Corrective Action Plans

Finding 382662 (2022-010)

Significant Deficiency 2022

County of Delta

MI

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Cash Management

2022-010: Significant Deficiency and Noncompliance – Improper Payments Requested for Reimbursement Statement of Condition/Criteria: Delta County prepared reimbursement requests by manually transferring data from the general ledger to summary spreadsheets. The transferred data contained errors that r...

2022-010: Significant Deficiency and Noncompliance – Improper Payments Requested for Reimbursement Statement of Condition/Criteria: Delta County prepared reimbursement requests by manually transferring data from the general ledger to summary spreadsheets. The transferred data contained errors that resulted in the request for reimbursement being overstated. However, there were other costs incurred that would have been eligible. Planned Corrective Action: County management will develop control to ensure a secondary review and approval process is put into place for all reimbursement request submissions so that only allowable costs are charged to the grant. Contact person responsible for corrective action: Ashleigh Young, County Controller/Administrator Anticipated Completion Date: March 2024

View Audit 296246

Finding 382296 (2022-001)

Significant Deficiency 2022

Addiction Recovery, Inc.

MD

Significant Deficiency

CORRECTIVE ACTION PLAN September 28, 2023 Addiction Recovery, Inc. respectfully submits the following corrective action plan for fiscal year end June 30, 2022. The deficiencies noted as the result of the audit are due to late submissions of special reporting required under the grantor, Departm...

CORRECTIVE ACTION PLAN September 28, 2023 Addiction Recovery, Inc. respectfully submits the following corrective action plan for fiscal year end June 30, 2022. The deficiencies noted as the result of the audit are due to late submissions of special reporting required under the grantor, Department of Health and Human Services - Provider Relief Fund (CFDA 93.498) compliance standards. To make certain all reports are filed in a timely manner, the organization has constructed a corrective action plan to ensure certain compliance requirements are met. Conversely, please note instructions and guidance were limited as our organization lacks familiarity with significant grants. In addition, the organization has never been subjected to a single audit. Despite this fact, a corrective action plan has been constructed to address all findings below. Corrective Action Planned: 1. Management will assign a specific staff member to manage compliance and reporting for all Federal grant awards. 2. Management will corroborate with our Compliance Officer who can advise on all Federal grant requirements. While the organization will be held responsible as a whole, specific individual persons such as Director of Finance and Director of Compliance are responsible for the implementation of the corrective action plan provided above.

View Audit 296002

Finding 381094 (2022-003)

Significant Deficiency 2022

Richland Community College

IL

Special Tests & Provisions Reporting Significant Deficiency

Condition: The College did not correctly report graduate enrollment status changes for 6 out of 40 15%. The 6 students were incorrectly reported due to errors in their financial aid system. We consider this condition to be a significant deficiency of the Special Tests and Provisions compliance requi...

Condition: The College did not correctly report graduate enrollment status changes for 6 out of 40 15%. The 6 students were incorrectly reported due to errors in their financial aid system. We consider this condition to be a significant deficiency of the Special Tests and Provisions compliance requirement. Statistical sampling was not used in making sampling selections. Corrective Action Plan: Richland Community College adjusted our internal procedures to send graduate enrollment files on a monthly basis instead of a semester basis. Responsible Party for Corrective Action Plan: Registrar Implementation Date for Correction Action Plan: Implemented during Fall 2022 semester

View Audit 295850

Finding 381083 (2022-003)

Significant Deficiency 2022

Stillaguamish Pointe

WA

HUD Housing Programs Subrecipient Monitoring Cash Management

Execute the transfer of cash into the residual receipts reserve account.

View Audit 295833

Finding 380869 (2022-003)

Significant Deficiency 2022

Silver Lake Regional School District

MA

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

Similar to 2022-001, the Silver Lake Regional School District will create and adhere to a Federal Grants Compliance Manual.

View Audit 295550

Finding 380818 (2022-008)

Significant Deficiency 2022

City of Lynn

MA

Allowable Costs / Cost Principles Reporting Significant Deficiency

Audit Finding Reference: 2022-008 Improve Internal Controls Over Reporting (Significant Deficiency) Planned Corrective Action: The City contracted with a third party to report our COVID spending. The City was made aware of the discrepancy and will use MUNIS in the future to validate expenses accor...

Audit Finding Reference: 2022-008 Improve Internal Controls Over Reporting (Significant Deficiency) Planned Corrective Action: The City contracted with a third party to report our COVID spending. The City was made aware of the discrepancy and will use MUNIS in the future to validate expenses accordingly. Completion Date Stephen T. Spencer, City of Lynn Comptroller December 31, 2024

View Audit 295538

Finding 380815 (2022-004)

Significant Deficiency 2022

City of Lynn

MA

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

Audit Finding Reference: 2022-004 Maintain Employer’s Time and Effort Records (Significant Deficiency) Planned Corrective Action: The district began implementing the Time and Effort process during fiscal year 2016. We now collect signed Time and Effort sheets twice per year for all employees paid 1...

Audit Finding Reference: 2022-004 Maintain Employer’s Time and Effort Records (Significant Deficiency) Planned Corrective Action: The district began implementing the Time and Effort process during fiscal year 2016. We now collect signed Time and Effort sheets twice per year for all employees paid 100% by Federal Grants. For those employees that are paid partially from Federal Grants, we collect them on a monthly basis. We will increase our diligence to strive for 100% efficiency in the future for the Department of Education Grant. In response to the CDBG, Time and Effort records were not maintained for all applicable employees. Community Development implemented the monthly collection of signed time and effort sheets for all employees paid with Federal Grants (in partial or full) a number of year ago, and will increase its diligence to ensure this procedure is consistently followed going forward. Name of Contact Person and Completion Date Kevin McHugh, City of Lynn School Business Manager James Marsh, Executive Director Community Development December 31, 2024

View Audit 295538 Questioned Costs: $1

Finding 380810 (2022-005)

Significant Deficiency 2022

City of Lynn

MA

School Nutrition Programs Internal Control / Segregation of Duties Allowable Costs / Cost Principles

Audit Finding Reference: 2022-005 Limit Federal Cash on Hand (Significant Deficiency) Planned Corrective Action: The district is aware of this finding and will be taking steps to address this in the coming months. The City needs to decrease the cash balance in the school lunch fund so that it fall...

Audit Finding Reference: 2022-005 Limit Federal Cash on Hand (Significant Deficiency) Planned Corrective Action: The district is aware of this finding and will be taking steps to address this in the coming months. The City needs to decrease the cash balance in the school lunch fund so that it falls within acceptable Federal guidelines. Name of Contact Person and Completion Date Kevin McHugh, City of Lynn School Business Manager December 31, 2024

View Audit 295538

Finding 380776 (2022-007)

Significant Deficiency 2022

City of Decatur

IL

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Recommendation: We recommend the City strengthen its review procedures over expenditures and ensure all reviews are properly documented. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: The City of Decatur acknowledg...

Recommendation: We recommend the City strengthen its review procedures over expenditures and ensure all reviews are properly documented. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: The City of Decatur acknowledges the need to comply with all Federal regulations concerning Federal grant funding. The grant program manager verbally approved expenditures but did not document approval of expenditures in writing. The Grant Administrator will train departments beginning January 1, 2024 to have grant program managers document approval of expenditures in writing so this error will not occur again. Name of the contact person responsible for corrective action: Grant Administrator Planned completion date for corrective action plan: 1/1/24

View Audit 295485

Finding 380775 (2022-006)

Significant Deficiency 2022

City of Decatur

IL

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Recommendation: We recommend the City strengthen its review procedures over reports to ensure all applicable data elements are accurate. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: The City acknowledges the need ...

Recommendation: We recommend the City strengthen its review procedures over reports to ensure all applicable data elements are accurate. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: The City acknowledges the need for compliance with Federal regulations to classify expenses in the proper category. A Grant Administrator has been hired in July 2023 to begin assisting departments that administer grant programs. The Grant Administrator has been reviewing grant program filings since July 2023. The ARPA grant has been particularly confusing with the Federal government changing reporting requirements several times and not having clear guidance for several months after implementation. Now that the guidance has been clarified, the Grant Administrator will ensure adherence to the Federal regulations for the ARPA grant. Name of the contact person responsible for corrective action: Grant Administrator Planned completion date for corrective action plan: 1/1/24

View Audit 295485

Finding 380767 (2022-005)

Significant Deficiency 2022

City of Decatur

IL

Procurement, Suspension & Debarment Significant Deficiency

Recommendation: We recommend ensuring a procedure is in place to verify vendors or contractors are not suspended or debarred from doing business with the government, prior to the purchase, and maintaining documentation of this. Explanation of disagreement with audit finding: There is no disagreemen...

Recommendation: We recommend ensuring a procedure is in place to verify vendors or contractors are not suspended or debarred from doing business with the government, prior to the purchase, and maintaining documentation of this. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: The City acknowledges the need for compliance with Federal regulations of suspension and debarment testing. A Grant Administrator has been hired in July 2023 to begin assisting departments that administer grant programs. The Grant Administrator met individually with each department in the third quarter of 2023 to remind them of Federal regulations including those surrounding suspension and debarment testing. The Grant Administrator has also reminded those departments of the requirements periodically throughout the remainder of 2023. Beginning in 2024, the Grant Administrator will send an email quarterly to remind departments of these Federal requirements and meet with departments on an ongoing basis about any questions they may have concerning Federal grants to ensure compliance with Federal requirements in the future. Name of the contact person responsible for corrective action: Grant Administrator Planned completion date for corrective action plan: 1/1/24

View Audit 295485

Finding 380750 (2022-002)

Significant Deficiency 2022

Native Villake of Kluti-Kaah

AK

Reporting Significant Deficiency § 200.512

Finding 2022-002 Late Reporting and Noncompliance with Reporting Requirements Type of Finding: Significant deficiency, noncompliance Name of Contact Person: Willard E. Hand Corrective Action Plan: The huge influx of funding from the federal government has placed a financial burden on all tribes, i...

Finding 2022-002 Late Reporting and Noncompliance with Reporting Requirements Type of Finding: Significant deficiency, noncompliance Name of Contact Person: Willard E. Hand Corrective Action Plan: The huge influx of funding from the federal government has placed a financial burden on all tribes, including our own. The added responsibility of administering and reporting on these funds resulted in less time for audit preparation and we were late in securing an auditor and submitting our report. Multiple COVID-19 surges also occurred in our community so our offices were closed sporadically during the year, taking time away from audit preparation. We have also found longer lead times in trying to secure an auditor in a timely manner. With so many more entities in the State receiving enough funds to qualify them for a single audit, auditors are booking several months in advance. We are working to eliminate the insufficiency securing an auditor to complete the FY23 report in a timely manner. Proposed Completion Date: September 30, 2023.

View Audit 295414

Finding 380749 (2022-001)

Significant Deficiency 2022

Native Villake of Kluti-Kaah

AK

Allowable Costs / Cost Principles Significant Deficiency

Finding 2022-001 Internal Control over Allowable Costs / Cost Principles Type of Finding: Significant deficiency, noncompliance Name of Contact Person: Willard E. Hand Corrective Action Plan: A number of payroll action forms were found to be missing signatures when a large number of temporary em...

Finding 2022-001 Internal Control over Allowable Costs / Cost Principles Type of Finding: Significant deficiency, noncompliance Name of Contact Person: Willard E. Hand Corrective Action Plan: A number of payroll action forms were found to be missing signatures when a large number of temporary employees were hired to man control gates to limit access to the community during the pandemic. Through in-house training with financial staff to review required new employee forms, the insufficiency has been resolved. Proposed Completion Date: September 30, 2023

View Audit 295414

Finding 372669 (2022-002)

Significant Deficiency 2022

Housing Authority of the City of Madera

CA

HUD Housing Programs Allowable Costs / Cost Principles Eligibility

Finding 2022-002 a. Comments on the Finding and Each Recommendation: Management agrees with both the finding and recommendations. b. Action(s) Taken or Planned on the Finding The management overseeing the process has been completely replaced to ensure a fresh perspective and unwavering dedication to...

Finding 2022-002 a. Comments on the Finding and Each Recommendation: Management agrees with both the finding and recommendations. b. Action(s) Taken or Planned on the Finding The management overseeing the process has been completely replaced to ensure a fresh perspective and unwavering dedication to implementing robust internal controls. To address the shortcomings identified in Finding 2022-002, the Authority commits to a targeted action plan aimed at ensuring timely compliance with reporting requirements. Central to our approach is the engagement of a fee accountant, recognized for expertise in HUD reporting and public housing financial management. This specialist will be tasked with overseeing and streamlining our reporting processes. By leveraging this expertise, we aim to quickly rectify past reporting lapses and ensure future submissions are timely and compliant with HUD requirements. The new fee accountant will conduct a comprehensive review of our current reporting mechanisms, identify bottlenecks, and implement best practices tailored to our operations. This decisive action, centered around the expertise of the newly appointed fee accountant, demonstrates our commitment to enhancing our financial management practices and aligning with HUD's reporting expectations. Through these measures, we anticipate not only meeting HUD's deadlines but also setting a new standard for operational excellence within our Authority.

View Audit 293769

Finding 372583 (2022-002)

Significant Deficiency 2022

County of Hancock, Maine

ME

Significant Deficiency

2022-002 Significant Deficiency Name of contact person: Michael Crooker, County Administrator Corrective Action: The County will work to ensure timely filing of required reports in the future. Proposed completion date: Management intends to have the policy in place immediately.

View Audit 293667

Finding 372246 (2022-001)

Significant Deficiency 2022

City of Lebanon

NH

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

Audit Finding Reference: 2022-001 Planned Corrective Action: The City has adopted an Airport Revenue Policy on 6/8/2023. Name of Contact Person and Completion Date: Name 1 Carl Gross, Airport Manager Name 2 Vicki Lee, Finance Director Anticipated Completion Date – Completed 6/8/2023

View Audit 293540

Finding 372109 (2022-008)

Significant Deficiency 2022

Carlton County, Minnesota

MN

Student Financial Aid Cash Management Reporting § 200.303

Finding Number: 2022-008 Finding Title: LCTS Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Ann Ozan – Fiscal Supervisor II. Corrective Action Planned: Document the review of the public health, corrections, and school district quarterly...

Finding Number: 2022-008 Finding Title: LCTS Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Ann Ozan – Fiscal Supervisor II. Corrective Action Planned: Document the review of the public health, corrections, and school district quarterly reports. Review is being done when the state report is prepared, but not currently documented. Anticipated Completion Date: December 31, 2023.

View Audit 293397

Finding 372082 (2022-001)

Significant Deficiency 2022

City of St. Albans

VT

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

March 29, 2023 Zack Fentross, CPA Marcum LLP 9 Executive Park Drive, Suite 100 Merrimack, NH 03054 Dear Zack, The purpose of this letter is to address planned corrective action to finding 2022-001 “Improve Controls and Documentation over Reporting” as described in the FY2022 single audit report. The...

March 29, 2023 Zack Fentross, CPA Marcum LLP 9 Executive Park Drive, Suite 100 Merrimack, NH 03054 Dear Zack, The purpose of this letter is to address planned corrective action to finding 2022-001 “Improve Controls and Documentation over Reporting” as described in the FY2022 single audit report. The City incorrectly indicated that it had not spent any SLFRF funds for the period ended March 31, 2022 when that was not the case. The City has reviewed its reporting on other grants and this oversite is an isolated event. Since discovering the error, we have taken action to correct the March 31, 2022 report by opening a case with Treasury, case #00194588. The City intends to discuss steps to correct the report with Treasury and do what is required to make the needed corrections. This appears to be an isolated, honest mistake. Given that the current reporting period for the SLFRF funds is upon us, we are confident that we will be able to correct the prior year oversight and complete the current report correctly and on time. Sincerely, Sarah Macy, CPFO Director of Finance and Administration (802) 524-1500 x 256 s.macy@stalabnsvt.com

View Audit 293359

Finding 371966 (2022-001)

None 2022

Tukwila School District No. 406

WA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Tukwila School District No. 406 September 1, 2021 through August 31, 2022 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Re...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Tukwila School District No. 406 September 1, 2021 through August 31, 2022 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2022-001 Finding caption: The District overcharged indirect costs to the Education Stabilization Fund program. Name, address, and telephone of District contact person: Veronica Birdsong 4640 S. 144th Street Tukwila, WA 98168 206-901-8010 Corrective action the auditee plans to take in response to the finding: On an annual basis make sure to review the current federal indirectrates via OPSI website within that current school year as indirect rates change from fiscal year to fiscal year and may not be reflected on grants that carryover from year to year. I did the calculations for the 2022-202 school year to account for the overage charged in indirect and made sure that amount was use for direct expenditures. This was the best option as the grant was still being expended and the correction could be made without needing to repay the indirect amount over claimed back to OSPI. Anticipated date to complete the corrective action: currently completed for the 2022-2023 school year.

View Audit 293224 Questioned Costs: $1

Finding 371185 (2022-003)

Significant Deficiency 2022

Lake County

MN

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding Number: 2022-003 Finding Title: Reporting Program: 10.665 Forest Service Schools and Roads Cluster, Schools and Roads – Grants to States Name of Contact Person Responsible for Corrective Action: Matthew Huddleston, County Administrator Corrective Action Planned: Report will be submitted by F...

Finding Number: 2022-003 Finding Title: Reporting Program: 10.665 Forest Service Schools and Roads Cluster, Schools and Roads – Grants to States Name of Contact Person Responsible for Corrective Action: Matthew Huddleston, County Administrator Corrective Action Planned: Report will be submitted by February 1 of each year. Anticipated Completion Date: 12-31-2023

View Audit 292830

Finding 371060 (2022-008)

Significant Deficiency 2022

Alameda Health System, A Public Hospital Authority

CA

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

Finding 2022-008: Reporting (Significant Deficiency over Internal Control and Instances of Noncompliance - Reporting) Response and Corrective Action Plan: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implement...

Finding 2022-008: Reporting (Significant Deficiency over Internal Control and Instances of Noncompliance - Reporting) Response and Corrective Action Plan: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implement policies and procedures to ensure performance reports are prepared and reviewed by separate individuals with evidence of review documented and that financial reports are submitted timely. The Health System will also ensure the “VSPS Point of View” is implemented for all programs. Anticipated Completion Date: by March 31, 2024 Responsible Person: : Ann Metzger, Vice President Finance

View Audit 292734

Finding 371059 (2022-007)

Significant Deficiency 2022

Alameda Health System, A Public Hospital Authority

CA

Cash Management Period of Performance Subrecipient Monitoring § 200.305

Finding 2022-007: Costs Incurred & Paid Prior to Reimbursements (Significant Deficiency over Internal Control and Instance of Noncompliance – Cash Management; Period of Performance) Response and Corrective Action Plan: Management agrees with finding. The Health System will review and modify policie...

Finding 2022-007: Costs Incurred & Paid Prior to Reimbursements (Significant Deficiency over Internal Control and Instance of Noncompliance – Cash Management; Period of Performance) Response and Corrective Action Plan: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implements policies, procedures, and processes to make sure that funds are disbursed for incurred expenditures prior to reimbursement requests. Anticipated Completion Date: by March 31, 2024 Responsible Person: : Ann Metzger, Vice President Finance

View Audit 292734

Finding 371058 (2022-006)

Significant Deficiency 2022

Alameda Health System, A Public Hospital Authority

CA

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

Finding 2022-006: Charges Not Specified in Grant Contracts (Significant Deficiency over Internal Control and Instances of Noncompliance – Allowable Costs/Cost Principles) Response and Corrective Action Plan: Management agrees with finding. The Health System will review and modify policies and proce...

Finding 2022-006: Charges Not Specified in Grant Contracts (Significant Deficiency over Internal Control and Instances of Noncompliance – Allowable Costs/Cost Principles) Response and Corrective Action Plan: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implement policies, procedures, and processes to make sure that expenditures are charged to the program in accordance with the grant contracts and that all invoices are reviewed and approved prior to disbursements. Anticipated Completion Date: by March 31, 2024 Responsible Person: : Ann Metzger, Vice President Finance

View Audit 292734

Finding 371057 (2022-005)

Significant Deficiency 2022

Alameda Health System, A Public Hospital Authority

CA

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

Finding 2022-005: Gift Card Tracking (Significant Deficiency over Internal Control and Instance of Noncompliance – Allowable Costs/Cost Principles) Response and Corrective Action Plan: Management agrees with finding. The Health System will review and modify policies and procedures over the program ...

Finding 2022-005: Gift Card Tracking (Significant Deficiency over Internal Control and Instance of Noncompliance – Allowable Costs/Cost Principles) Response and Corrective Action Plan: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implements policies, procedures, and processes to properly track the distribution of gift cards for victims of crime. Anticipated Completion Date: by March 31, 2024 Responsible Person: : Ann Metzger, Vice President Finance

View Audit 292734

Finding 371054 (2022-002)

Significant Deficiency 2022

Alameda Health System, A Public Hospital Authority

CA

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding 2022-002: Approval of non-payroll expenditures (Significant Deficiency over Internal Control and Instances of Noncompliance over Major Federal Program and Questioned Costs – Allowable costs/Cost Principles) Response and Corrective Action Plan: Management agrees with finding. The Health Sys...

Finding 2022-002: Approval of non-payroll expenditures (Significant Deficiency over Internal Control and Instances of Noncompliance over Major Federal Program and Questioned Costs – Allowable costs/Cost Principles) Response and Corrective Action Plan: Management agrees with finding. The Health System will review and modify policies and procedures for non-payroll expenditures to ensure management’s review/approval is documented. Anticipated Completion Date: by March 31, 2024 Responsible Person: Ann Metzger, Vice President Finance

View Audit 292734

Corrective Action Plans

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