Corrective Action Plans

Finding 58710 (2022-001)

Significant Deficiency 2022

MI

Significant Deficiency

June 21, 2023 Glen Olivache, CPA, PC P.O. Box 32605 Detroit, Ml 48232 Re: Corrective Action Plan for Wayne County Healthy Communities In response to the audit finding for fiscal year 2022, Wayne County Healthy Communities has implemented processes and procedures to address the finding. ? Find...

June 21, 2023 Glen Olivache, CPA, PC P.O. Box 32605 Detroit, Ml 48232 Re: Corrective Action Plan for Wayne County Healthy Communities In response to the audit finding for fiscal year 2022, Wayne County Healthy Communities has implemented processes and procedures to address the finding. ? Finding Number 2022-01 WCHC Management agrees with the finding and will conduct a review of the current process for data intake and application of sliding fee calculations into eClinicalWorks (our Electronic Health Record [EHR] system) performed by front desk staff. Process improvement actions will be taken (including trainings) to ensure all front desk staff have full understanding of the process, address any concerns, and avoid future errors. Anticipated Completion Date: December 15, 2023 Individuals Responsible: Amaal Haimout, Chief Operating Officer Brian Middaugh, Chief Financial Officer Sincerely, Ka'leef Stanton Morse, MHS, MBA Chief Executive Officer Wayne County Healthy Communities KMorse@waynecounty.com 313-702-2710 Cc: Amaal Haimout Brian Middaugh

View Audit 56604

Finding 58705 (2022-002)

Significant Deficiency 2022

Housing Authoirty of the City of Salem

OR

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Finding 2022-002: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Programs Federal Catalog Numbers: 14.871 Noncompliance ? N. Special Tests and Provisions - Housing Quality Standards Non Compliance Material to the Financial ...

Finding 2022-002: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Programs Federal Catalog Numbers: 14.871 Noncompliance ? N. Special Tests and Provisions - Housing Quality Standards Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions Criteria: Housing Quality Standards Inspections. The PHA must inspect the unit leased to a family at least annually to determine if the unit meets the Housing Quality Standards (HQS) and the PHA must conduct quality control re-inspections. The PHA must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). For units that fail inspection the PHA must correct all life threatening HQS deficiencies within 24 hours and all other deficiencies within 30 days. Condition: Based upon inspection of the Authority?s files and on discussion with management, there were failed inspections that did not pass reinspection within 30 days without penalty. Context: There were approximately 741 failed inspections during the audit period. Of a sample size of twenty-five (25) failed inspections, four (4) failed inspections did not pass reinspection within 30 days. HAP was not abated nor was the tenant evicted. Our sample size is statistically valid. Cause: There is a significant deficiency in internal controls over the compliance for the special tests and provisions type of compliance related to HQS inspections. The Authority has not properly performed HQS inspections in compliance with program requirements following the expiration of HUD waivers as a result of insufficient staffing . Effect: The Section 8 Housing Choice Vouchers Program is in non-compliance with the special tests and provisions type of compliance related to HQS inspections. Recommendation: We recommend the Authority design and implement a corrective action plan that will assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: The Authority accepts the recommendation of the auditor, and will make the following changes to its inspection process to ensure enforcement of Housing Quality Standards (or any subsequent replacement): ? On or before July 1, 2023: o The standard notice used to notify the program participant and property owner of deficiencies will be updated to include the following language: ? HAP will be abated as early as the 1st of the month following the date of the scheduled reinspection. ? This will mitigate the need for additional notice prior to the abatement period. ? ?Tenant-caused? fail items may result in termination of rental assistance. ? The letter will include language notifying the program participant that they may request an extension or reasonable accommodation if additional time is needed to correct deficiencies. ? This will create a clear trail of documentation for the file to allow SHA to demonstrate when extensions are provided as a reasonable accommodation. ? Additionally, this will provide SHA with additional information that may facilitate referrals to community supports to assist with specific tenant-caused circumstances, such as ?high fuel load? (high amount of tenant possessions creating risk of fire/injury/damage to unit). Melanie Fletcher will be responsible to implement this corrective action by September 30, 2023.

View Audit 56513

Finding 58704 (2022-001)

Significant Deficiency 2022

Housing Authoirty of the City of Salem

OR

HUD Housing Programs Eligibility Significant Deficiency

Corrective Action Plan For the year ended September 30, 2022 U.S. Department of Housing and Urban Development: Housing Authority of the City of Salem respectfully submits the following corrective action plan for the year ended September 30, 2022. Auditor: Novogradac and Company, LLP Certified...

Corrective Action Plan For the year ended September 30, 2022 U.S. Department of Housing and Urban Development: Housing Authority of the City of Salem respectfully submits the following corrective action plan for the year ended September 30, 2022. Auditor: Novogradac and Company, LLP Certified Public Accountants 1144 Hooper Avenue Suite 203 Toms River, New Jersey 08753 The findings from the September 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Federal Award Findings and Questioned Costs Finding 2022-001: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Catalog Numbers: 14.871 Noncompliance ? E. Eligibility ? Tenant Files Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Eligibility Criteria:Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority?s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 2,723 Section 8 Housing Choice Vouchers units and 123 Mainstream Vouchers units. Of a sample size of forty-seven (47) tenant files, the following was noted: ? Lead based paint form was missing in 14 files ? Annual inspection report was missing in 1 file Our sample size is statistically valid. Cause: There is a significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers Program is in non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation:We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: The Authority accepts the recommendations of the auditor and has issued the following directives to staff in order to prevent future recurrence of similar issues: ? Administrative Advisory 2023-02 ? This Administrative Advisory requires staff, effective June 12, 2023, to obtain the Lead Based Paint (LBP) Disclosure form for any new leases / moves related to units built before 1978, as well as requiring staff to review files at annual recertification and request the LBP Disclosure form for those units built prior to 1978 as part of the recertification process. Using this method, all LBP disclosures shall be present in tenant files by the end of calendar year 2025 (SHA is moving to biennial recertifications as part of its Moving to Work Initiative). ? Administrative Advisory 2023-03 ? This Administrative Advisory directs staff to ensure that original applications and initial eligibility documentation are scanned when files are archived, or new volumes are created. Additionally, staff have been advised to pull the original application and initial eligibility forward into new volumes. If the original application and initial eligibility information are found to be incomplete or missing at the time the file is archived, staff have been instructed to document the file and replace the missing information with the best available documentation to demonstrate date of original application and that initial eligibility criteria were met. Due to the conditions of the COVID-19 pandemic, SHA was unable to contract a third party inspector to conduct inspections of units that it owns and operates, as required by HUD regulations. This led to a gap of more than 24 months between an initial inspection and a biennial inspection for a resident living in a SHA-owned unit. Inspections of SHA-owned units have since been completed under an agreement with a neighboring housing authority and will continue to be completed in accordance with HUD regulations and requirements going forward. Melanie Fletcher will be responsible to implement this corrective action by September 30, 2023.

View Audit 56513

Finding 58699 (2022-001)

Significant Deficiency 2022

Rowan County Housing Authority

NC

Questioned Costs HUD Housing Programs Reporting

Section II - Financial Statement Findings None Reported Section III - Federal Award Findings and Questioned Costs Finding 2022-001 Name of Contact Person: Sara Potts Executive Director Corrective Action: We concur. Management will review the internal control procedures as they relate to Reports ...

Section II - Financial Statement Findings None Reported Section III - Federal Award Findings and Questioned Costs Finding 2022-001 Name of Contact Person: Sara Potts Executive Director Corrective Action: We concur. Management will review the internal control procedures as they relate to Reports and will implement procedures to insure all Reports are submitted timely. Proposed Completion Date: Immediately

View Audit 56173 Questioned Costs: $1

Finding 58689 (2022-001)

Significant Deficiency 2022

City of Cosmos

MN

Reporting Significant Deficiency

Auditor Prepared Financial Statements Name of Contact Person: John Douville, City Administrator Correction Action: The City Administrator will continue to review GASB pronouncements and GASB disclosure checklists to ensure he is aware of financial statement requirements and new pronouncements. Pro...

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

View Audit 56170

Finding 58688 (2022-001)

Significant Deficiency 2022

Washington Housing Authority

NC

Eligibility HUD Housing Programs Reporting

Corrective Action Plan For the Year Ended September 30, 2022 Section II - Financial Statement Findings: None Reported Section III - Federal Award Findings and Questioned Costs Finding 2022-001 Name of Contact Person: Michael Best Executive Director Corrective Action: We will implement proper intern...

Corrective Action Plan For the Year Ended September 30, 2022 Section II - Financial Statement Findings: None Reported Section III - Federal Award Findings and Questioned Costs Finding 2022-001 Name of Contact Person: Michael Best Executive Director Corrective Action: We will implement proper internal control procedures for the Public and Indian Housing program eligibility requirements. Proposed Completion Date: Immediately

View Audit 54770

Finding 58678 (2022-001)

Significant Deficiency 2022

Gti Energy and Subsidiaries

IL

Subrecipient Monitoring Cash Management Significant Deficiency

Finding Number: 2022-001 Condition: Controls in place did not minimize the time elapsing between the transfer of funds and disbursement to a GTI Energy subrecipient. Planned Corrective Action: The one exception noted related to a disbursement made in January 2022, prior to the full implementation of...

Finding Number: 2022-001 Condition: Controls in place did not minimize the time elapsing between the transfer of funds and disbursement to a GTI Energy subrecipient. Planned Corrective Action: The one exception noted related to a disbursement made in January 2022, prior to the full implementation of the corrective action plan in May of 2022. GTI Energy management believes the prior year?s corrective action plan successfully addressed this finding, as the remainder of the transactions tested were paid within 30 calendar days. Contact person responsible for corrective action: Michael Momot, Sr. Manager, Accounting and Contract Administration Anticipated Completion Date: Fully corrected as of May 31, 2022

View Audit 54739

Finding 58676 (2022-002)

Significant Deficiency 2022

Bedford Public Schools

MI

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

2022-002 ? Equipment/Real Property Management ? Prior Approval for Capital Expenditures U.S. Department of Education ? Education Stabilization Fund (ALN 84.425D); Passed through MDE; All project numbers. Auditor Description of Condition and Effect. The District was unable to provide support for pr...

2022-002 ? Equipment/Real Property Management ? Prior Approval for Capital Expenditures U.S. Department of Education ? Education Stabilization Fund (ALN 84.425D); Passed through MDE; All project numbers. Auditor Description of Condition and Effect. The District was unable to provide support for prior approval for certain capital expenditures for equipment purchased with federal funds. The District did not follow federal requirements to obtain prior approval for capital expenditures. Auditor Recommendation. We recommend that the District reviews its policies to ensure that prior approval for capital expenditures is obtained whenever federal funds are used. Corrective Action. The District misinterpreted the approval of ESSER funds used for air purification equipment and will comply with all federal procurement regulations in the future. Responsible Person: Julie Campbell, Chief Financial Officer Anticipated Completion Date: June 30, 2023

View Audit 54255

Finding 58608 (2022-002)

Significant Deficiency 2022

Whittier College

CA

Reporting Significant Deficiency

Finding 2022-002 Reporting Criteria: According to the 2022 OMB Compliance Supplement - ED will be collecting an annual report for HEERF grantees in April 2022. ED will share more information regarding this annual report, which will require institutions to report on their uses of HEERF I CARES Act...

Finding 2022-002 Reporting Criteria: According to the 2022 OMB Compliance Supplement - ED will be collecting an annual report for HEERF grantees in April 2022. ED will share more information regarding this annual report, which will require institutions to report on their uses of HEERF I CARES Act funds, HEERF II CRRSAA funds, and HEERF III ARP funds in advance of the ARP annual reporting deadline. Statement of Condition: Whittier College failed to report the amounts within the Institutional Expenditures section of the second HEERF Annual Report accurately. Corrective Action Planned: ORSP will ensure that adequate time is devoted to annual report completion to allow for careful review of calculations and classification of expenditures. Name of contact Person responsible for corrective action plan: Lisa Newton, Associate Director of Research and Sponsored Programs Anticipated completion date: The correction to 2021 Institutional Expenditures will be made between March 6 to March 24, 2023 when the Annual Report Data Collection Tool is open to correct previously submitted Year 2 data.

View Audit 54920

Finding 58539 (2022-001)

Significant Deficiency 2022

Johnson City Independent School District

TX

Significant Deficiency

Finding Summary: The District failed to maintain property records that include a description of the property, the

View Audit 55325

Finding 58476 (2022-003)

Significant Deficiency 2022

Mt. Graham Regional Medical Center, Inc.

AZ

Allowable Costs / Cost Principles Significant Deficiency § 200.303

Finding 2022-003 Federal Agency Name Department of Health and Human Services Program Name: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution/Federal Financial Assistance Listing #93.498 Finding Summary: The Medical Center's eligible expenses listing had errors when agre...

Finding 2022-003 Federal Agency Name Department of Health and Human Services Program Name: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution/Federal Financial Assistance Listing #93.498 Finding Summary: The Medical Center's eligible expenses listing had errors when agreed to underlying supporting documentation. Responsible Individuals: Kathleen Williams, Chief Financial Officer Corrective Action Plan: We will implement new control process which ensures amounts reported are reviewed and accurately reported. Anticipated Completion Date: September 27, 2023

View Audit 55247

Finding 58464 (2022-003)

Significant Deficiency 2022

Independent School District No. 833

MN

Questioned Costs Internal Control / Segregation of Duties Special Tests & Provisions

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE AND REPORTABLE INSTANCE OF NONCOMPLIANCE ? FEDERAL COMMUNICATIONS COMMISSION, EMERGENCY CONNECTIVITY FUND PROGRAM ? FEDERAL ALN 32.009 2022-003 Internal Control Over Compliance and Noncompliance With Special Tests and Provisions Requirement...

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE AND REPORTABLE INSTANCE OF NONCOMPLIANCE ? FEDERAL COMMUNICATIONS COMMISSION, EMERGENCY CONNECTIVITY FUND PROGRAM ? FEDERAL ALN 32.009 2022-003 Internal Control Over Compliance and Noncompliance With Special Tests and Provisions Requirements Finding Summary 47 CFR ? 54.1711 requires that the District only seek support for eligible equipment provided to students and school staff who would otherwise lack connected devices sufficient to engage in remote learning. The District did not have sufficient controls in place within its Emergency Connectivity Fund Program to assure compliance with federal special tests and provisions requirements. Corrective Action Plan Actions Planned ? The District will review its procedures relating to special tests and provisions requirements specifically relating to eligible equipment for which the District could seek reimbursement to ensure compliance in the future with any additional federal awards. Official Responsible ? Kris Blackburn, Fiscal Services Director. Planned Completion Date ? March 31, 2023. Disagreement With or Explanation of Finding ? The District is in agreement with this finding. Plan to Monitor ? The District?s Fiscal Services Director will ensure appropriate controls are in place to verify the District?s compliance with federal special tests and provisions requirements.

View Audit 55289 Questioned Costs: $1

Finding 58463 (2022-002)

Significant Deficiency 2022

Independent School District No. 833

MN

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

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE ? U.S. DEPARTMENT OF THE TREASURY, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS ? FEDERAL ALN 21.027 2022-002 Internal Control Over Compliance With Federal Suspension and Debarment Requ...

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE ? U.S. DEPARTMENT OF THE TREASURY, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS ? FEDERAL ALN 21.027 2022-002 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR ? 180 requires Independent School District No. 833 (the District) to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the coronavirus state and local fiscal recovery funds federal program. The District did not have sufficient controls in place within its coronavirus state and local fiscal recovery funds federal program to assure that it was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned ? The District will review policies and procedures relating to suspension and debarment for its federal programs and will ensure that all parties with which it contracts for goods or services are eligible to participate in contracts involving the expenditures of federal program funding. Official Responsible ? Kris Blackburn, Fiscal Services Director. Planned Completion Date ? June 30, 2023. Disagreement With or Explanation of Finding ? The District is in agreement with this finding. Plan to Monitor ? The District?s Fiscal Services Director will ensure appropriate controls are in place to verify that any vendor with which the District contracts for federal program goods or services exceeding $25,000 is not listed as suspended or debarred on the federal Excluded Parties List System website.

View Audit 55289

Finding 58450 (2022-002)

Significant Deficiency 2022

Charles Drew Health Center, Inc.

NE

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

CORRECTIVE ACTION PLAN Management has developed the following for consistent adjustments to patient accounts according to the SFDS: 1. Management will work with the electronic payment system contractors to update system parameters for automatic system generated discounts in accordance with the slidi...

CORRECTIVE ACTION PLAN Management has developed the following for consistent adjustments to patient accounts according to the SFDS: 1. Management will work with the electronic payment system contractors to update system parameters for automatic system generated discounts in accordance with the sliding discount schedule. This process began February 28, 2023. 2. Management will implement a monthly audit of a statistically relevant sample of all encounters subjected to the sliding fee adjustment process to test the consistency of the adjustment with the SFDS. This process began February 28, 2023. 3. Management will implement a process to ensure that all reviews and audit corrections are performed by a person other than the person performing the review and all adjustments to patient accounts are reviewed subsequent to processing. Anticipated completion date is June 30, 2023.

View Audit 49524

Finding 58448 (2022-002)

Significant Deficiency 2022

Cleveland Area Hospital Trust

OK

Allowable Costs / Cost Principles Cash Management Reporting § 200.303

Consideration of Amounts Reimbursed from Other Sources Finding 2022-002 Federal Agency Name Department of Health and Human Services Program Name: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution/Federal Financial Assistance Listing #93.498 Finding Summary: The expenses re...

Consideration of Amounts Reimbursed from Other Sources Finding 2022-002 Federal Agency Name Department of Health and Human Services Program Name: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution/Federal Financial Assistance Listing #93.498 Finding Summary: The expenses reported as eligible for the American Rescue Plan (ARP) Rural Distribution were overstated. The error related to not identifying expenses that were reimbursement from other sources. Responsible Individuals: Ray Moss CFO Corrective Action Plan: We will implement an additional layer of review as part of the response of the findings above. Anticipated Completion Date: September 27, 2023

View Audit 55720

Finding 58440 (2022-002)

Significant Deficiency 2022

Independent School District No. 911

MN

Internal Control / Segregation of Duties Special Tests & Provisions Procurement, Suspension & Debarment

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE ? FEDERAL COMMUNICATIONS COMMISSION, EMERGENCY CONNECTIVITY FUND PROGRAM ? FEDERAL ALN 32.009 2022-002 Internal Control Over Compliance With Special Tests and Provisions Finding Summary 47 CFR ? 54.1711 requires that the District only see...

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE ? FEDERAL COMMUNICATIONS COMMISSION, EMERGENCY CONNECTIVITY FUND PROGRAM ? FEDERAL ALN 32.009 2022-002 Internal Control Over Compliance With Special Tests and Provisions Finding Summary 47 CFR ? 54.1711 requires that the District only seek support for eligible equipment provided to students and school staff who would otherwise lack connected devices sufficient to engage in remote learning. During our audit, we noted the District did not have sufficient controls in place within its Emergency Connectivity Fund Program to assure compliance with federal special tests and provisions requirements. We noted that the District requested federal reimbursement for purchased technology devices prior to those devices being used or deployed, and thus not yet meeting the definition of eligible equipment for which the District could seek reimbursement. Corrective Action Plan Actions Planned ? The finding resulted from a timing issue caused by unfamiliarity with a new federal program. The District subsequently deployed all devices for which it was reimbursed to students in accordance with the unmet needs defined and approved in its award applications. The District understands the applicable guidance and will ensure that future reimbursement requests under the Emergency Connectivity Fund Program will not be made until after the equipment has been placed in service. Official Responsible ? Director of Finance and Operations, Christopher Kampa. Planned Completion Date ? March 31, 2023. Disagreement With or Explanation of Finding ? The District is in agreement with this finding. Plan to Monitor ? The District?s Director of Finance and Operations, Christopher Kampa, will assure appropriate internal controls are in place to verify future compliance with special tests and provisions requirements for the Emergency Connectivity Fund Program.

View Audit 55911

Finding 58436 (2022-004)

Significant Deficiency 2022

Tucson Unified School District No. 1

AZ

Allowable Costs / Cost Principles Reporting Significant Deficiency

2022-004 Education Stabilization Fund ? Assistance Listing No. 84.425 Recommendation: We recommend the District to follow its Time and Effort Procedures For Federal Grants to ensure all Certifications are completed in accordance with policy. We also recommend the District to retain evidence of HR ap...

2022-004 Education Stabilization Fund ? Assistance Listing No. 84.425 Recommendation: We recommend the District to follow its Time and Effort Procedures For Federal Grants to ensure all Certifications are completed in accordance with policy. We also recommend the District to retain evidence of HR approvals of authorized wage rates. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: : In December 2022, the District updated its Time & Effort Procedures to reflect unique circumstances that might prevent the effective collection of Time & Effort logs, such as employees who separate from the district before a certification can be completed and a 90-day timeline for completion of certification when an employees? salary and benefits costs are re-coded to a Federal grant. These procedures will be reviewed annually to ensure compliance with Federal requirements. With regards to evidence related to Human Resources approvals of authorized wage rate, the District is developing a written standard operating procedure (SOP) for determining wage and salary placements and adjustments. The SOP will set forth the steps for evaluating and setting wages, including any approval process and/or required documentation. Human Resources will maintain records of all updated and approved wage rates for employees hired by the District. Name of the contact person responsible for corrective action: For Time & Effort procedures: Jon Lansa, Senior Director Grants & Federal Programs and Ricky Hernandez, Chief Financial Officer. For authorized wage rates: Jon Fernandez, Chief Human Capital Officer. Planned completion date for corrective action plan: Time and effort procedures update completed December 31, 2022. For authorized wage rates, September 30, 2023.

View Audit 55907

Finding 58435 (2022-003)

Significant Deficiency 2022

Tucson Unified School District No. 1

AZ

Questioned Costs Subrecipient Monitoring Reporting

2022-003 Education Stabilization Fund ? Assistance Listing No. 84.425 Recommendation: We recommend the District to review its current procedures over the review of contracts to ensure prevailing wage rates clauses are included in the contract and implement a monitoring control to ensure certified pa...

2022-003 Education Stabilization Fund ? Assistance Listing No. 84.425 Recommendation: We recommend the District to review its current procedures over the review of contracts to ensure prevailing wage rates clauses are included in the contract and implement a monitoring control to ensure certified payrolls are submitted by the contractor or subcontractor in a timely manner as required by the regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: For all Requests for Proposals (RFP), Invitations for Bid (IFB), and Requests for Quotations (RFQ), the District provides a ?Special Requirements: Federal Requirements? section in all of the terms and conditions that prospective vendors must review. All vendors are required to acknowledge that they read, understand, and will abide by the various Federal requirements. Among them, a clause of building projects states, ?Davis-Bacon Act ? the OFFEROR shall complete with the Davis-Bacon Act (40 U.S.C. 276a to 276a-7) as supplemented by the Department of Labor regulations (29 CFR Part 5).? Any prospective vendor is required to maintain records for the operations under the awarded contract for a period of not less than five (5) years for the District?s review. The District is currently identifying construction project vendors and requesting documentation to show evidence that the vendors met the requirements of Davis-Bacon. Davis-Bacon requirements have been implemented since July 1, 2022, and missing documentation from vendors will be collected by June 30, 2024. Name of the contact person responsible for corrective action: Ricky Hernandez, Chief Financial Officer Planned completion date for corrective action plan: Process was implemented by June 30, 2022. Vendors with missing documentation will be collected by June 30, 2024.

View Audit 55907 Questioned Costs: $1

Finding 58429 (2022-002)

Significant Deficiency 2022

Lutheran Seniorlife

PA

Procurement, Suspension & Debarment Reporting Significant Deficiency

2022-002 Federal agency: U.S. Department of Health and Human Services Federal Program Title: COVID-19 Provider Relief Fund Assistance Listing #: 93.498 Criteria or specific requirement: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. ...

2022-002 Federal agency: U.S. Department of Health and Human Services Federal Program Title: COVID-19 Provider Relief Fund Assistance Listing #: 93.498 Criteria or specific requirement: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. 116-136, 134 Stat. 563) and are to be used to prevent, prepare for, and respond to coronavirus and that the funds shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. These funds may not be used to reimburse expenses of losses that have been reimbursed from other sources or that other sources are obligated to reimburse. Condition: The Organization's internal controls over reporting were not effective. Context: During the audit, it was determined that one out of 13 expenditures selected for testing did not agree to the supporting payment. Recommendation: We recommend expenditures only be allocated to Provider Relief Funds after they have been paid. Action taken in response to finding: Management acknowledges the error in the report and for future reporting periods will verify expenditures have been paid before reporting. Name of contact person responsible for corrective action: Jeffrey Carraway

View Audit 55905

Finding 58428 (2022-001)

Significant Deficiency 2022

Lutheran Seniorlife

PA

Reporting Significant Deficiency Internal Control / Segregation of Duties

2022-001 Federal agency: U.S. Department of Health and Human Services Federal Program Title: COVID-19 Provider Relief Fund Assistance Listing #: 93.498 Criteria or specific requirement: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. ...

2022-001 Federal agency: U.S. Department of Health and Human Services Federal Program Title: COVID-19 Provider Relief Fund Assistance Listing #: 93.498 Criteria or specific requirement: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. 116-136, 134 Stat. 563) and are to be used to prevent, prepare for, and respond to coronavirus and that the funds shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. These funds may not be used to reimburse expenses of losses that have been reimbursed from other sources or that other sources are obligated to reimburse. Condition: The Organization's internal controls over reporting were not effective. Context: During the audit, it was determined that on three out of five reports selected for testing, lost revenue was overstated due to differences between revenue reported under the actual revenue method (option one) for reporting lost revenue and the underlying internal financial information. Recommendation: We recommend management implement additional procedures to review reported revenue before submitting reports and adjust the system report used to compile the revenue information to ensure it is correct and reflects the utilization of Provider Relief Funds to replace lost revenue. Action taken in response to finding: Management acknowledges the error in selecting an incomplete management revenue report for reporting purposes. For future reporting periods, management will correct the management report utilized and ensure it balances with total revenues. Management will correct the amounts report for 2019 through 2022 beginning with Provider Relief Funds reporting period #4. Name of contact person responsible for corrective action: Jeffrey Carraway

View Audit 55905

Finding 58427 (2022-004)

Significant Deficiency 2022

Lutheran Seniorlife

PA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

2022-004 Federal agency: U.S. Department of Housing and Urban Development Federal Program Title: Mortgage Insurance ? Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities Assistance Listing #: 14.129 Criteria or specific requirement: REAC Inspection Resul...

2022-004 Federal agency: U.S. Department of Housing and Urban Development Federal Program Title: Mortgage Insurance ? Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities Assistance Listing #: 14.129 Criteria or specific requirement: REAC Inspection Results Condition: St. John received a REAC inspection score of less than 31, which denotes the property has physical deficiencies that do not meet contractual obligations to HUD. Context: Results of REAC inspection 613308. Recommendation: St. John should work to address all REAC inspection findings. Action taken in response to finding: Subsequent to this survey, the facility incurred significant flooding, which required immediate action. Due to this, St. John did not have the ability to address the findings from the survey. With a protracted insurance claims process and the impact of Covid-19 on building operations, work on the outstanding deficiencies has been delayed. Due to the risk to residents and staff, all outside visitors including maintenance contractors and other vendors has been limited for a number of periods during the pandemic during FY21. Management completed an assessment of the facility?s use and has begun a repositioning plan to bring new living options into the building. In order to complete the needed improvements to the building, St. John has completed a refinancing of its existing HUD debt and negotiated a construction loan to fund the improvements. The closing on the refinancing of the existing HUD loan and the construction loan took place on July 8, 2021. Name of contact person responsible for corrective action: Jeffrey Carraway

View Audit 55905

Finding 58426 (2022-003)

Significant Deficiency 2022

Lutheran Seniorlife

PA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

2022-003 Federal agency: U.S. Department of Housing and Urban Development Federal Program Title: Mortgage Insurance ? Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities Assistance Listing #: 14.129 Criteria or specific requirement: Failure to Maintain A...

2022-003 Federal agency: U.S. Department of Housing and Urban Development Federal Program Title: Mortgage Insurance ? Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities Assistance Listing #: 14.129 Criteria or specific requirement: Failure to Maintain Approved Management Agreements Condition: St. John Lutheran Care Center (St. John) was charged a management fee by Lutheran SeniorLife, its parent but did not have an approved management contract meeting the requirements of the regulatory agreement. Context: St. John did not have an approved management agreement. Recommendation: St. John should enter into an approved management agreement with Lutheran SeniorLife. Action taken in response to finding: St. John updated internal agreements to reflect the change from Lutheran Affiliated Services to Lutheran SeniorLife, but neglected to complete the process with HUD. St John will submit the paperwork to obtain a certified HUD approved management agreement. While the organization was operating without this agreement in place, management fees charged were only to reimburse costs incurred in performing these management functions. During Fiscal Year 2021, St John entered into a refinancing plan with a lender in order to facilitate a repositioning of the facility and to enable facility improvements that were identified. The closing on the refinancing of the existing HUD loan took place on July 8, 2021. Name of contact person responsible for corrective action: Jeffrey Carraway

View Audit 55905

Finding 58412 (2022-004)

Significant Deficiency 2022

Tgu Public School District No. 60

ND

Reporting Significant Deficiency

2022-004 Official Responsible for Insuring CAP Dani Haman, Head Start fiscal officer, will be responsible to ensure that the appropriate measures are taken. Correcting Plan The District will provide necessary training. The Planned Completion Date of CAP Immediately

View Audit 54193

Finding 58405 (2022-002)

Significant Deficiency 2022

Town of Easton

MD

Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency § 200.317 § 200.318 § 200.327

Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend the Town establish and document procurement policies and procedures in conformity with the Federal requirements ?? 200.317 through 200.327. Explanation of disagreement with audit finding: T...

Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend the Town establish and document procurement policies and procedures in conformity with the Federal requirements ?? 200.317 through 200.327. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Town of Easton will modify the current procurement procedures to add an additional section for those services, materials or products procured that have a Federal Grant Revenue source. Name(s) of the contact person(s) responsible for corrective action: Donald Richardson Planned completion date for corrective action plan: June 30, 2023

View Audit 54126

Finding 58397 (2022-001)

Significant Deficiency 2022

Weiser Valley Hospital District Dba Weiser Memorial Hospital

ID

Procurement, Suspension & Debarment Material Weakness Significant Deficiency

2022-001 Policies and Procedures for Federal Awards Corrective action planned: We did not have a written policy and procedure in place for federal awards at year-end. Upon discovery, we have created required policies and procedures and have implemented them to our organization. Anticipated completi...

2022-001 Policies and Procedures for Federal Awards Corrective action planned: We did not have a written policy and procedure in place for federal awards at year-end. Upon discovery, we have created required policies and procedures and have implemented them to our organization. Anticipated completion date: December 16, 2022 Contact person responsible for corrective action: Pamela Stampfli, CFO

View Audit 54777

Corrective Action Plans

Filters