Corrective Action Plans

Finding 397987 (2023-010)

Significant Deficiency 2023

Boys and Girls Club of Dane County, Inc.

WI

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

Recommendation: Timecards should reflect all time, or 100% effort of each employee’s total hours actually spent on work within the scope of his or her employment regardless of how many or how few hours an employee works. Effort certification must reflect actual work performed and cannot be budget dr...

Recommendation: Timecards should reflect all time, or 100% effort of each employee’s total hours actually spent on work within the scope of his or her employment regardless of how many or how few hours an employee works. Effort certification must reflect actual work performed and cannot be budget driven or assigned. A written time and effort policy and procedures should be designed and implemented to meet grantor requirements and recordkeeping requirements of the organization. Ac􀆟on Taken: A cost allocation plan has now been established and will be reviewed by our Board. Timecards for all staff, including salaried staff, are now being filled out with actual hours spent per grant versus budgeted hours and for each grant coded, there are high level comments to explain what work was accomplished for the grant. There is also now a Financial Specialist on staff that reviews timecards for accuracy in this regard. The contact person responsible for this corrective action plan is Wendi Speed, CFO, as well as the HR team that will implement the policy. The anticipated completion date is June 30, 2025.

View Audit 306700

Finding 397955 (2023-001)

Significant Deficiency 2023

Youthbuild Lake County, INC

IL

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

There has been changes in our fiscal department that will allow YBLC, Inc to be on time with compliance

View Audit 306666

Finding 397949 (2023-001)

Significant Deficiency 2023

City of South Haven

MN

Reporting Significant Deficiency

Auditor Prepared Financial Statements. Name of Contact Person: Melissa Stensor, City Clerk. Correction Action: The City Clerk will continue to review GASB pronouncements and GASB disclosure checklists to ensure she is aware of financial statement requirements and new pronouncements. Proposed Compl...

Auditor Prepared Financial Statements. Name of Contact Person: Melissa Stensor, City Clerk. Correction Action: The City Clerk will continue to review GASB pronouncements and GASB disclosure checklists to ensure she is aware of financial statement requirements and new pronouncements. Proposed Completion Date: The City Council will implement the above procedures immediately.

View Audit 306665

Finding 397858 (2023-001)

Significant Deficiency 2023

City of Weslaco

TX

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.328

The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed Implementation date: September 30, 2024

View Audit 306592

Finding 397709 (2023-002)

Significant Deficiency 2023

Operation Care

CA

Reporting Subrecipient Monitoring Significant Deficiency

Finding Reference Number: 2023-002 Description of Finding: The Organization submitted its Audited Financial Statements and Single Audit Report to the federal clearinghouse in May 2024, 2 months after it was due. Statement of Concurrence or Nonconcurrence: Operation Care agrees with the find...

Finding Reference Number: 2023-002 Description of Finding: The Organization submitted its Audited Financial Statements and Single Audit Report to the federal clearinghouse in May 2024, 2 months after it was due. Statement of Concurrence or Nonconcurrence: Operation Care agrees with the finding as stated above. Corrective Action: Operation Care will ensure that all future Audited Financial Statements and Single Audit Reports are submitted to the federal clearing house no later than March 31st of each year. If Operation Care is needing an extension, the Fiscal Director will work with the Auditors to ensure that an extension is filed so Operation Care will stay in compliance. The Fiscal Director will also cross train the Executive Director on SEFA updates and Audited Financial Statements to ensure if there is turnover in personnel, someone at Operation Care will be able to provide the proper documentation to the Auditors in a timely manner. Name of Contact Person: Ashley Carnicello, Executive Director, (209) 223-2897 ashley@operationcare.org Bruce Platt, Fiscal Director (209) 223-2897 bruce@operationcare.org Projected Completion Date: The Fiscal Director will cross train the Executive Director by the end of the Fiscal Year, June 30, 2024 to ensure timely submission of Audited Financial Statements and Single Audit Reports. In addition, the Fiscal Director and Executive Director will begin submitting requests for Auditors by September 30th of each year. This will allow Operation Care to begin the Audit process earlier, therefore making the March 31st deadline more feasible.

View Audit 306556

Finding 397708 (2023-001)

Significant Deficiency 2023

Operation Care

CA

Reporting Significant Deficiency § 200.502

Finding Reference Number: 2023-001 Description of Finding: The schedule of Expenditures of Federal Awards (SEFA) was not complete, and expenditures reported on the SEFA were revised during the single audit. Statement of Concurrence or Nonconcurrence: Operation Care agrees with the finding a...

Finding Reference Number: 2023-001 Description of Finding: The schedule of Expenditures of Federal Awards (SEFA) was not complete, and expenditures reported on the SEFA were revised during the single audit. Statement of Concurrence or Nonconcurrence: Operation Care agrees with the finding as stated above. Corrective Action: Beginning immediately, Operation Care will keep a running, updated SEFA. As soon as Operation Care receives a grant agreement, the Fiscal Director and Executive Director will review it to see if there are federal funds. If so, the Fiscal Director will enter the grant, along with the CFDA number and all other pertinent information into the SEFA. At the end of the grant year, the SEFA will then be updated to reflect Federal Expenses. The updated SEFA will then be provided to the Executive Director. Name of Contact Person: Ashley Carnicello, Executive Director, (209) 223-2897 ashley@operationcare.org Bruce Platt, Fiscal Director (209) 223-2897 bruce@operationcare.org Projected Completion Date: SEFA will be updated by June 15, 2024 and will continue to be updated as needed.

View Audit 306556

Finding 397692 (2023-002)

Significant Deficiency 2023

Roof Above, Inc.

NC

Subrecipient Monitoring Reporting Significant Deficiency

Corrective Action Plan Significant Deficiency - Reporting Finding 2023-002 Roof Above will develop a policy for formal documentation of review of required reports prior to submission. Contact person responsible for corrective action: Kaedon Grinnell, Chief Program Officer Anticipated completion d...

Corrective Action Plan Significant Deficiency - Reporting Finding 2023-002 Roof Above will develop a policy for formal documentation of review of required reports prior to submission. Contact person responsible for corrective action: Kaedon Grinnell, Chief Program Officer Anticipated completion date: September 30, 2024

View Audit 306553

Finding 397461 (2023-083)

Significant Deficiency 2023

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

Finding: The Department of Social and Health Services did not have adequate internal controls to ensure individuals are eligible to receive benefits for the Money Follows the Person program. Questioned Costs: Assistance Listing # 93.791 Amount $0 Status: Corrective action complete Correc...

Finding: The Department of Social and Health Services did not have adequate internal controls to ensure individuals are eligible to receive benefits for the Money Follows the Person program. Questioned Costs: Assistance Listing # 93.791 Amount $0 Status: Corrective action complete Corrective Action: The Department partially agrees with the finding. The Department agrees that the Financial and Social Services Communication (14-443) forms were not provided to terminate the enrollment of the four exceptions identified in the finding. However, in those exceptions, the Roads to Community Living (RCL) disenrollment communication was made in accordance with the existing Nursing Facility Case Management policy as defined in Chapter 10 of the Long-Term Care (LTC) Manual. In addition, all clients met eligibility criteria for RCL services or were converted to another Home and Community Based program within the 365-day RCL demonstration year limitation. In these cases, the client was converted to a state plan or waiver with the new program start date noted on the 14-443 forms. The 14-443 form is a communication tool used by the Department’s public benefit specialists. For Modified Adjusted Gross Income (MAGI) enrolled Medicaid participants, benefits are managed by the Washington State Health Care Authority and the 14-443 form is not required or used by the Department’s public benefit specialists. This MAGI beneficiary communication detail was not articulated in the RCL chapter of the LTC Manual. As of May 2024, the Department updated Chapter 29 of the LTC Manual to clarify instructions related to when the 14-443 form must be completed for MAGI participants and what needs to be included on the form when it is required. Completion Date: May 2024 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

View Audit 306534

Finding 397429 (2023-067)

Significant Deficiency 2023

State of Washington C/o Office of Financial Management

WA

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

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure monthly foster care maintenance payments to children’s caregivers were adequate and accurate for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Amoun...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure monthly foster care maintenance payments to children’s caregivers were adequate and accurate for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Department is committed to strengthening internal controls and complying with grant requirements. As stated in the finding’s Cause of Condition, the Department utilizes FamLink as the case management system for the Foster Care program which, due to system limitations, did not have the reporting capabilities to track rate setting reviews during the audit period. To assist with tracking rate setting requirements, the Department: • Created a new report in FamLink to assist rate assessors in identifying six-month reviews that have not been performed timely. • Implemented monthly tracking by supervisors to assist with internal controls and compliance. In response to the auditor’s recommendations and to assist in compliance, the Department has submitted a request to the technical team for an update to the report to also show when the next rate assessment is due. Completion Date: Estimated June 2024 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 306534

Finding 397428 (2023-066)

Significant Deficiency 2023

State of Washington C/o Office of Financial Management

WA

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

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure payments to providers for travel and family visits were allowable and adequately supported for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Amo...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure payments to providers for travel and family visits were allowable and adequately supported for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Department is committed to strengthening internal controls and complying with grant requirements. As stated in the finding’s Cause of Condition, the Department was unable to fully implement the prior corrective action plan during the audit period. In April 2023, the Fiscal Integrity Unit collaborated with other divisions to implement the following internal controls: • Utilized algorithms in the Sprout system to identify reimbursement requests outside of a reasonable amount. • Required providers to submit additional documentation or explanation for those identified amounts. • Implemented a re-run process for prior billing periods to eliminate potential double billings by providers. • Trained headquarters and field office accounting staff to utilize the new algorithms and review additional documentation prior to processing payments. • Required program staff review and approval of all vendor invoices prior to release of payment for the Eastern Washington regions. In January 2024, the Fiscal Integrity Unit identified and implemented regional program approvals for Western Washington providers. The Contracts office has also taken the following actions: • In August 2023, filled one vacant staff position dedicated to reviewing child welfare contracts to include family time visit payments. • In November 2023, developed compliance audit plans for child welfare contracts and began fiscal monitoring of family time visit payments. • In December 2023, filled an additional vacant staff position dedicated to reviewing child welfare contracts. The conditions noted in this finding were previously reported in findings 2022-048 and 2021-040. Completion Date: January 2024 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 306534

Finding 397187 (2023-008)

Significant Deficiency 2023

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Equipment & Real Property Management

Finding: The Employment Security Department did not have adequate internal controls to ensure it submitted accurate monthly reports for the Unemployment Insurance program. Questioned Costs: Assistance Listing # 17.225 17.225 COVID-19 Amount $0 Status: Corrective action complete Correctiv...

Finding: The Employment Security Department did not have adequate internal controls to ensure it submitted accurate monthly reports for the Unemployment Insurance program. Questioned Costs: Assistance Listing # 17.225 17.225 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: In response to the prior year’s finding, the Department immediately implemented the secondary review of the monthly ETA 9055 performance reports. However, the auditor’s recommendation and the Department’s implementation occurred after state fiscal year 2023 had begun. The Department expects adequate internal controls to be in place and functioning for fiscal year 2024 and onward. The conditions noted in this finding were previously reported in finding 2022-005. Completion Date: May 2023 Agency Contact: Jay Summers External Audit Manager PO Box 9046 Olympia, WA 98507-9046 (360) 529-6718 Joshua.Summers@esd.wa.gov

View Audit 306534

Finding 397170 (2023-003)

Significant Deficiency 2023

Dakota Plains Legal Services, Inc.

SD

Internal Control / Segregation of Duties Cash Management Eligibility

Legal Services Corporation FFAL #09-742018 Legal Services Corporation - Basic Field - General FFAL #09-742018 Legal Services Corporation - Basic Field - Native American Eligibility Significant Deficiency in Internal Control over Compliance and Noncompliance Condition: The auditor's testing detecte...

Legal Services Corporation FFAL #09-742018 Legal Services Corporation - Basic Field - General FFAL #09-742018 Legal Services Corporation - Basic Field - Native American Eligibility Significant Deficiency in Internal Control over Compliance and Noncompliance Condition: The auditor's testing detected two instances in which U.S. Citizen Attestation was not retained. Management's Response: All employees have received additional training on compliance procedures, and new employees will receive the same. All files being closed are now reviewed first for accuracy by the case handler of that file. The files are double checked by the office secretary. At the end of the quarter, all files are sent to compliance for a third review. Any needed corrections are noted by compliance and the file is then sent back to the office where it originated from to be corrected. Then the corrections to the file are reported back to compliance to verify that they have been made. All Legal Secretary staff have just completed a mandatory two-day in-person training session, which in large part covered this and other compliance related issues. By the end of June 2024, all case handlers will receive in-person training on compliance issues. The program has also started a new procedure where any client coming into an office is asked to complete an attestation statement which can be added to the client file if needed. Responsible Individuals: Dawn Marshall, Co-Compliance Officer, Kaeleigh Lundberg, Co-Compliance Officer, Tom Mortland, Executive Director, Lori Stanford, Deputy Director. Anticipated Completion Date: July 31, 2024.

View Audit 306525

Finding 397162 (2023-001)

Significant Deficiency 2023

City of Texas City, Texas

TX

Internal Control / Segregation of Duties Subrecipient Monitoring HUD Housing Programs

Please note the following corrective action plan regarding the CD BG-CAPER for the single audit report for FY-2023. Should you have any questions or require additional information, please contact me at your convenience. I. Corrective Action Plan Finding #2023-001 - Entitlement Grants Cluster; Perfo...

Please note the following corrective action plan regarding the CD BG-CAPER for the single audit report for FY-2023. Should you have any questions or require additional information, please contact me at your convenience. I. Corrective Action Plan Finding #2023-001 - Entitlement Grants Cluster; Performance Reporting Corrective Action Plan The City will identify and assign additional personnel to cross-train on CAPER preparation as well as filing protocols for subsequent periods. Anticipated Completion Date September 30, 2024 Auditee Contact Person Jon R. Branson, Executive Director of Management Services

View Audit 306520

Finding 397067 (2023-001)

Significant Deficiency 2023

The University of Vermont Health Network INC

VT

Allowable Costs / Cost Principles Cash Management Reporting § 200.303

Management’s Views and Corrective Action Plan 2023-001 Significant deficiency in reporting for lack of submitting required documentation related to HRSA for previously reported Provider Relief Funds Cluster: Not applicable Federal Granting Agency: Health Resources and Services Administration (HRSA) ...

Management’s Views and Corrective Action Plan 2023-001 Significant deficiency in reporting for lack of submitting required documentation related to HRSA for previously reported Provider Relief Funds Cluster: Not applicable Federal Granting Agency: Health Resources and Services Administration (HRSA) Award Year: 1/1/2020 6/30/2023 Assistance Listing #: 93.498 Assistance Listing Title: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Pass-through entity: Not applicable Management has reassessed its internal controls over the review and approval of PRF submissions. The Network has now completed all PRF portal submissions, and this program has come to an end. Leadership Responsible: Steve Warren, Network Mgr. Grants Management Finance; Melissa Laurie, Network VP/Corporate Controller Anticipated Completion Date: 3/1/2024

View Audit 306487

Finding 397045 (2023-001)

Significant Deficiency 2023

Ensign College

UT

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Management Views and Corrective Action Plan Year Ending December 31, 2023 Finding 2023-001 - Inappropriate Amounts Included in Loan Notification Letters (Significant Deficiency) Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.268 Award T...

Management Views and Corrective Action Plan Year Ending December 31, 2023 Finding 2023-001 - Inappropriate Amounts Included in Loan Notification Letters (Significant Deficiency) Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.268 Award Title: Federal Direct Loan Program Award Years: 7/2022 – 6/2024 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan The first instance where disbursement dates and amounts were not included in the communication because the system incorrectly captured the student’s name rather than the date and amount of disbursements was caused by a system update. When PeopleSoft system updates are installed, they sometimes affect the data tables where our notification letters pull from. In this instance an update changed a table referenced in the query used to compile loan notification letters. The letter for this student was sent out before the query could be updated to correct for this change. Because of this issue, management has decided to have all loan notification letters compiled manually, effective January 2024, until a consultant can be brought in to help address the issue. Once the system configuration is corrected, we will return to using automated letters, but will continue to review a sample of loan notification letters each semester as an additional control. The second instance where loan disbursement letters were not sent due to the system not being updated to reflect the new academic was the result of a training issue. During 2023, the College made system changes to address prior year audit findings. These changes were made during the 2022-23 academic year and when the 2023-24 academic year started the system settings were not updated. The financial aid staff responsible for setting up the new academic year in the system will receive additional system setup training to ensure this type of issue does not happen in future academic years. Timing Starting in May 2024, Riley Niemand, Financial Aid Manager will work with a consultant to correct the automated loan notification letter process and to implement a process to review loan notification letters after a system update. This process will be completed by August 31, 2024. In May 2024, Chris Reitz, Controller, will also implement a financial aid review process to ensure loan notifications are completely, accurately, and timely sent to the student and/or parent each semester. System setup training to individuals involved in the process of setting up the new academic year in the system will be completed by Chris Reitz and Riley Niemand in May 2024. Sincerely, S. Christopher Reitz Director of Financial Services and Controller creitz@ensign.edu 801-524-8109

View Audit 306421

Finding 397024 (2023-002)

Significant Deficiency 2023

Town of Swansea

MA

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

Moving forward, internal controls have been updated to require all projects that necessitate prevailing wage rates have the proper backup and documentation.

View Audit 306406

Finding 396996 (2023-004)

Significant Deficiency 2023

City of Idaho Falls, Idaho

ID

Reporting Significant Deficiency § 200.328

Federal Agency Name: U.S. Department of Transportation; Pass-through Number: Federal Aviation Administration; Assistance Listing Number: 20.106; Program Name: Airport Improvement Grant; Significant Deficiency in Internal Control Over Compliance – Compliance Requirement – Reporting Finding Summa...

Federal Agency Name: U.S. Department of Transportation; Pass-through Number: Federal Aviation Administration; Assistance Listing Number: 20.106; Program Name: Airport Improvement Grant; Significant Deficiency in Internal Control Over Compliance – Compliance Requirement – Reporting Finding Summary: The required SF-425 annual reports due December 31, 2022, were submitted late. Corrective Action Planned: The City concurs with the auditors’ findings. The City has corrected this reporting issue. The annual reports due December 31, 2023, were submitted on time. Responsible Individual(s): Mark Hagedorn, Finance Manager/Treasurer; Brooks Slyter, Assistant Finance Manager; Ian Turner, Airport Director; Bruce Young, Assistant Airport Director – Finance & Administration Anticipated Completion Date: December 2023

View Audit 306396

Finding 396743 (2023-001)

Significant Deficiency 2023

Town of Carlisle

SC

Subrecipient Monitoring Allowable Costs / Cost Principles Procurement, Suspension & Debarment

The Town will work to formalize written policies and procedures related to federal awards as required under Uniform Guidance. This action will be performed by the Finance Team, with approval of the Finance Committee and Select Board. We anticipate that the policies and procedures will be completed b...

The Town will work to formalize written policies and procedures related to federal awards as required under Uniform Guidance. This action will be performed by the Finance Team, with approval of the Finance Committee and Select Board. We anticipate that the policies and procedures will be completed by June 30, 2024.

View Audit 306378

Finding 396718 (2023-002)

Significant Deficiency 2023

Healthworks Kha Foundation, Inc.

KS

Cash Management Allowable Costs / Cost Principles Significant Deficiency

Identification: 93.301 United States Department of Health and Human Services, COVID‐19 Small Hospital Improvement Program; Noncompliance Finding/Significant Deficiency, Cash Management Corrective Action Plan: The Foundation will work with the Kansas Department of Health and Environment (KDHE) to ret...

Identification: 93.301 United States Department of Health and Human Services, COVID‐19 Small Hospital Improvement Program; Noncompliance Finding/Significant Deficiency, Cash Management Corrective Action Plan: The Foundation will work with the Kansas Department of Health and Environment (KDHE) to return the interest earned on advances of federal grant awards and establish procedures to track interest earned on advances of federal grant awards in future periods. Anticipated completion date: The Foundation is currently working with KDHE to return the interest earned on federal grant awards and anticipates completion during 2024.

View Audit 306356

Finding 396712 (2023-002)

Significant Deficiency 2023

Aids Taskforce of Greater Cleveland, Inc.

OH

Questioned Costs Cash Management Allowable Costs / Cost Principles

Housing Opportunities for Persons with AIDS – Assistance Listing No. 14.241 Recommendation: We recommend the Organization designs controls to ensure the general ledger detail for each grant is reconciled to the monthly draw requests before they are submitted to the grantor for reimbursement. Explana...

Housing Opportunities for Persons with AIDS – Assistance Listing No. 14.241 Recommendation: We recommend the Organization designs controls to ensure the general ledger detail for each grant is reconciled to the monthly draw requests before they are submitted to the grantor for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: ATGC will delay the billing of any expense reimbursements until the general ledger activity has been reconciled ensuring all related expenses properly allocated within the ATGC General Ledger. Name(s) of the contact person(s) responsible for corrective action: Simpson Huggins Planned completion date for corrective action plan: June 30, 2024

View Audit 306347 Questioned Costs: $1

Finding 396694 (2023-001)

Significant Deficiency 2023

Swope Health Services and Subsidiaries

MO

Questioned Costs Period of Performance Reporting

Identifying Number: 2023-001 Finding: Swope Health Services and Subsidiaries expended federal funding on an invoice with a service period outside of the Period of Availability for Period 5 of the Provider Relief Fund. Corrective Actions Taken or Planned: Management will evaluate and alter the ac...

Identifying Number: 2023-001 Finding: Swope Health Services and Subsidiaries expended federal funding on an invoice with a service period outside of the Period of Availability for Period 5 of the Provider Relief Fund. Corrective Actions Taken or Planned: Management will evaluate and alter the accounts payable invoice review process as necessary to mitigate the risk of inaccurate recording of prepaid expenditures, as was the case in this finding. Management will consider the need to reorganize the assignment of duties as they pertain to the processing and review of invoices and vendor payments to ensure a sufficient level of review of material transactions to ensure accurate accounting of vendor payments. Person Responsible: Naimish Patel, CFO Anticipated Completion Date: Plan to be completed by December 31, 2024

View Audit 306320 Questioned Costs: $1

Finding 396652 (2023-002)

Significant Deficiency 2023

City of Fayetteville

NC

Internal Control / Segregation of Duties Reporting Significant Deficiency

Management's Response: The City agrees with the audit recommendations Responsible Party: Jody Picarells, Chief Financial Officer Corrective Action Plan: The corrective action plan will consist of the following measures: 1. Ensure staff are trained on proper submission of the PR29-CDBG Cash on Ha...

Management's Response: The City agrees with the audit recommendations Responsible Party: Jody Picarells, Chief Financial Officer Corrective Action Plan: The corrective action plan will consist of the following measures: 1. Ensure staff are trained on proper submission of the PR29-CDBG Cash on Hand Quarterly Report to include due dates for review and timely submission. 2. Ensure adequate staff are available, any combination of permanent, temporary or contracted positions, and assigned the task of timely submission of the PR29-CDBG Cash on Hand Quarterly Report. Proposed Implementation Date: May 31, 2024

View Audit 306255

Finding 396627 (2023-002)

Significant Deficiency 2023

Midmichigan Health Services

MI

Questioned Costs HUD Housing Programs Significant Deficiency

Finding Number: 2023-002 Condition: Not all patients received updated adjustments based on the new schedule. Planned Corrective Action: Previously the sliding fee scale/medical care discount applications and adjustments were performed by billing department staff. Unfortunately, billing department d...

Finding Number: 2023-002 Condition: Not all patients received updated adjustments based on the new schedule. Planned Corrective Action: Previously the sliding fee scale/medical care discount applications and adjustments were performed by billing department staff. Unfortunately, billing department did not follow the policies implemented by Management that were in place to manage the sliding fee scale/medical care discount program. Moving forward the sliding fee scale/medical care discount program will be managed and processed by the finance department. The finance department will ensure that the original policies to manage this program will be followed going forward. Contact person responsible for corrective action: Financial Analyst, Courtney Miller Anticipated Completion Date: 6/1/2024

View Audit 306236 Questioned Costs: $1

Finding 396622 (2023-001)

Significant Deficiency 2023

Midmichigan Health Services

MI

Allowable Costs / Cost Principles Cash Management HUD Housing Programs

Finding Number: 2023-001 Condition: The Company received funds for costs that were reasonable, allowable and allocable to the award, but did not disburse the funds for all costs within three business days and did not immediately return the funds. Planned Corrective Action: The Finance Department man...

Finding Number: 2023-001 Condition: The Company received funds for costs that were reasonable, allowable and allocable to the award, but did not disburse the funds for all costs within three business days and did not immediately return the funds. Planned Corrective Action: The Finance Department manager will ensure that any funds drawn are distribute and paid out within three business days. The Company distributes payments to vendors on Friday and all draws will be performed on the Tuesday, Wednesday, or Thursday of the week when a payment is scheduled for that Friday. Contact person responsible for corrective action: Finance Manager, Celeste Kubiak Anticipated Completion Date: 06/01/2024

View Audit 306236

Finding 396578 (2023-003)

Significant Deficiency 2023

Washburn Center for Children

MN

Allowable Costs / Cost Principles Cash Management Period of Performance § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: Block Grants for Community Mental Health Services CFDA # 93.958 Finding Summary: There was no formal documentation of review and approval of wage rates prior to the submission of the reimbursement request to SAMHSA for three ...

Federal Agency Name: Department of Health and Human Services Program Name: Block Grants for Community Mental Health Services CFDA # 93.958 Finding Summary: There was no formal documentation of review and approval of wage rates prior to the submission of the reimbursement request to SAMHSA for three months selected for testing. Responsible Individuals: Mohamed Omar, MBA, MS, Chief Administrative Officer and Mark Copps, Finance Director / Controller Corrective Action Plan: During 2023, management implemented a formal documentation of the review including the appropriate level of management sign off and date of review on the supporting documentation. Anticipated Completion Date: October 2023

View Audit 306158

Corrective Action Plans

Filters