the worker has worked the case properly & if not immediate feedback, staff...

Finding: 2023-007 New Medicaid Supervisor started 6/1/23 & has put new procedures in place & training of staff to eliminate the errors that occurred during the audit. All cases are reviewed before being processed to make sure the worker has worked the case properly & if not immediate feedback, staffing & 2nd party review form is provided to the worker. Due to COVID & the State continuing cases this resulted in 15 of 35 of our errors. Of the 20 left, one is from 2018 due to the claim being paid in 2023 for a date of service of 2018. The other 19 relate to a current recert, however, review shows these were still worked prior to new supervisor & new procedures put into place. New staff has been brought in & are being trained one-on-one. It is anticipated that it will take 6 months - 1 year to get the new workers completely trained in their program. Team also has a pending new hire. Staffing cases & 2nd party reviews will continue indefinitely. It was recently determined that workers were not reviewing the eligibility check for correct income/household size. Training has the workers checking this now. Section III - Federal Award Findings and Questioned Costs (continued) 6 months - 1 year

View Audit 315389

Finding 478705 (2023-001)

Significant Deficiency 2023

Nek Broadband

VT

Internal Control / Segregation of Duties Significant Deficiency

The management of NEK Broadband acknowledges the finding of a significant deficiency in internal controls noted by our auditors. We have implemented a new control to present all general journal entries as part of the monthly financial statement package to be reviewed by the finance and audit committ...

The management of NEK Broadband acknowledges the finding of a significant deficiency in internal controls noted by our auditors. We have implemented a new control to present all general journal entries as part of the monthly financial statement package to be reviewed by the finance and audit committee. Documentation of that review will be included in the monthly meeting minutes of the finance and audit committee. Further, we plan to implement a new accounting system with workflow controls, approval requirements and an integrated inventory system within the next year.

View Audit 315374

Finding 478688 (2023-001)

Significant Deficiency 2023

National Council of Young Men's Christian Association of the USA

IL

Subrecipient Monitoring Internal Control / Segregation of Duties Reporting

Summary: During the fiscal year ended December 31, 2023, subgrants over $30,000 subject to Federal Funding Accountability and Transparency Act (FFATA) reporting were not submitted to the FFATA Subaward Reporting System (FSRS) website. Corrective Action Planned: We have implemented the following cont...

Summary: During the fiscal year ended December 31, 2023, subgrants over $30,000 subject to Federal Funding Accountability and Transparency Act (FFATA) reporting were not submitted to the FFATA Subaward Reporting System (FSRS) website. Corrective Action Planned: We have implemented the following controls in 2024 to address the deficiency: On a monthly basis, the Director, Development Operations and Grantmaking will prepare a report listing all subgrants awarded from the prior month. This report will include modifications to subgrants from earlier fiscal periods. The Senior Director, Federal Funding or the Vice President, Emerging Opportunities will review the report for accuracy and completeness. The Senior Manager, Accounting will then submit any subgrants over the $30,000 threshold to the FSRS website the month following the award or modification. The Senior Director, Revenue & Budget will review submitted FSRS submissions on a monthly basis. Anticipated Completion Date: Completed April 30, 2024 Name of Contact Person Responsible for the Plan: Jeff Johnson

View Audit 315327

Corrective Action Plans

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