Corrective Action Plans

Finding 43557 (2022-002)

Significant Deficiency 2022

HI

Internal Control / Segregation of Duties Eligibility Reporting

Finding No. 2022-002: Reporting (Significant Deficiency) Action Management implemented procedures for review of the expenses to be reported for infection control. For the fiscal year ended June 30, 2022, a review was conducted but only against the General Ledger report for the reporting period. R...

Finding No. 2022-002: Reporting (Significant Deficiency) Action Management implemented procedures for review of the expenses to be reported for infection control. For the fiscal year ended June 30, 2022, a review was conducted but only against the General Ledger report for the reporting period. Rather than relying solely on the General Ledger report, each invoice listed on the report will be pulled from Accounts Payable and reviewed both by the Controller and CFO to ensure the appropriateness of the expense to be reported on the PRF report prior to submission.

View Audit 38479

Finding 43511 (2022-003)

Significant Deficiency 2022

Northwestern Health Sciences University

MN

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

Federal Perkins Loans ? Assistance Listing No.: 84.038 Recommendation: We recommend that the University implement a procedure to ensure that all necessary MPNs are retained in accordance with the federal regulation. Explanation of disagreement with audit finding: There is no disagreement with the ...

Federal Perkins Loans ? Assistance Listing No.: 84.038 Recommendation: We recommend that the University implement a procedure to ensure that all necessary MPNs are retained in accordance with the federal regulation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All Perkins funds were audited in FY21 and we acknowledge that there are some files with missing MPNs. All the files have either been purchased from DOE or are currently receiving active payments. If payments do not remain current, we assign these loans to DOE after one year. There is no opportunity to recreate MPNs on these old loans, so no corrective action is possible. Name of the contact person responsible for corrective action: Michelle Hegarty, CFO Planned completion date for corrective action plan: December 2021

View Audit 49665

Finding 43509 (2022-004)

Significant Deficiency 2022

Northwestern Health Sciences University

MN

Student Financial Aid Reporting Significant Deficiency

Student Financial Aid Cluster ? Assistance Listing No.: Various Recommendation: We recommend that the University review their policies surrounding federal grants and ensure a review process is in place to ensure that all necessary compliance requirements are met. Explanation of disagreement with a...

Student Financial Aid Cluster ? Assistance Listing No.: Various Recommendation: We recommend that the University review their policies surrounding federal grants and ensure a review process is in place to ensure that all necessary compliance requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Registrar will be taking over all submissions going forward to ensure timely and accurate responses. Name of the contact person responsible for corrective action: Kris Ragozzino, Registrar Planned completion date for corrective action plan: May 1, 2023

View Audit 49665

Finding 43508 (2022-001)

Significant Deficiency 2022

Northwestern Health Sciences University

MN

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

Student Financial Aid Cluster ? Assistance Listing No.: Various Recommendation: We recommend reviewing the components of the enrollment roster file to ensure the correct effective date is reported correctly for both the "Campus Level" and "Program Level". Explanation of disagreement with audit fin...

Student Financial Aid Cluster ? Assistance Listing No.: Various Recommendation: We recommend reviewing the components of the enrollment roster file to ensure the correct effective date is reported correctly for both the "Campus Level" and "Program Level". Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We report directly to the National Student Clearing house and rely on their punctuality in forwarding our report to NSLDS. On an institutional level, graduation processes have been modified to include secondary verification of graduate files. Monthly audits are performed to monitor report results. If errors are discovered during the audit, updates will be made to the report prior to sending to the National Student Clearinghouse and the report will be corrected. Lastly, when a new employee accidently makes an error, the staff is re-educated in student drop and withdrawal business rules to prevent further communication lapses regarding student enrollment. Name of the contact person responsible for corrective action: Kris Ragozzino, Registrar Planned completion date for corrective action plan: Already in place.

View Audit 49665

Finding 43465 (2022-001)

Significant Deficiency 2022

Tuba City Unified School District No.15

AZ

Procurement, Suspension & Debarment Special Tests & Provisions Reporting

CORRECTIVE ACTION PLAN - FINDING 2022-001 We have prepared the accompanying corrective action plan as required by the standards applicable to the financial audit contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Adm...

CORRECTIVE ACTION PLAN - FINDING 2022-001 We have prepared the accompanying corrective action plan as required by the standards applicable to the financial audit contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). CFDA Number 84.041 Program Title Impact Aid Federal Agency U.S. Department of Education Condition The District did not retain documentation sufficient to determine the Davis-Bacon compliance clause was included in advertised specifications for two construction projects paid with federal Impact Aid funds. Corrective Action Plan The District has implemented a review of all construction bids funded with federal Impact Aid funds to ensure that the bid notifications include a clause that the contractors will have to be in compliance with the Davis-Bacon Act. District Contact Leah Begay, Business Manager Completion Date March 24, 2023

View Audit 45733

Finding 43418 (2022-001)

Significant Deficiency 2022

United Bronx Parents, Inc.

NY

Reporting Significant Deficiency § 200.512

Major Federal Awards Findings Finding 2022-001 ? Reporting Condition: Due to the 30 calendar day requirement, the federal reporting deadline for the Single Audit reporting package was May 28, 2022; however, the Organization did not file their data collection form by that date. Recommendation: We re...

Major Federal Awards Findings Finding 2022-001 ? Reporting Condition: Due to the 30 calendar day requirement, the federal reporting deadline for the Single Audit reporting package was May 28, 2022; however, the Organization did not file their data collection form by that date. Recommendation: We recommend that management implement processes, procedures and related controls to ensure that the data collection form is completed and submitted within the earlier of 30 calendar days after receipt of the auditor?s report or nine months after the end of the audit period. Response: Management will ensure that all information is timely entered into and submitted to, the Federal Audit Clearinghouse on an annual basis.

View Audit 50511

Finding 43413 (2022-001)

Significant Deficiency 2022

Higher Ground Academy

MN

Equipment & Real Property Management Procurement, Suspension & Debarment Significant Deficiency § 200.313

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE AND REPORTABLE NONCOMPLIANCE ? U.S. DEPARTMENT OF EDUCATION ? PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, COVID-19 ? EDUCATION STABILIZATION FUND, FEDERAL ALN 84.425 2022-001 Internal Control Over Compliance With Equipment and Real Pr...

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE AND REPORTABLE NONCOMPLIANCE ? U.S. DEPARTMENT OF EDUCATION ? PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, COVID-19 ? EDUCATION STABILIZATION FUND, FEDERAL ALN 84.425 2022-001 Internal Control Over Compliance With Equipment and Real Property Management and Reportable Noncompliance Finding Summary 2 CFR ? 200.313 (c)(1) and (d)(1) requires that Higher Ground Academy (the Academy) obtain approval from the federal funding agency or pass-through agency prior to the purchase of equipment with federal funding. The Academy must also maintain property records adequate to identify and track equipment purchased with federal funding, including the federal award under which the equipment was purchased. During our audit, we noted the Academy did not have sufficient controls in place within the Education Stabilization Fund federal program to assure compliance with federal equipment and real property management requirements, resulting in reportable noncompliance. Corrective Action Plan Actions Planned ? This condition and the resulting noncompliance was caused by a misunderstanding of the cost threshold at which federal equipment and real property management compliance requirements must be applied, due to the Academy?s adopted internal capitalization threshold being lower than the federal threshold. The Academy intends to revise its internal capitalization threshold to align with the federal threshold, and to review its other control procedures relating to equipment and real property management requirements to ensure compliance for future federal awards expenditures. Official Responsible ? Samuel Yigzaw, Executive Director. Planned Completion Date ? June 30, 2023. Disagreement With or Explanation of Finding ? The Academy agrees with this finding. Plan to Monitor ? The Academy?s Executive Director, Samuel Yigzaw, will oversee the implementation of proposed corrective actions and verify that appropriate controls are in place and understood by individuals responsible for federal program oversite at the Academy to ensure future compliance with federal equipment and real property management requirements.

View Audit 41477

Finding 43360 (2022-001)

Significant Deficiency 2022

Indiana Afterschool Network, Inc.

IN

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.334

Views of Responsible Officials and Planned Corrective Actions Each quarter, Indiana Afterschool Network will develop an estimated allocation of each employee?s personnel expense to each source of funding, including federal funds. The estimated allocation will be based on the employee?s work plan for...

Views of Responsible Officials and Planned Corrective Actions Each quarter, Indiana Afterschool Network will develop an estimated allocation of each employee?s personnel expense to each source of funding, including federal funds. The estimated allocation will be based on the employee?s work plan for the upcoming quarter. The estimated allocation will be retained in IAN?s electronic Dropbox files for a period as long as the funding sources? longest document retention requirement. Each pay period, IAN will review the estimated personnel expense allocation to determine whether each employee?s actual time was spent as estimated at the start of the quarter. IAN supervisors will conduct this review for each employee on their team. The supervisors will document the actual grant allocation for each employee on their team, and the documentation will include their approvals. The supervisors will provide these approvals to IAN?s CFO. The CFO will retain the approvals in IAN?s electronic Dropbox files for a period as long as the funding sources? longest document retention requirement. The CEO will be responsible for implementation of this correction. The CFO will oversee the process once implemented. Sincerely, Lakshmi Hasanadka Chief Executive Officer

View Audit 50829

Finding 43349 (2022-002)

Significant Deficiency 2022

Samaritan Medical Center

NY

Significant Deficiency Internal Control / Segregation of Duties

Finding #2022-002 Response: We agree with the finding noted by the auditors. Timing of the submission of the HRSA report and completion of the 2022 audit caused the difference. The 2022 revenue data will be corrected in future period reporting. Responsible Party: Maxine Briggs, CFO Estimated C...

Finding #2022-002 Response: We agree with the finding noted by the auditors. Timing of the submission of the HRSA report and completion of the 2022 audit caused the difference. The 2022 revenue data will be corrected in future period reporting. Responsible Party: Maxine Briggs, CFO Estimated Completion: 12/31/2023

View Audit 45183

Finding 43348 (2022-002)

Material Weakness 2022

Mississippi State Medical Association

MS

Questioned Costs Reporting Internal Control / Segregation of Duties

See Corrective Action Plan for chart/table

View Audit 45182 Questioned Costs: $1

Finding 43335 (2022-002)

Significant Deficiency 2022

Oklahoma Panhandle State University

OK

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

Department of Education Oklahoma Panhandle State University respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are nu...

Department of Education Oklahoma Panhandle State University respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF EDUCATION 2022-002 Higher Education Emergency Relief Fund (HEERF) - Reporting Assistance Listing Number: 84.425 Type of Finding: Compliance, Other Matter Significant Deficiency in Internal Control over Compliance Recommendation: We recommend the University review and update current procedures to ensure HEERF program reporting requirements are completed timely and to ensure review of reports are documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has evaluated and updated procedures to ensure documentation of supervisory review and reports are filed timely. Name(s) of the contact person(s) responsible for corrective action: Elizabeth McMurphy, VP of Fiscal Affairs Planned completion date for corrective action plan: December 2022 If the Department of Education has questions regarding this plan, please call Elizabeth McMurphy at 580-349-1566.

View Audit 48774

Finding 43321 (2022-001)

Significant Deficiency 2022

Jewish Foundation for Group Homes, Inc.

MD

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

February 23, 2023 Federal Agency: US Department of Health and Human Services Jewish Foundation for Group Homes, Inc. (d.b.a. Makom) respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021, through June 30, 2022 The findings from the...

February 23, 2023 Federal Agency: US Department of Health and Human Services Jewish Foundation for Group Homes, Inc. (d.b.a. Makom) respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021, through June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FINANCIAL STATEMENT AUDIT None FINDINGS?FEDERAL AWARD PROGRAMS AUDIT 2022-001 ? Allowable Costs and Activities Federal Agency: US Department of Health and Human Services Federal program title: Provider Relief Fund Assistance Listing No. 93.498 Award Period: Reporting Period 2 for Funds Received July 1, 2020, to December 31, 2020, used through December 31, 2021 Recommendation: The auditors recommended that management develop and document clear and consistent policies and procedures for determining overnight stipend pay to improve the controls surrounding payments and comply with federal awards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. However, Makom has discontinued the policy of paying overnight stipends. Action taken in response to finding: Management will ensure that in the future any such disbursement procedures are supported by clear and consistent policies and procedures to ensure the controls surrounding these special disbursements comply with federal awards. Name of the contact person responsible for corrective action: David Ervin, CEO Planned completion date for corrective action plan: July 1, 2022 If the Health Resources and Service Administration has questions regarding this plan, please call Diane Rubinstein, Chief Financial Officer, at 240-283-6004.

View Audit 44380

Finding 43320 (2022-001)

Significant Deficiency 2022

Delaware County Community College

PA

Reporting Significant Deficiency

U.S. Department of Education: Delaware County Community College respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Herbein + Company, Inc., 2763 Century Boulevard, Reading, PA 19610 Audit Period: Year en...

U.S. Department of Education: Delaware County Community College respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Herbein + Company, Inc., 2763 Century Boulevard, Reading, PA 19610 Audit Period: Year ended June 30, 2022 Contact Person: Dr Patricia Benson, Vice President, Finance & Administration/Treasurer Anticipated Completion Date: March 31, 2023 The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Section III - Federal Award Findings and Questioned Costs 2022-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program COVID-19 - Higher Education Emergency Relief Fund (HEERF) Student Aid Portion ALN 84.425E Award #P425F20035 Condition/Cause The College was not in compliance with a segment of the reporting requirements of Section 18004(a)(1) pertaining to the College?s website for inspection by the public related to HEERF III (ARP) funding. Recommendation The requirements for the reporting under HEERF student aid have evolved over the life of the grant, and it is important to ensure reporting requirements are being met as they change. We recommend the College update their website for the information related to the student portion of HEERF III (ARP) including the disbursement methodology and the number of students who received the funding. Management Response The College?s methods used to determine which students received the emergency financial aid grants and the total number of students who received funding, was documented internally for supporting parties and stakeholders. However, the website was not updated in a timely manner, but has since been modified. If the Department has any questions regarding this plan, you can contact Delaware County Community College at 610-359-5100 or 901 Media Line Road, Media, PA 19063. Respectfully, Dr. Patricia Benson Vice President, Finance & Administration/Treasurer

View Audit 44378

Finding 43302 (2022-006)

Significant Deficiency 2022

YWCA West Central Michigan

MI

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

Finding Number: 2022-006 Condition: For each of the four Crime Victim Assistance grants, thirteen monthly financial status reports (FSR) and eight quarterly work plan reports were not filed within 30 days and 15 days, respectively, of period end, as required by the grant agreements. Planned Corre...

Finding Number: 2022-006 Condition: For each of the four Crime Victim Assistance grants, thirteen monthly financial status reports (FSR) and eight quarterly work plan reports were not filed within 30 days and 15 days, respectively, of period end, as required by the grant agreements. Planned Corrective Action: Management will establish a reporting calendar for review and approval during the onboarding of each grant agreement. Management will periodically review the completeness and accuracy of and adherence to the reporting calendar. After several staffing changes were made, all reports and financial status reports have been submitted timely. A calendar has been created as of August 2022 and being fully utilized. Contact person responsible for corrective action: Kelly Scott, Deputy CEO Anticipated Completion Date: 2/1/2022

View Audit 39808

Finding 43273 (2022-004)

Significant Deficiency 2022

Concordia University, St. Paul

MN

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Higher Education Emergency Relief Fund ? Assistance Listing No. 84.425E and 84.425F Recommendation: We recommend that the University review their policies surrounding federal grants and ensure a review process is in place to ensure that all necessary compliance requirements are met. Explanation of d...

Higher Education Emergency Relief Fund ? Assistance Listing No. 84.425E and 84.425F Recommendation: We recommend that the University review their policies surrounding federal grants and ensure a review process is in place to ensure that all necessary compliance requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The university?s participation in the Higher Education Emergency Relief Fund program ended in June 2022. During the fiscal year, 21-22, the university reviewed the reports to ensure that they were accurate. If, in the future, the university receives federal funds beyond the ongoing financial aid programs, we will establish a review process related to the public reporting. Name of the contact person responsible for corrective action: Michael Dorner, Vice President for Finance Planned completion date for corrective action plan: June 30, 2022

View Audit 49806

Finding 43252 (2022-005)

Significant Deficiency 2022

Concordia University, St. Paul

MN

Student Financial Aid Reporting Significant Deficiency

Student Financial Assistance Cluster ? Assistance Listing No. Various Recommendation: We recommend the University review its procedures to ensure that key personnel changes are reported to the Department of Education in the required 10-day timeframe. Explanation of disagreement with audit finding: T...

Student Financial Assistance Cluster ? Assistance Listing No. Various Recommendation: We recommend the University review its procedures to ensure that key personnel changes are reported to the Department of Education in the required 10-day timeframe. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CSP has made sure that more than the Financial Aid Director has the information to access the E-APP. We also put into place a secondary designated person for SAIG and other portals and process as able. Name of the contact person responsible for corrective action: Amanda McCaughan, SFA Director Planned completion date for corrective action plan: February 2023

View Audit 49806

Finding 43251 (2022-003)

Significant Deficiency 2022

Concordia University, St. Paul

MN

Student Financial Aid Reporting Significant Deficiency

Student Financial Assistance Cluster ? Assistance Listing No. Various Recommendation: We recommend that the University review their policies surrounding federal grants and ensure a review process is in place to ensure that all necessary compliance requirements are met. Explanation of disagreement wi...

Student Financial Assistance Cluster ? Assistance Listing No. Various Recommendation: We recommend that the University review their policies surrounding federal grants and ensure a review process is in place to ensure that all necessary compliance requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Registrar's Office has been working with National Student Clearinghouse since September 22, 2022, to review findings on error reports and how to resolve the specific errors. For example, Social Security Number not matching error was instructed to send a card via email and trying to identify a safe way to provide that student information instead of through an unsecured email inbox. We are actively working on the current error report for students who flag as NSLDS errors, even though the NSC data is accurate. NSC has verified that reporting is moving to NSLDS. The Registrar's team will keep all email communication to the NSC Audit team regarding error reporting. Name of the contact person responsible for corrective action: Lynn Lundquist, Registrar Planned completion date for corrective action plan: September 2022

View Audit 49806

Finding 43250 (2022-002)

Significant Deficiency 2022

Concordia University, St. Paul

MN

Student Financial Aid Reporting Significant Deficiency

Student Financial Assistance Cluster ? Assistance Listing No. Various Recommendation: We recommend the University review its reporting procedures to ensure the students? statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: T...

Student Financial Assistance Cluster ? Assistance Listing No. Various Recommendation: We recommend the University review its reporting procedures to ensure the students? statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Registrar's Office reports enrollment data every 30 days to the National Student Clearinghouse. Registrar's Office individually updates student records to maintain compliance with the 60-day update in NSLDS. The Registrar's Office has been communicating with the National Student Clearinghouse since September of 2022 regarding timelines of NSC to NSLDS updates. NSC has confirmed that updated information has been reported in time. Registrar's Office has sought specific information regarding audit findings as reported information to NSC is within the timeline. Registrar Team has been reviewing Program and Campus Level information since September of 2022 as regulations had been newly modified. Name of the contact person responsible for corrective action: Lynn Lundquist, Registrar Planned completion date for corrective action plan: April 2023

View Audit 49806

Finding 43214 (2022-001)

Significant Deficiency 2022

Community Mental Health Partnership of Southeast Michigan

MI

Subrecipient Monitoring Internal Control / Segregation of Duties Significant Deficiency § 200.332

FY 2022 CMHPSM Single Audit Findings Response Finding 2022-001: Considered a significant deficiency in internal control over compliance/immaterial non-compliance Program: ALN 93.959 Block Grants for Prevention and Treatment of Substance Abuse (Treatment and Access Management) Condition:...

FY 2022 CMHPSM Single Audit Findings Response Finding 2022-001: Considered a significant deficiency in internal control over compliance/immaterial non-compliance Program: ALN 93.959 Block Grants for Prevention and Treatment of Substance Abuse (Treatment and Access Management) Condition: During testing of contracts with subrecipients it was noted that these contracts did not include portions of required disclosures. Corrective Action: CMHPSM will revise all contracts that disburse Block Grant Funds so that they include that the recipient is a subrecipient and include the grant number. Matt Berg and CJ Witherow are responsible for implementing this change. The change to be complete by August 31, 2023.

View Audit 44644

Finding 43213 (2022-002)

Significant Deficiency 2022

Community Mental Health Partnership of Southeast Michigan

MI

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.309

Finding 2022-002: Considered a significant deficiency in internal control over compliance/immaterial non-compliance Program: ALN 93.959 Block Grants for Prevention and Treatment of Substance Abuse (ARPA Prevention) Criteria: As detailed by 2 CFR 200.309, ?A non-Federal entity may charge to the Feder...

Finding 2022-002: Considered a significant deficiency in internal control over compliance/immaterial non-compliance Program: ALN 93.959 Block Grants for Prevention and Treatment of Substance Abuse (ARPA Prevention) Criteria: As detailed by 2 CFR 200.309, ?A non-Federal entity may charge to the Federal award only allowable costs incurred during the period of performance and any costs incurred before the Federal awarding agency or pass-through entity made the Federal award that were authorized by the Federal awarding agency or pass-through entity.?. Condition: During testing it was noted that $112,581 of costs that were allowable under ARPA Treatment were incorrectly allocated from ARPA Treatment to ARPA Prevention. Corrective Action: All finance staff responsible for any allocation of grant funding have undergone additional training or reading on how to allocate grants. The was completed by April 30, 2023.

View Audit 44644 Questioned Costs: $1

Finding 43211 (2022-003)

Significant Deficiency 2022

The Villages, Inc.

KS

Allowable Costs / Cost Principles Period of Performance Significant Deficiency

2022-003 Review and Approval of Grant Expenditures (Significant Deficiency) Department of Health and Human Services Unaccompanied Alien Children Program, Assistance Listing Number 93.676 Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performa...

2022-003 Review and Approval of Grant Expenditures (Significant Deficiency) Department of Health and Human Services Unaccompanied Alien Children Program, Assistance Listing Number 93.676 Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance Recommendation: The Organization should implement controls and processes that ensure grant expenditures charged to the program are reviewed to ensure costs are allowable and properly supported. Action Taken (Unaudited):. All expenses must be approved by the Executive Director prior to payment. Approvals are documented either via physical signature or email. A schedule has been established so that expenses are reviewed in a more timely and organized manner. Contact Name ? Kaleena Harmer Expected Completion Date ? 08/31/2022

View Audit 45599

Finding 43210 (2022-002)

Significant Deficiency 2022

The Villages, Inc.

KS

Significant Deficiency Internal Control / Segregation of Duties

2022-002 Maintenance of Written Procedures of Internal Control over Compliance (Significant Deficiency) Department of Health and Human Services Unaccompanied Alien Children Program, Assistance Listing Number 93.676 Recommendation: The Organization should develop written policies for the internal ...

2022-002 Maintenance of Written Procedures of Internal Control over Compliance (Significant Deficiency) Department of Health and Human Services Unaccompanied Alien Children Program, Assistance Listing Number 93.676 Recommendation: The Organization should develop written policies for the internal control over compliance of federal awards. Action Taken (Unaudited): Management is in the process of updating its control procedures to include proper written policies for the internal control over compliance of federal awards. The Finance Manager will use the COSO format to ensure procedures are documented within the required guidelines. Contact Name ? Kaleena Harmer Expected Completion Date ? 12/31/2023

View Audit 45599

Finding 43187 (2022-002)

Significant Deficiency 2022

La Clinica Tepeyac

CO

Internal Control / Segregation of Duties Subrecipient Monitoring Significant Deficiency

2022-002 Consolidated Health Centers Grant ? Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates...

2022-002 Consolidated Health Centers Grant ? Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. The auditors also recommended the Organization put a process in place to make sure all applications are retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement the following peer review process: ? A peer review is required to determine the appropriate sliding fee calculation was made based on family size and income of the applicant. ? A reference and training guide will be created by the Organization for front desk staff and enrollment specialists to utilize by September 30, 2023. ? Each sliding fee application will be reviewed by a peer and signed off by both the submitter and the peer reviewer. A verification checklist will be utilized to ensure the sliding fee application is accurate and complete. ? The finance department will receive a list of all new sliding fee applications from the previous month and pull a sample of twenty applications to review for accuracy and to confirm the peer review occurred. ? The Organization will implement a process where the patients will complete the sliding fee application prior to seeing the provider. The process is expected to be implemented by October 31, 2023. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Jim Garcia, CEO, at 720-274-2941.

View Audit 48323

Finding 43138 (2022-003)

Significant Deficiency 2022

Pinnacles Prep Charter School

WA

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

Pinnacles agrees that appropriate time and effort reports were not kept. The reports were created but never signed. Moving forward, the School will implement procedures to ensure that these reports are signed in a timely manner.

View Audit 39552

Finding 43137 (2022-004)

Significant Deficiency 2022

Pinnacles Prep Charter School

WA

Internal Control / Segregation of Duties Subrecipient Monitoring Cash Management

Pinnacles agrees that appropriate claim packets with documentation that tie exactly to the amounts claimed for reimbursement were not kept. The contracted CFO did keep records, but due to not copying and pasting correctly, could not get back exactly to the amounts claimed. Moving forward, the contr...

Pinnacles agrees that appropriate claim packets with documentation that tie exactly to the amounts claimed for reimbursement were not kept. The contracted CFO did keep records, but due to not copying and pasting correctly, could not get back exactly to the amounts claimed. Moving forward, the contracted CFO will keep a list of what exactly was claimed for reimbursement at each claim.

View Audit 39552

Corrective Action Plans

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