Corrective Action Plans

Finding 504720 (2022-003)

Significant Deficiency 2022

VA

Reporting Questioned Costs Subrecipient Monitoring

Federal Award Finding and Questioned Costs Finding Reference Number: 2022-003 Other Federal Program Information: Federal Agency: U.S. Department of Health and Human Services Awards: Assistance Listing Number 93.498 COVID-19 – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Aw...

Federal Award Finding and Questioned Costs Finding Reference Number: 2022-003 Other Federal Program Information: Federal Agency: U.S. Department of Health and Human Services Awards: Assistance Listing Number 93.498 COVID-19 – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Periods: Period 3 – January 1, 2021 to June 30, 2022 Period 4 – June 30, 2021 to December 31, 2022 Description: Preparation of Schedule of Expenditures of Federal Awards Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: The System’s policy and procedures should be designed to ensure accurate reporting as required by the Uniform Guidance. View of Responsible Officials: There is no disagreement with the audit finding. Corrective Action Planned: Management will design and ensure written policies and procedures will be created outlining processes and control activities to ensure reporting to federal awarding agencies and pass-through entities are complete and accurate. During the current fiscal year, Inova began implementing enhancements to Oracle’s Grants Accounting module. Once completed, this will assist management to automate certain processes and procedures that were not available after the initial implementation. The enhanced reporting capabilities will include automated reporting that will identify grants that expended federal awards. Grants Accounting will schedule quarterly meetings with Finance and GMO leadership present. The purpose of these meetings will be to review federal funding received that will ultimately be used in the preparation of financial reports submitted to the appropriate governing agencies. The Director of Grants Accounting will guide the meetings and obtain approvals from department leaders confirming amounts to be reported for federal grant awards. In preparation of the meetings, the Director of Grants Accounting will prepare an agenda to guide discussions of grant terms and conditions and applicable FAQs, more explicitly for awards received outside of Inova’s normal course of business (i.e., COVID-19). These meetings will also provide an opportunity for Finance, GMO, and Grants Accounting leaders to review the unique characteristics of the federal grant award programs on at least a quarterly basis. Meeting minutes will be maintained to document discussions and actions to be taken. The minutes will also serve as support for accounting memos related to special awards received that document Inova’s understanding of the award and related reporting requirements. All accounting memos will be prepared by the Director of Grants Accounting and reviewed by the Senior Director of Financial Reporting. Name(s) of the Contact Person(s) Responsible for Corrective Action: Christopher T. Smith, Vice President of Finance and Corporate Controller, 571-472-8122. Christopher Trump, Senior Director of Financial Reporting, 571-373-2868. Michael H. Lowen, Director, Grant Accounting, 571-472-8108. Planned completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2023.

View Audit 327330

Finding 504718 (2022-001)

Significant Deficiency 2022

Inova Health System

VA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

Federal Program Information: Federal Agency: U.S. Department of Health and Human Services Awards: Assistance Listing Number 93.498 COVID-19 – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Periods: Period 3 – January 1, 2021 to June 30, 2022 Period 4 – June 30, 2021 to ...

Federal Program Information: Federal Agency: U.S. Department of Health and Human Services Awards: Assistance Listing Number 93.498 COVID-19 – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Periods: Period 3 – January 1, 2021 to June 30, 2022 Period 4 – June 30, 2021 to December 31, 2022 Description: Review and Approval of the expenditures included in the HRSA portal submission Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: Management should design internal controls related to the documentation of the review of the expenditures for the HRSA portal submission to ensure that the reported amounts are accurate. View of Responsible Officials: Management concurs with the finding and will implement procedures to ensure that HRSA reporting reports are prepared by individuals with HRSA reporting experience and reviewed by management prior to submission. Name(s) of the Contact Person(s) Responsible for Corrective Action: Christopher T. Smith, Vice President of Finance and Corporate Controller, 571-472-8122. Christopher Trump, Senior Director of Financial Reporting, 571-373-2868. Michael H. Lowen, Director, Grant Accounting, 571-472-8108. Corrective Action Planned: Activities Allowed or Unallowed, Allowable Costs/Cost Principles - Inova has an established process that identifies actions needed to carry out specific responses to identified internal control risks related to the review of the expenditures for the HRSA portal submissions, specifically that the reported amounts are accurate. Part of that process is to review the HRSA portal submissions for specific allowable activities requirements, and those activities/costs that require pre-approval by the awarding agency. Additionally, monthly, the Director of Grants Accounting reviews the budget versus actual reports investigating unusual or unexpected variances and documents results of follow-up work performed. In order to improve both of these processes and ensure more accurate reviews, Inova’s Director of Grants Accounting will develop a training program that ensures a timely cadence, of no less than bi-annually, whereby all applicable personnel obtain current knowledge of allowable activities and associated costs to be submitted to HRSA and other governing agencies as deemed appropriate. The program will include self-guided training in addition to enlisting industry experts to instruct on relevant updates. External trainings will be documented either electronically, if so allowed, or through properly recorded minutes. Reporting - Management will identify, and put into effect, actions needed to carry out specific responses to identified risks related to reporting. Such actions will include enhancing current knowledge of reporting requirements through a training program as discussed above, develop and document all controls over reporting that were leveraged to create and review manually prepared spreadsheets and reports. Prior to the HRSA portal submissions, our review process, as identified above, will be formally documented and evidenced by proper signoffs. Further, we will also address segregation of duties concerns that will alleviate risk of fraud and develop and appropriately document bridge between source data and final reports for any reconciling items and lack of or inappropriate source data or analysis used as the basis of reporting. Inova management will review, and periodically update applicable award agreements or contracts for specific reporting requirements and establish a reporting calendar for review and approval. The calendar will be periodically reviewed with the Grants Management Office (“GMO”) for the completeness and accuracy of and adherence to the reporting calendar. Written policies and procedures will be created outlining processes and control activities for ensuring reporting to federal awarding agencies and pass-through entities are complete and accurate. Planned Completion Date for Corrective Action Planned: Ongoing with a completion date of December 31, 2023.

View Audit 327330

Finding 504580 (2022-003)

Material Weakness 2022

Minneola District Hospital No. 2

KS

Material Weakness Reporting Significant Deficiency

2022-003 – Reporting Corrective action planned: The District will save the emails that show they sent the audit to the USDA in the audit folder. Anticipated completion date: Immediately Contact person responsible for corrective action: Controller

View Audit 327167

Finding 504579 (2022-002)

Material Weakness 2022

Minneola District Hospital No. 2

KS

Special Tests & Provisions Material Weakness Significant Deficiency

2022-002 – Special Tests and Provisions Corrective action planned: The District will open a new bank account that will hold the debt reserve amount. A deposit into the debt reserve account will be made monthly via auto transfer on the tenth of each month until December 2027. There will be one withd...

2022-002 – Special Tests and Provisions Corrective action planned: The District will open a new bank account that will hold the debt reserve amount. A deposit into the debt reserve account will be made monthly via auto transfer on the tenth of each month until December 2027. There will be one withdrawal from this account done annually to transfer funds to a CD. The annual payment amount will have its own account with the amount of the next years’ payment. Anticipated completion date: November 30, 2024 Contact person responsible for corrective action: Controller

View Audit 327167

Finding 504148 (2022-005)

Significant Deficiency 2022

Okanogan County Child Development Association

WA

Internal Control / Segregation of Duties Significant Deficiency

Recommendation: We recommend the Association adopt controls to reconcile payroll liability balances at least quarterly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Containment During the previous audit, we i...

Recommendation: We recommend the Association adopt controls to reconcile payroll liability balances at least quarterly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Containment During the previous audit, we implemented benefit plans in the system allowing for accurate and timely reporting. Worked with Fiscal Consultant to implement entry of all liabilities into the fiscal software. Root Cause Due to a lack of knowledge of the software system not all information was migrated into the new software system in a timely manner, making it difficult to use at its full potential. OCCDA had a large turnover in the fiscal team. The transition to the new fiscal software was during the height of the COVID-19 pandemic, making it difficult to complete training and migration of the new system. Action Taken Reassessing the payroll system set up and the mapping of the payroll liabilities, working towards reconciling the balance sheet accounts at minimum quarterly. We have reached out to the fiscal software support to help review our mapping and processes of payroll. We will continue to work with them to fine tune the software.

View Audit 326592

Finding 504147 (2022-004)

Significant Deficiency 2022

Okanogan County Child Development Association

WA

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

Recommendation: We recommend that Association staff familiarize themselves with the terms of the loan agreement and put controls in place to ensure funds are properly transferred to the reserve account at least annually. Explanation of disagreement with audit finding: There is no disagreement with ...

Recommendation: We recommend that Association staff familiarize themselves with the terms of the loan agreement and put controls in place to ensure funds are properly transferred to the reserve account at least annually. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Containment: Fiscal Manager has reviewed the loan requirements. Root Cause Due to large turnover in the fiscal team and the lack of knowledge of loan requirements. Action Taken Fiscal Manager has reviewed loan documents and requirements making ourselves familiar with the reserve account requirements. Moving forward the transfer to the reserve account will happen on a monthly basis in conjunction with the mortgage payment.

View Audit 326592

Finding 504146 (2022-003)

Significant Deficiency 2022

Okanogan County Child Development Association

WA

Internal Control / Segregation of Duties Cash Management Significant Deficiency

Recommendation: The Association establish controls that allow for the timely and accurate recording of grants and contracts receivable from reimbursement-based awards in the same period as their corresponding expenditures. Explanation of disagreement with audit finding: There is no disagreement wit...

Recommendation: The Association establish controls that allow for the timely and accurate recording of grants and contracts receivable from reimbursement-based awards in the same period as their corresponding expenditures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Containment Through this audit process and staff turnover, tasks have been distributed and processes have been implemented immediately to meet the expectations that an AR transaction be entered into the fiscal system within a timely manner of one week or sooner. Root Cause Due to a lack of knowledge of the new software system. Not all information was migrated into the new software system in a timely manner, making it difficult to use at its full potential. OCCDA had a large turnover in the fiscal team during the audit process. The transition to the new fiscal software was during the height of the COVID-19 pandemic, making it difficult to complete training and migration of the new system. Action Taken Immediately in 2023, the fiscal team implemented adding reports/documentation to all requests for funding to allow for better tracking and record keeping. Newly hired staff have established a clear understanding of the naming conventions for clarity and accurate reporting. Tasks have been realigned to specific positions so that all duties are covered and responsibilities are defined. This will ensure that all fiscal tasks are completed timely and accurately establishing controls for reimbursement funding. Training has been provided for the fiscal team on the internal processes and procedures to ensure the timely entry of all data and the importance of accurate monthly reports. We have reorganized the chart of accounts in support of the software consultants, we have added additional program numbers to track grants separately by funding year to allow us to close each grant yearly. Our Fiscal Assistant has been trained to complete all accounts receivable. Receivable billings are completed in the month that they are performed. All receipts are recorded in the month they are received. Monthly reports continue to be sent out each month for the Leadership team to review, allowing for transparency and additional reviews and accuracy. Name(s) of contact person(s) responsible for corrective action: Fiscal Manager Planned completion date for corrective action plan: Completed

View Audit 326592

Finding 504145 (2022-002)

Significant Deficiency 2022

Okanogan County Child Development Association

WA

Internal Control / Segregation of Duties Significant Deficiency

Recommendation: The Association follow its own documented controls to ensure it prepares bank reconciliations on a timely and accurate basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: Containment Thro...

Recommendation: The Association follow its own documented controls to ensure it prepares bank reconciliations on a timely and accurate basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: Containment Through this audit process and staff turnover, tasks have been separated and processes have been implemented immediately to meet the expectations that all transactions are entered into the fiscal system within a timely manner of one week or sooner. Also, immediately the AR data entry process was established and the fiscal staff were trained on this procedure. Root Cause Due to a lack of knowledge of the new software system. Not all information was migrated into the new software system in a timely manner, making it difficult to use at its full potential. OCCDA had a large turnover in the fiscal team during the audit processing, making it difficult to find information or pull reports that were not fully migrated. The transition to the new fiscal software was during the height of the COVID-19 pandemic, making it difficult to complete training and migration of the new system. Action Taken In 2023, newly hired staff established a clear understanding of the naming conventions for clarity and accurate reporting. The fiscal team has assigned tasks ensuring duties are covered and responsibilities are defined. This will ensure that all fiscal tasks are completed timely and accurately. Training has been provided for the fiscal team on the internal processes and procedures. Journal entries have been minimized, and detailed entry of all transactions is the preferred method to allow for detailed review. Review from not only the fiscal staff but also the leadership team when completing their monthly reviews ensures accuracy and checks and balances. In 2023 the fiscal team has completed timely data entry of all transactions and in 2024 there will be timely bank reconciliations. Moving forward these regular and timely reconciliations as well as continued detailed entries will allow for simple and accurate monthly bank reconciliations and ensure timely detection of errors. Bank reconciliations have been completed on a timely basis each month no later than the 15th for the prior month since. This is a continued practice and reconciliation will continue to be current for all accounts. Journal entries continue to be minimized and detailed entry of all transactions are the preferred method of entry. Separation of duties continues to be a practice, with the Fiscal Assistant completing the entries into the fiscal software and the Fiscal Manager reviewing the data entry before payments are processed. Name(s) of contact person(s) responsible for corrective action: Fiscal Manager Planned completion date for corrective action plan: March 2024 (Q1)

View Audit 326592

Finding 504142 (2022-007)

Significant Deficiency 2022

Okanogan County Child Development Association

WA

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.430

Recommendation: The Association follow its own documented controls to ensure it prepares adequate time-and-effort documentation to support payroll costs charged to the federal grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in re...

Recommendation: The Association follow its own documented controls to ensure it prepares adequate time-and-effort documentation to support payroll costs charged to the federal grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Containment Supervisors have had long-time systems in place to review activity logs and their alignment with electronic time sheets. OCCDA policy changes in 2020 are documented in the staff handbook, which states that timesheets are submitted and approved electronically in EWS. In October 2023, a statement was added to the timekeeping system that states, “Submission of this electronic form constitutes your signature on the form. By electronically signing this form you are attesting to the accuracy of the information contained therein and the submission is authorized by you.” Root Cause Due to a lack of knowledge of the new system, fiscal staff could not pull reports out of the timekeeping system. Action Taken Upon implementation of the new timekeeping system in previous years, the staff handbook was updated to reflect the procedure of electronic submission of timesheets, but the fiscal policy will be updated to accurately reflect procedures by February 2024. Beginning in 2023, the staff allocations have been uploaded on a shared document where the Fiscal Manager and payroll both have access. Allocations are reviewed whenever there are any changes in duties or funding and at a minimum of quarterly. When there are changes, a formal status change is completed by HR and sent to payroll for processing and updates in the spreadsheet and the software. Beginning in January 2024 timesheets will be entered into the timekeeping system by staff indicating the number of hours spent in each funding program allowing for real time, accurate allocation of time. Time entry will continue to be reviewed by supervisors or the next in the chain of command when the supervisor is unavailable and paid based on the entered time. Quarterly allocations will be reviewed in the payroll system to ensure that we are staying within the budget. Electronic submission of timesheets was implemented in 2024. The staff allocations have been uploaded on a shared document where the Fiscal Manager and payroll both have access. Allocations are reviewed whenever there are any changes in duties or funding and at a minimum quarterly. When there are changes, a formal status change is completed by HR and sent to payroll for processing and updates in the spreadsheet and the software. Beginning in January 2024 timesheets have been entered into the timekeeping system by staff indicating the number of hours spent in each funding program allowing for real time, accurate allocation of time. Time entry will continue to be reviewed by supervisors or the next in the chain of command when the supervisor is unavailable and paid based on the entered time. Name(s) of contact person(s) responsible for corrective action: Fiscal Manager Planned completion date for corrective action plan: March 2024 (Q1)

View Audit 326592

Finding 504139 (2022-003)

Significant Deficiency 2022

Town of Plainville

MA

Reporting Significant Deficiency

Finding 2022-003 “Improve Compliance with and Controls Over Reporting” Correction Action to be taken: We have been updating and developing written policies and procedures related to Federal awards as required under Uniform Guidance. Once approved, these procedures will guide applicants in ensuring ...

Finding 2022-003 “Improve Compliance with and Controls Over Reporting” Correction Action to be taken: We have been updating and developing written policies and procedures related to Federal awards as required under Uniform Guidance. Once approved, these procedures will guide applicants in ensuring proper reporting guidelines are followed. Expected Completion Date: We anticipate that the policies and procedures will be completed and approved by June 30, 2025. Contact Person: Julie Hebert, Finance Director

View Audit 326566

Finding 504136 (2022-002)

Significant Deficiency 2022

Town of Plainville

MA

Allowable Costs / Cost Principles School Nutrition Programs Questioned Costs

Finding 2022-002 “Improve Time and Effort Documentation” Correction Action to be taken: The Town is reviewing all school contracts and time sheets for inefficiencies and requiring adjustments or more documentation as necessary. Expected Completion Date: We anticipate that all major inefficiencies...

Finding 2022-002 “Improve Time and Effort Documentation” Correction Action to be taken: The Town is reviewing all school contracts and time sheets for inefficiencies and requiring adjustments or more documentation as necessary. Expected Completion Date: We anticipate that all major inefficiencies within school payroll will be eradicated by June 30, 2025. Contact Person: Julie Hebert, Finance Director; Janet Jannell, Treasurer/Collector; Gale Clark, School Business Manager

View Audit 326566 Questioned Costs: $1

Finding 504072 (2022-014)

Significant Deficiency 2022

Unified Government of Wyandotte County and Kansas City, Kansas

KS

Questioned Costs Subrecipient Monitoring Reporting § 200.303

Finding 2022-014 U.S Department of Homeland Security Staffing for Adequate Fire and Emergency Response (SAFER) – 97.083 Management’s Response: Management agrees that reports should be available for all reporting periods. It was discovered in 2023 during document submittals that reports were stored...

Finding 2022-014 U.S Department of Homeland Security Staffing for Adequate Fire and Emergency Response (SAFER) – 97.083 Management’s Response: Management agrees that reports should be available for all reporting periods. It was discovered in 2023 during document submittals that reports were stored on the individual’s local computer and not reposed on the network. Key personnel turnover led to the reports not being available. The IT department has ensured that the documents stored locally on individual computer are now backed up by the network to prevent future issues, and compliance reports are to be stored on the department network drive and shared with Finance for a central depository. Views of Responsible Officials and Corrective Action: Management has begun the process of centralizing documents related to reporting, monitoring and compliance. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

View Audit 326473

Finding 504070 (2022-012)

Significant Deficiency 2022

Unified Government of Wyandotte County and Kansas City, Kansas

KS

Reporting Questioned Costs Significant Deficiency § 200.303

Finding 2022-012 U.S Department of Treasury COVID 19 – Coronavirus State and Local Fisal Recovery Funds – 21.027 Management’s Response: Management agrees that compliance reporting timing is important to grant management. The Unified Government of Wyandotte County & Kansas City KS experienced delay...

Finding 2022-012 U.S Department of Treasury COVID 19 – Coronavirus State and Local Fisal Recovery Funds – 21.027 Management’s Response: Management agrees that compliance reporting timing is important to grant management. The Unified Government of Wyandotte County & Kansas City KS experienced delays in reporting as a direct result of a cyber security event that occurred for the period of April 2022 – June 2022. There were also issues with the federal reporting system due to the Treasury having the City and County as two separate entities. Both issues have been resolved and all reports have been submitted in a timely manner in 2023 and to date in 2024. Views of Responsible Officials and Corrective Action: In concert with our ARPA consultant, we were able to combine the City & County on the portal and report timely quarterly since this initial issue in the reporting portal. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

View Audit 326473

Finding 503757 (2022-005)

Significant Deficiency 2022

City of Portland Maine

ME

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding 2022-005 Improve Compliance with American Rescue Plan Reporting Planned Corrective Action: In future reporting periods the City will ensure all activity is included within our U.S. Treasury Reporting Portal quarterly submissions, including activity from the formula approach to our revenue re...

Finding 2022-005 Improve Compliance with American Rescue Plan Reporting Planned Corrective Action: In future reporting periods the City will ensure all activity is included within our U.S. Treasury Reporting Portal quarterly submissions, including activity from the formula approach to our revenue replacement category. Anticipated Completion Date: June 30, 2024 Contact Person: Brendan O’Connell, Director of Finance

View Audit 326022

Finding 503676 (2022-004)

Significant Deficiency 2022

Southwestern Christian University, Inc.

OK

Questioned Costs Subrecipient Monitoring Reporting

Common Origination and Disbursement (COD) Reporting Planned Corrective Action: Southwestern Christian University will provide ongoing training to employees involved in posting batches to student ledgers. This training will include the importance of understanding when posting batches to student ledg...

Common Origination and Disbursement (COD) Reporting Planned Corrective Action: Southwestern Christian University will provide ongoing training to employees involved in posting batches to student ledgers. This training will include the importance of understanding when posting batches to student ledgers, batch dates cannot be changed from the posting information provided by the financial aid department. The 10 student's disbursement dates have been updated in COD to reflect the disbursement date of the student ledger. All 10 students in the finding were from the same batch. Person Responsible for Corrective Action Plan: Rita Palmer, Director of Financial Aid Anticipated Date of Completion: Immediately

View Audit 325887

Finding 503671 (2022-002)

Significant Deficiency 2022

Public Defender Association

WA

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring

Significant deficiency in internal control over compliance for allowable costs related to adequate documentation. Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: • This is primarily related to the absence of receipts for expen...

Significant deficiency in internal control over compliance for allowable costs related to adequate documentation. Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: • This is primarily related to the absence of receipts for expense items under $75. There are three items contributing to this finding: 1) Receipts that were not able to be located related to employees who had left the organization and did not provide receipts prior to departure - $0 of sample list. 2) Receipts that were simply not able to be found - $0 from sample list. 3) In general, PDA relies on our credit card platform for the repository of credit card receipts. The forum used during 2021 was “Elan”. Elan only retains receipts up to a maximum of 12 months from the date of spending. Due to the timing of the audit, in most cases 7-12 months had passed when the receipts were requested, and we were not able to extract from that system and therefore relied on employees’ records (see #1-2 above). Total amount related to expiration of receipts in Elan - $114.40. • PDA’s policy is to retain and upload receipts for all spending, no minimum. • In May of 2022, PDA moved to a new credit card platform (“Center”), which retains receipts into perpetuity. Anticipated completion date: This was implemented in May of 2022. Name(s) of the contact person(s) responsible for corrective action: Co-Executive Directors, Finance team

View Audit 325874

Finding 503648 (2022-001)

Significant Deficiency 2022

Hughes Village Council

AK

Questioned Costs Subrecipient Monitoring Reporting

Finding 2022-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Jennifer Babcock Corrective Action Plan: Hughes Village Council is now compliant with all past due audits. In order to ensure audits are completed on time, HVC will sch...

Finding 2022-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Jennifer Babcock Corrective Action Plan: Hughes Village Council is now compliant with all past due audits. In order to ensure audits are completed on time, HVC will schedule the audit at least 3 months prior to the March deadline. Proposed Completion Date: 10/15/2024

View Audit 325853

Finding 503645 (2022-001)

Significant Deficiency 2022

Hospital Comunitario Buen Samaritano, Inc.

PR

Questioned Costs Reporting Significant Deficiency § 200.512

Finding No. 2022-001-Reporting-Late filing of data collection form and reporting package We agree that we have not been reporting on a timely basis current findings and results. We have established a schedule to ensure that the submission of all required annual reports is strictly adhered to. To thi...

Finding No. 2022-001-Reporting-Late filing of data collection form and reporting package We agree that we have not been reporting on a timely basis current findings and results. We have established a schedule to ensure that the submission of all required annual reports is strictly adhered to. To this end, we aim to complete the year-end closing within the first 20 days after the end of the calendar year, in order to complete the audit within the first 90 days after the end of the calendar year. This Plan must be implemented no later than December 27, 2024.

View Audit 325833

Finding 503450 (2022-007)

Significant Deficiency 2022

West Side Community Health Services INC

MN

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303

Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend management implement a review process to check individual's compensation charged to federal grants against annual federal limitations prior to drawdown of funds. Explanation of disagreement with audit finding...

Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend management implement a review process to check individual's compensation charged to federal grants against annual federal limitations prior to drawdown of funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement review processes to identify individuals over federal wage limitations moving forward before being charged to federal grants. Name(s) of the contact person(s) responsible for corrective action: Duke Fokuo Planned completion date for corrective action plan: December 2024

View Audit 325563 Questioned Costs: $1

Finding 503449 (2022-006)

Significant Deficiency 2022

West Side Community Health Services INC

MN

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.303

Health Centers Cluster, Provider Relief Fund – Assistance Listing No. 93.2242/93.527, 93.498 Recommendation: We recommend implementing a formal policy and procedure where there is a review of all required reporting by an individual that did not prepare the report. Documentation should be retained to...

Health Centers Cluster, Provider Relief Fund – Assistance Listing No. 93.2242/93.527, 93.498 Recommendation: We recommend implementing a formal policy and procedure where there is a review of all required reporting by an individual that did not prepare the report. Documentation should be retained to support the review/approval occurrence. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a formal review process for reporting and retain documentation of review. Name(s) of the contact person(s) responsible for corrective action: Duke Fokuo Planned completion date for corrective action plan: December 2024

View Audit 325563

Finding 503448 (2022-005)

Significant Deficiency 2022

West Side Community Health Services INC

MN

Cash Management Reporting Significant Deficiency § 200.303

Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend reviewing reconciliation procedures between detailed grant expenditures and summary schedules used in reporting/draw down requests to ensure sufficient detail to support draw downs. Also recommend a detailed ...

Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend reviewing reconciliation procedures between detailed grant expenditures and summary schedules used in reporting/draw down requests to ensure sufficient detail to support draw downs. Also recommend a detailed review and approval process for federal grant eligible expenditures and draw downs, to identify issues prior to draw down or reporting in the future. Documentation should be retained to support review/approval occurrence. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review and improve reconciliation and review process around eligible expenditures for federal grants, and drawdowns of federal funds. Name(s) of the contact person(s) responsible for corrective action: Duke Fokuo Planned completion date for corrective action plan: December 2024

View Audit 325563

Finding 503201 (2022-002)

Significant Deficiency 2022

Tishomingo County Special Municipal Separate School District

MS

Questioned Costs Eligibility School Nutrition Programs

2022-002 a. Name of Contact Person Responsible for Corrective Action Name: Mary Beth Sheffield Title: Child Nutrition Director Phone Number: 662-423-3206 b. Corrective Action Planned: The District will increase training to appropriate personnel and ensure all documentation is fully reviewed to make ...

2022-002 a. Name of Contact Person Responsible for Corrective Action Name: Mary Beth Sheffield Title: Child Nutrition Director Phone Number: 662-423-3206 b. Corrective Action Planned: The District will increase training to appropriate personnel and ensure all documentation is fully reviewed to make sure requirements are met before processing eligibility applications. c. Anticipated Completion Date: 10/08/2024

View Audit 325287

Finding 503068 (2022-003)

Significant Deficiency 2022

Hope Toledo Services

OH

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs

Other- Significant Deficiency in Internal Control over Compliance with respect to record retention Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that management continue to recruit for staff to fill the needed positions in the finance ...

Other- Significant Deficiency in Internal Control over Compliance with respect to record retention Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that management continue to recruit for staff to fill the needed positions in the finance department as they continue to grow. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The Organization is actively seeking to hire additional staffing for the finance department. It has currently been operated on a parttime basis and our growth has exceeded that capacity. Name of the contact person responsible for corrective action: John C. Jones, President and CEO Planned completion date for corrective action plan: December 31, 2024 If the U.S. Department of Treasury has questions regarding this plan, please call John C. Jones at 419- 720-4281.

View Audit 325040

Finding 503067 (2022-002)

Significant Deficiency 2022

Hope Toledo Services

OH

Questioned Costs HUD Housing Programs Reporting

Reporting Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that reports are prepared and reviewed by separate individuals. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in ...

Reporting Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that reports are prepared and reviewed by separate individuals. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The Organization will add a layer of review for the prepared reports prior to submission to the grantor. Name of the contact person responsible for corrective action: John C. Jones, President and CEO Planned completion date for corrective action plan: October 31, 2024

View Audit 325040

Finding 502528 (2022-001)

Significant Deficiency 2022

Harlem Center for Education, Inc.

NY

Questioned Costs Eligibility Significant Deficiency

The Organization accepts the recommendation of the auditor. In the future, the Organization will implement an additional internal control regarding the verification of eligibility for Educational Opportunity Centers' participants. Specifically, in cases where the staff member who signed the "Verific...

The Organization accepts the recommendation of the auditor. In the future, the Organization will implement an additional internal control regarding the verification of eligibility for Educational Opportunity Centers' participants. Specifically, in cases where the staff member who signed the "Verification of Eligibility and Acceptance" form does not check off the citizenship status or need areas on the form, the data entry specialist will return the participant folder to that staff member to obtain the required eligibility information before including the participant in the database. In the event that the eligibility information is unobtainable, the participant will not be input into the database nor counted as a participant. In addition, more periodic testing of files will be undertaken to identify any participants who do not have the necessary eligibility information, with corrective action taken as needed.

View Audit 324518 Questioned Costs: $1

Corrective Action Plans

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