Corrective Action Plans

Finding 24843 (2022-001)

Significant Deficiency 2022

FL

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking

2022-001 Awarding of Direct Loans and Pell Grants Recommendation: We recommend the College evaluate its policies and procedures for identifying transfer credits and other changes made after the initial packaging to ensure that federal awards are revised as needed. Explanation of disagreement with au...

2022-001 Awarding of Direct Loans and Pell Grants Recommendation: We recommend the College evaluate its policies and procedures for identifying transfer credits and other changes made after the initial packaging to ensure that federal awards are revised as needed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Beacon is implementing a new comprehensive software system (Jenzabar One) which ? paired with NetPartner and PowerFAIDS ?will better identify changes in student status. The system will also include InfoMaker software which the financial aid office will use to pull information needed to double check for late changes in student eligibility. Full implementation of the new software is now estimated to occur in December 2022. In the interim, enhanced procedures have been put in place by the Financial Aid Office to prevent further issues: a. Requesting an updated anticipated graduation list from the Registrar at the beginning of each term to confirm students are awarded appropriately b. Requesting a final graduation list from the Registrar at the end of each term to identify any students whose graduation plan has been delayed and making immediate adjustments to their aid eligibility, if needed. c. Performing a finalized review of all graduating students prior to the end of the academic year to ensure proper adjustments have been made. d. Requesting updated reports from the Registrar of any student receiving credit for transfer coursework prior to the start of each semester and making adjustments immediately to their aid eligibility; e. Prior to disbursement, a second review of all students is being performed to identify students whose grade-level conflicts with determination level for pending loans f. A final review prior to the end of each term is conducted so late adjustments can be made if needed. Name(s) of the contact person(s) responsible for corrective action: Daphne Parks, Vice President of Processing at FAS; Stephanie Knight, Director of Enrollment Services & Financial Aid, Beacon College; Carrie Santaw, Registrar, Beacon College Planned completion date for corrective action plan: Interim measures ? already implemented. Software implementation is scheduled to go live in December 2022.

View Audit 20958 Questioned Costs: $1

Finding 24832 (2022-001)

Significant Deficiency 2022

Intermounain Esd

OR

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

RESOLUTION TO ADOPT THE CORRECTIVE ACTION PLAN FOR THE JUNE 30, 2022 AUDIT FINDINGS lnterMountain Education Service District submits the following corrective action plan in response to a deficiency reported in our audit for the fiscal year ended June 30, 2022. The audit was completed by the independ...

RESOLUTION TO ADOPT THE CORRECTIVE ACTION PLAN FOR THE JUNE 30, 2022 AUDIT FINDINGS lnterMountain Education Service District submits the following corrective action plan in response to a deficiency reported in our audit for the fiscal year ended June 30, 2022. The audit was completed by the independent auditing firm Dickey and Tremper, LLP and reported below. The plan of action was adopted by the governing body at their meeting on January 19, 2023 as indicated by the signatures below. Significant Deficiency #2022-001 Auditor Discussion and Recommendation: Condition and criteria: The District should have control processes in place to ensure that projects subject to prevailing wage requirements are performed under those requirements. There were two small projects that were subject to Federal prevailing wage requirements but did not get performed or documented for those requirements. Cause: The District's controls are established to follow prevailing wage requirements for projects over $50,000, which is the State of Oregon requirement and was unaware that the Federal requirement was for projects over $2,000. Context and effect: The District has very few capital projects funded by grant dollars, but there were two HVAC projects for $48,966 and $38,840, which fell between the Federal and State guidelines. Materials were the main portion of the costs of the project and the difference between prevailing wage rates to actual rates are not expected to be material to IMESD or the program. Auditor's recommendation: We recommend the District update their policies and procedures to identify Federal prevailing wage requirements at the lower threshold. Management's Plan of Action Individuals Involved: Mark Mulvihill, Superintendent/Management Beth O'Hanlon, Chief Financial Officer/Management Denyce Kelly, Program Resources Director Darrick Cope, Facilities Director Corrective Action Plan Management has reviewed the federal compliance supplement for Assistance Listing 84.425 Education Stabilization Fund, in particular Section F Equipment/Rea/ Property Management. Capital projects now go through a review process to ensure both state and federal procurement laws are followed. In addition, Management has updated procurement procedures to include review of compliance supplement for federal funded purchases. Time Frame Review Assistance Listing completed by October 6, 2022. Procurement procedures will be completed by December 31, 2022. BE IT RESOLVED THAT the Board of Directors of lnterMountain Education Service District adopts the Corrective Action Plan noted above. DATED: January 18, 2023

View Audit 22132

Finding 24827 (2022-001)

Significant Deficiency 2022

Exeter Housing Authority

NH

HUD Housing Programs Significant Deficiency Special Tests & Provisions

2022-001 Auditee's response and Planned Corrective Action Planned Implementation Date of Corrective Action: All annuals, interims, and rent increases being processed after March 1, 2023. Person Responsible for corrective Action: Margaret Dooling - HCV Housing Manager The Exeter Housing Authority has...

2022-001 Auditee's response and Planned Corrective Action Planned Implementation Date of Corrective Action: All annuals, interims, and rent increases being processed after March 1, 2023. Person Responsible for corrective Action: Margaret Dooling - HCV Housing Manager The Exeter Housing Authority has changed the policy of documenting rent reasonableness. Going forward all files will document the rent reasonableness by filling out the point system chart at the bottom of each inspection report on bottom of the rent reasonableness point total page. This will be compared to the Rent Reasonableness Chart for the particular year that is supplied by NHHFA on the price range based on the total points. A copy of the NHHFA chart will also be attached in the file as well. This will be done for every new admission, annual inspection, as well as rent increase request.

View Audit 25187

Finding 24826 (2022-002)

Significant Deficiency 2022

Rockhurst University

MO

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.328 § 200.329

Finding No. 2022-002 Corrective Action Plan University Response: The University concurs with the finding concerning quarterly reporting of HEERF funds. Corrective Action: Rockhurst will conduct an additional review of the released guidance and reporting requirements to ensure compliance of any pub...

Finding No. 2022-002 Corrective Action Plan University Response: The University concurs with the finding concerning quarterly reporting of HEERF funds. Corrective Action: Rockhurst will conduct an additional review of the released guidance and reporting requirements to ensure compliance of any published, missing or future reports. In accordance with HEERF guidance, any reports with expenses that were incorrectly reported will be revised and publicly published, if applicable. Responsible Official: Kris Pace, Controller Anticipated Completion Date: June 30, 2023

View Audit 23899

Finding 24767 (2022-001)

Significant Deficiency 2022

Clackamas County Childrens Commission

OR

Allowable Costs / Cost Principles Significant Deficiency

Finding 2022-001: Review of expense allocations CFDA. 93.600 Agency. Department of Health and Human Services Significant Deficiency: There was inconsistent documentation of allocation rates for invoices charged to the grant. Allocations other than the rates determined by management were used on f...

Finding 2022-001: Review of expense allocations CFDA. 93.600 Agency. Department of Health and Human Services Significant Deficiency: There was inconsistent documentation of allocation rates for invoices charged to the grant. Allocations other than the rates determined by management were used on five out of forty nonpayroll expenses. Recommendation: System allocations should be reviewed regularly by an appropriate member of management and invoice allocations should be consistent with the approved allocations. Corrective Action: Clackamas County Children?s Commission (CCCC) agrees with the auditors? findings, and the following action will be taken to improve the situation. Allocations, and the supporting documentation for how those were derived will be periodically printed to PDF format for historical recording of changes, and the dates any changes were made. We will review the allocation codes of the accounting system monthly and deactivate those that we are not going to use in order to avoid errors in the allocation of expenses. Additionally, we will continue to review the transactions prior to posting in the accounting system to correct any errors. Anticipated Completion Date: September 2022

View Audit 21470

Finding 24763 (2022-001)

Significant Deficiency 2022

Springfield City School District

OH

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

Finding Number: 2022-001 Planned Corrective Action: The District has added additional language to the federal procurement checklist to ensure that all federal contracts are compliant with Federal Prevailing wage rate requirements. Anticipated Completion Date: Immediately Responsible Contact Per...

Finding Number: 2022-001 Planned Corrective Action: The District has added additional language to the federal procurement checklist to ensure that all federal contracts are compliant with Federal Prevailing wage rate requirements. Anticipated Completion Date: Immediately Responsible Contact Person: Nicole Cottrell, cottrellnl@scsdoh.org, (937) 505-2825

View Audit 21916

Finding 24684 (2022-002)

Significant Deficiency 2022

Guild

MN

Subrecipient Monitoring Cash Management Period of Performance

Finding 2022-002 Federal Agency Name: Department of Housing and Urban Development, Passed through Hearth Connections Program Name: Continuum of Care CFDA # 14.267 Finding Summary: Identified three months in which the reimbursement amount received from the pass-through entity was more than the Org...

Finding 2022-002 Federal Agency Name: Department of Housing and Urban Development, Passed through Hearth Connections Program Name: Continuum of Care CFDA # 14.267 Finding Summary: Identified three months in which the reimbursement amount received from the pass-through entity was more than the Organization?s documentation. In addition, there was no indication that a review was performed of the information submitted for one of the four months tested, which resulted in the reimbursement amount from the pass-through entity being more than the support maintained by the Organization for three of the 12 months and no documentation of the review for one of the months. Responsible Individuals: Paul Bloomer, VP of Finance Corrective Action Plan: Schedule meetings with 3rd party vendor to identify the significant rounding errors occurring. Develop an agreement on rounding procedures to be used by both parties ensuring reconciliation. Anticipated Completion Date: 12/31/23 ? Note- this system of reimbursement terminated on 3/31/23

View Audit 21274

Finding 24620 (2022-014)

Significant Deficiency 2022

The City of New York

NY

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring § 200.303

Finding No. 2022-014 Department(s) New York City Human Resources Administration Program(s) Assistance Listing Number 14.241, Housing Opportunities for Persons with AIDS Corrective Action(s) The auditors selected a non-statistical sample of nineteen (19) units that were subject to an initial inspect...

Finding No. 2022-014 Department(s) New York City Human Resources Administration Program(s) Assistance Listing Number 14.241, Housing Opportunities for Persons with AIDS Corrective Action(s) The auditors selected a non-statistical sample of nineteen (19) units that were subject to an initial inspection by HRA during fiscal 2022 and noted that for three (3) selections, HRA was unable to provide a copy of the inspection checklist that was completed by the QA Inspector prior to assistance being provided for the unit. Unfortunately, during the height of the COVID-19 pandemic, many housing vendor staff were working remotely, and a few documents may have been mislaid. To ensure continual compliance with federal HOPWA grant requirements, HRA will enhance its efforts to confirm that housing vendors properly maintain a copy of inspection checklists completed prior to initial move in. Monitoring visits conducted by HRA will include a review of the checklists. Anticipated Completion Date April 2023 and ongoing Person(s) Responsible for Implementation Pamela Xiomara Farquhar Assistant Deputy Commissioner FarquharX@hra.nyc.gov

View Audit 22749

Finding 24541 (2022-002)

Significant Deficiency 2022

Okeechobee County, Fl

FL

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.303

COVID-19 Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 20.027 Recommendation: We recommend all reports submitted to grantors be reviewed by knowledgeable personnel before submittal. A copy of the review, approval, approval date, and submittal date should be maintained as...

COVID-19 Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 20.027 Recommendation: We recommend all reports submitted to grantors be reviewed by knowledgeable personnel before submittal. A copy of the review, approval, approval date, and submittal date should be maintained as evidence. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Staff will ensure that all reports submitted to grantors be reviewed by knowledgeable personnel before submitting. A copy of the review, approval, approval date, and submittal date will be maintained as evidence. Name(s) of the contact person(s) responsible for corrective action: Budget and Grants Director Johnathan Blanco. Planned completion date for corrective action plan: September 30, 2023.

View Audit 21248

Finding 24539 (2022-003)

Significant Deficiency 2022

Okeechobee County, Fl

FL

Subrecipient Monitoring Cash Management Significant Deficiency § 200.303

Airport Improvement Program ? Assistance Listing No. 20.106 Recommendation: We recommend all reports submitted to grantors be reviewed by knowledgeable personnel before submittal. A copy of the review, approval, approval date, and submittal date should be maintained as evidence. Explanation of disag...

Airport Improvement Program ? Assistance Listing No. 20.106 Recommendation: We recommend all reports submitted to grantors be reviewed by knowledgeable personnel before submittal. A copy of the review, approval, approval date, and submittal date should be maintained as evidence. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Staff will ensure that all reports submitted to grantors be reviewed by knowledgeable personnel before submitting. A copy of the review, approval, approval date, and submittal date will be maintained as evidence. Name(s) of the contact person(s) responsible for corrective action: Budget and Grants Director Johnathan Blanco. Planned completion date for corrective action plan: September 30, 2023.

View Audit 21248

Finding 24413 (2022-065)

Significant Deficiency 2022

State of Michigan

MI

Reporting Allowable Costs / Cost Principles Significant Deficiency

Finding 2022-065 Unemployment Insurance, ALN 17.225 See Department of Labor and Economic Opportunity, Unemployment Insurance Agency, Unemployment Administration Fund, Report on Expenditure of Federal Awards, Year Ended September 30, 2022, Corrective Action Plan, Finding 2022-001.

View Audit 20093

Finding 24400 (2022-001)

Significant Deficiency 2022

Central Methodist University

MO

Reporting Significant Deficiency

Description of Finding: The University publicly posted the required institutional reports for HEERF to their website using actual grants disbursed to student data, rather than disbursement only reimbursed by the G5 draw downs during the quarters. No other issues were noted with the accuracy of the...

Description of Finding: The University publicly posted the required institutional reports for HEERF to their website using actual grants disbursed to student data, rather than disbursement only reimbursed by the G5 draw downs during the quarters. No other issues were noted with the accuracy of the reports. However, the University also did not post all of the required information in the student reports for HEERF. Statement of Concurrence or Nonconcurrence: Management agrees these reports were incomplete due to lack of uncertainty with the HEERF reporting requirements and disbursements made in the current accounting system. Corrective Action: Management will adjust reports noting the required quarterly reports on the website and only use quarterly funds received for providing all of the student report information for HEERF. Name of Contact Person: Julee Sherman, VP for Finance and Administration, Fayette MO 660-248-6203. Projected Completion Date: May 2023.

View Audit 22803

Finding 24397 (2022-002)

Material Weakness 2022

Ocala Housing Authority

FL

HUD Housing Programs Eligibility Material Weakness

2022-002 Tenant Files: Eligibility Program: U.S. Department of HUD: Section 8 Housing Choice Vouchers (CFDA 14.871) Type of Finding: Material Weakness in Internal Control and Material Noncompliance This is a repeat finding of 2021-001 from September 30, 2021 (Other Matter and Significant Deficiency ...

2022-002 Tenant Files: Eligibility Program: U.S. Department of HUD: Section 8 Housing Choice Vouchers (CFDA 14.871) Type of Finding: Material Weakness in Internal Control and Material Noncompliance This is a repeat finding of 2021-001 from September 30, 2021 (Other Matter and Significant Deficiency in Internal Control over Compliance). Originally reported as finding 2019-001 from September 30, 2019 (Material Weakness in Internal Control and Material Noncompliance) Statement of Condition: Out of a total tenant population of approximately 1,114 vouchers, 25 files were selected for testing. Exceptions were noted as follows: ? 1 tenant file had the following errors: o The tenant?s annual recertification application is missing. o The tenant?s signed 9886 form is missing. o The wrong utility allowance schedule was used to calculate the tenants? utility allowance. Correcting this error would cause the HAP rent to increase by $9. o The tenant?s signed HAP contract is missing. ? 1 tenant file had the following errors: o The name and social security number for one of the tenant?s dependents was reported incorrectly on the 50058 form. o The tenant?s utility allowance was calculated correctly but was reported incorrectly on the 50058 form. Correcting this error would cause the HAP rent to increase by $56. ? 1 tenant file had the following errors: o The lease agreement was not signed by the tenant. o The tenant?s assets was reported in error. Correcting this error would cause the rent to increase by $8. ? 2 tenant files where the tenants? income was miscalculated. Correcting the errors would cause the HAP rent for one of tenant files to decrease by $12 and the other to increase by $181. ? 2 tenant files where the wrong utility allowance schedule was used to calculate the tenants? utility allowance. Correcting these errors would cause the HAP rent for one of the tenant files to decrease by $13 and the other to increase by $14. ? 1 tenant file where the family?s assets was reported in error. Correcting the errors had no effect on the HAP rent. ? 1 tenant file where a member of the household moved but was reported on the 50058 form. ? 1 tenant file where the tenant?s signed HAP contract is missing. ? 1 tenant file where the EIV report was never generated or was misplaced. In addition to the above, we noted the following during our new admissions testing (out of a total of 118 new admission, 18 files were selected for testing.): ? 1 tenant file where the member of the household did not checkmark the checkbox on the 214-affidavit form indicating that they are a U.S. Citizen or permanent resident. However, the member?s birth certificate confirms that the member is a U.S. Citizen. ? 1 tenant file where the tenant?s signed 214-affidavit is missing. However, the member?s birth certificate confirms that the member is a U.S. Citizen. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: The Authority concurs with this finding. The Authority has an established review, oversight and training process and will continue to improve its review, oversight, and training process to ensure proper procedures are being followed. All audit findings of the files tested will have been corrected. The Authority has implemented a quality control system so that every file receives a quality review for appropriate third-party verification and upfront income and assistance is determined. The agency has created a Family Worksheet and an HCV Computation Worksheet to help staff identify errors in calculations and to check for accuracy prior to completing Annual Reexaminations and Interim Recertifications. The agency has changed its filing system to enable staff to thoroughly review all forms prior to admission and during regular recertification and interim adjustment processing. The agency created an Other Adult packet to ensure 214 forms and other pertinent are completed for all adult household members. The HCV Counselor caseloads have been distributed equitably amongst Counselors to promote efficiency and accuracy while working on each HCV participant?s file. The Counselor?s caseload is divided alphabetically and assigned by multifamily developments to track and monitor counselors? strength and weaknesses, and to determine if additional training and/or monitoring is needed. Internal file reviews are being completed and management will continue to conduct a 10% review for each Counselor?s processing of annual recertifications. This percentage may increase if work product indicates a need for more stringent review. To further ensure compliance and accuracy, the HCV Program Manager will review at least 1 out of every 5 intake files. The Authority has had a significant turnover in the HCV department over the past 24 months. All HCV staff will attend Voucher Specialist training and Nan McKay HCV Rental Calculation Certification training. Effective Date: June 20, 2023 Contact Information Gwendolyn B. Dawson, CEO Ocala Housing Authority 1629 NW 4th Street Ocala, Florida 34475 (352) 369-2636

View Audit 22927

Finding 24392 (2022-001)

Significant Deficiency 2022

City of Sierra Vista, Arizona

AZ

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Program Name/Assistance Listing Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Contact Person: David Felix, Chief Financial Officer Anticipated Completion Date: May 18, 2023 Planned Corrective Action: When the City received notification of the awa...

Program Name/Assistance Listing Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Contact Person: David Felix, Chief Financial Officer Anticipated Completion Date: May 18, 2023 Planned Corrective Action: When the City received notification of the award of CSLFRF funds, the CFO and City Attorney reviewed the law and, based on how it was written, felt that we could apply it to the Fire Department?s salary expenses as over 80% of their calls are for emergency medical services, they are the first responders to a 911 EMS call, and they usually transport the patients to the hospital. Neither in the initial law documentation, nor in the initial application, was there an option to select a $10M de minimus revenue loss option. If this was available, the City would have chosen that up front. We completed the interim report based on data created by inquiries run in our General Ledger on the date we submitted the report. We believed the data was saved on our system, but we can not find the electronic copy of it. As adjustments have been made to the data since then, we are unable to recreate a report that matches the data on the interim report. We can get within $800, but not the exact amount. Going forward, we will ensure the data is saved and put in a place that it is easier to retrieve.

View Audit 19937

Finding 24247 (2022-002)

Significant Deficiency 2022

Decatur County Community Schools

IN

Procurement, Suspension & Debarment Subrecipient Monitoring School Nutrition Programs § 200.303 § 200.318 § 200.319 § 200.320

2022-002 Child Nutrition Cluster ? Assistance Listing No. 10.553/10.555/10.559 Recommendation: We recommend that the School Corporation ensures that documentation of Procurement's decisions on any purchases that are excluded from the requirements noted in the Procurement Policy are retained for audi...

2022-002 Child Nutrition Cluster ? Assistance Listing No. 10.553/10.555/10.559 Recommendation: We recommend that the School Corporation ensures that documentation of Procurement's decisions on any purchases that are excluded from the requirements noted in the Procurement Policy are retained for audit purposes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This finding was an unusual situation and will be corrected. The procurement transaction in question was originally include in a large building project and would not have been paid with federal dollars. Due to issues with the general contractor, timeliness of completion, and the beginning of the school year, one portion of the project in the school kitchen was pulled from the general contractor and a quote was obtained from one vendor. Quotes from at least three (3) vendors and documentation of any unusual circumstances will be maintained for auditor review. Name(s) of the contact person(s) responsible for corrective action: Louise S. Smith and Jennifer Niese Planned completion date for corrective action plan: March 31, 2023

View Audit 21894

Finding 24236 (2022-002)

Significant Deficiency 2022

Move United

MD

Reporting Subrecipient Monitoring Significant Deficiency

CORRECTIVE ACTION PLAN For the Year Ended September 30, 2022 January 24, 2023 Move United (the Organization) respectfully submits the following Corrective Action Plan for the year ended September 30, 2022. Name and address of independent public accounting firm: CST Group CPAs, PC 10740 Parkridge Blv...

CORRECTIVE ACTION PLAN For the Year Ended September 30, 2022 January 24, 2023 Move United (the Organization) respectfully submits the following Corrective Action Plan for the year ended September 30, 2022. Name and address of independent public accounting firm: CST Group CPAs, PC 10740 Parkridge Blvd, Fifth Fl Reston, VA 20191 Audit period: 10/1/2021 ? 9/30/2022 The findings from the Schedule of Findings and Questioned Costs for the year ended September 30, 2022 are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section III ? Federal Award Findings and Questioned Costs Significant Deficiency: 2022-02 ? Timely Submission of Quarterly SF-425 Report Recommendation: We recommend that the Organization review its monitoring process for the quarterly reporting of SF-425 reports, and ensure reports are filed timely within the requirements of the reporting deadlines. If an extension is necessary for any instances of reporting, a request for extension should be filed with the federal agency, along with a justified explanation for the additional time needed. Otherwise, all quarterly reports should be filed timely no later than 30 days after the end of each calendar quarter. Views of Responsible Officials and Planned Corrective Action: Move United will put in place a three tier redundancy plan for ensuring that filings, both within the VA Salesforce system and within the Payment Management System, are filed prior to or on time each quarter. The Chief Financial Officer, Programs Director and Grants Administrator will work collaboratively to complete the necessary data compilation at least one week prior to the filing deadline. All three individuals will be trained on and have access to the two systems. In the event one individual is incapacitated at the time of filing, one of the other two will complete the filing on time. Person Responsible: Chief Financial & Operating Officer Planned Completion Date: Immediately

View Audit 20725

Finding 24223 (2022-001)

Significant Deficiency 2022

Dayspring Programs, Inc. and Subsidiaries

MD

Reporting Significant Deficiency § 200.512

1. Develop and implement a schedule. Audit Commencement should be initiated by mid-september following the close of FY. 2. Conduct a weekly follow-up meeting to ensure that all internal and external documents are being produced and supplied to appropriate parties 3. Ensure that all internal personne...

1. Develop and implement a schedule. Audit Commencement should be initiated by mid-september following the close of FY. 2. Conduct a weekly follow-up meeting to ensure that all internal and external documents are being produced and supplied to appropriate parties 3. Ensure that all internal personnel are given the knowledge and resources to mitigate the disruption that may come from any employee transition or turnover. 4. Conclude the audit by the end of December of the following end of the FY.

View Audit 20481

Finding 24217 (2022-002)

Significant Deficiency 2022

Washington County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding: 2022-002 Name of Contact Person: Tammy Mixon, Medicaid Supervisor Corrective Action: "Of the eight errors found during this audit, only four were repeat findings from previous audit year. Those four findings occurred prior to the training from August 24, 2021, wh...

Finding: 2022-002 Name of Contact Person: Tammy Mixon, Medicaid Supervisor Corrective Action: "Of the eight errors found during this audit, only four were repeat findings from previous audit year. Those four findings occurred prior to the training from August 24, 2021, which was as a result of the previous year findings. Therefore, the workers had not been trained on the proper procedures at the time in which these errors occurred, as they were in the previous timeframe. Further, two of the four cases mentioned were correct later in the file due to COVID 19 waivers, but the audit did not cover the timeframe in which the corrections were found. Of the four findings that were not repeat, the agency has obtained training materials from the Operation Support Team for the State of NC for training to correct. The agency rebuts that this is a repeat finding. as the findings occurred during the timeframe prior to training from previous period findings. Further, only half of the findings were the same as the previous period. The agency denies this is a Significant Deficiency, as there were eight findings out of sixty cases pulled, and half of those findings fell within a timeframe prior to training to correct the issue. These findings were discussed in the monthly Medicaid meeting September 2022. OST training materials have been obtained and will be used for training to prevent future errors. Second party review form was also updated to capture in-kind income for prevention of future errors. " Proposed Completion Date: The training occurred on August 30, 2022 and September 7, 2022. Second party review form was made available for use October 1, 2022.

View Audit 20596

Finding 24209 (2022-001)

Significant Deficiency 2022

Catholic Community Services of Utah

UT

Allowable Costs / Cost Principles Cash Management Eligibility

Finding 2022-001 Federal Agency Name: U.S. Department of State Program Name: Refugee Admissions - Reception and Placement CFDA # 19.510 Finding Summary: In connection with the audit procedures performed over the Refugee Admission - Reception and Placement program, we noted instances when indirect co...

Finding 2022-001 Federal Agency Name: U.S. Department of State Program Name: Refugee Admissions - Reception and Placement CFDA # 19.510 Finding Summary: In connection with the audit procedures performed over the Refugee Admission - Reception and Placement program, we noted instances when indirect cost calculations included an insignificant amount of ineligible costs. Responsible Individuals: Rose Olivas, Contract Compliance Director and Dawn Miera, Finance Director Corrective Action Plan: Contract Compliance and Finance will meet every time we receive a new type of grant. The two teams will go over allowable costs and which costs are allowed to be applied to the de minimis rate. All applicable spreadsheets will be updated separately for each new contract and training for billing preparers and reviewers will be ongoing. Anticipated Completion Date: Ongoing

View Audit 20978

Finding 24167 (2022-001)

Significant Deficiency 2022

Steel City Academy, Inc.

IN

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

The Executive Director, Managing Director of Operations, Finance Team and select board members will go through Federal Grants Training within the next 6 months. All contracts for construction projects will go through legal review before being signed by management. A contract checklist will be develo...

The Executive Director, Managing Director of Operations, Finance Team and select board members will go through Federal Grants Training within the next 6 months. All contracts for construction projects will go through legal review before being signed by management. A contract checklist will be developed to identify necessary provisions based on the funding source. This will be implemented immediately by the Executive Director and the Managing Director of Operations. The Board of Directors will approve all contracts over $15,000. Once the contract is implemented the Finance Team will ensure that all payroll documentation will be submitted in accordance with the cadence outlined in the contract.

View Audit 20234

Finding 24122 (2022-002)

Material Weakness 2022

Flathead Community Health Center Inc. Dba Greater Valley Health Center

MT

Special Tests & Provisions Material Weakness Significant Deficiency

2022-002 Application of Sliding Fee Discounts Corrective action planned: The Center plans to: 1. Continue to provide frequent education and training for front-desk staff to assist in preparation and required completion of the sliding fee applications and proof of income forms. 2. Meet with front des...

2022-002 Application of Sliding Fee Discounts Corrective action planned: The Center plans to: 1. Continue to provide frequent education and training for front-desk staff to assist in preparation and required completion of the sliding fee applications and proof of income forms. 2. Meet with front desk staff to identify and correct barriers to compliance with completion of sliding fee application and income verification and retention of those documents within the electronic record. 3. Develop workflow to identify when patients have exhausted their limited Medicaid dental benefits and would now qualify for sliding fee discount. Ensure sliding fee scale application and verification of income are completed prior to delivery of additional services. 4. Develop internal report to identify accounts with sliding fee scale identified with no end date recorded. For identified accounts, determine appropriate end date for sliding fee discount and enter it into the system. 5. Continue to do real time audits of front desk personnel to identify needs for additional training and to reinforce the process and appropriate documentation. 6. Institute a separate QA position for the purpose of review of patients with an identified sliding fee scale discount in place. Anticipated completion date: October 31, 2023 Contact person responsible for corrective action: Mary Sterhan, CEO

View Audit 20141

Finding 24108 (2022-005)

Significant Deficiency 2022

Universidad Teologica Del Caribe, Inc.

PR

Student Financial Aid Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

Compliance requirement - Special tests and provisions ? Gramm-Leach Bliley Act- Student Information Security Institutional Comments on Findings and Recommendations: (a) The institution agrees with the auditor on this finding. The Information Security Program Coordinator's functions were not specifie...

Compliance requirement - Special tests and provisions ? Gramm-Leach Bliley Act- Student Information Security Institutional Comments on Findings and Recommendations: (a) The institution agrees with the auditor on this finding. The Information Security Program Coordinator's functions were not specified in a formal written contract, therefore, the consultant does not have a detail for the functions and responsibilities of his designation. (b) The institution agrees with the auditor on this finding. The Institution has yet to comply with, needs to terminate and correct some of the nine elements that are included in the FTC (Federal Trade Commission). Actions Taken or Planned: 1. A contract with the IT Program Coordinator is being finished with a breakdown of the responsibilities expected for the GLBA requirements. We should be starting it in May 2023. 2. There has been progress in the action plan where a set of estimated time of completion is provided. We will keep doing so and monitor every aspect of the risk assessment to cover and safeguard each area found with a document that indicates any advances. 3. The Institution with the IT Coordinator will keep monitoring each step for the progress and any delay with a task report where it will show any advance or delay for the pending findings so that we can track the development closely until finished. 4. Finally, we will continue with the efforts to document and complete the corrections to the risk assessment results.

View Audit 20027

Finding 24107 (2022-004)

Significant Deficiency 2022

Universidad Teologica Del Caribe, Inc.

PR

Student Financial Aid Special Tests & Provisions Eligibility

Compliance requirement - Special tests and provisions ? Enrollment Reporting Institutional Comments on Findings and Recommendations: (a) The institution agrees with the auditor on this finding in that there was one (1) case where the information of enrollment of this student was not available for ex...

Compliance requirement - Special tests and provisions ? Enrollment Reporting Institutional Comments on Findings and Recommendations: (a) The institution agrees with the auditor on this finding in that there was one (1) case where the information of enrollment of this student was not available for examination. After multiples student search, the institution was unable to locate through the NSLDS the reported status update for said student. (b) The institution also agrees with the auditor in that there were (6) six cases where he noted that institution failed to report the student's status before the thirty (30) day deadline for the NSLDS web reporting. (c) The institution also agrees with the auditor in that there was one (1) instance where the institution submitted one (1) of its's enrollment report updates after the 15 days required timeline. Actions Taken or Planned: The institution would continue to submit its Enrollment Reports monthly in order to notify changes of student status to the Department of Education on a timely basis and to maintain the information of student's enrollment status more effectively.

View Audit 20027

Finding 24105 (2022-001)

Significant Deficiency 2022

Universidad Teologica Del Caribe, Inc.

PR

Student Financial Aid Matching / Level of Effort / Earmarking Eligibility § 200.303

Compliance requirement ? Other ? Policies and Procedures requirements. Institutional Comments on Findings and Recommendations: 1 The institution agrees with the auditors on this finding in which the current University Catalog containing the updated general disclosures for enrolled or prospective st...

Compliance requirement ? Other ? Policies and Procedures requirements. Institutional Comments on Findings and Recommendations: 1 The institution agrees with the auditors on this finding in which the current University Catalog containing the updated general disclosures for enrolled or prospective students were not updated on time for the fiscal year. 2 The institution agrees with the auditors on this finding in which the Drug and Alcohol Abuse Prevention Program did not fully comply with the distribution requirement in writing for each student. It also agrees that the institution did not perform a recent biennial review of its Drug and Alcohol Abuse Prevention Program. Actions Taken or Planned: The institution has already updated, published, and distributed its Catalog to accurately represent the vision and goals, our academic offerings and administrative policies and procedures of our operation. As related to the institutions Drug and Alcohol Abuse Prevention Program, the same was also updated, revised, published, and distributed to all active students and staff. The updated Drug and Alcohol Abuse Prevention Program is also available for distribution for all prospective students and any potential employees through the Admissions and Human Resources offices respectively. The same would also be posted on the Web page of the institution. Evidence of both issues were submitted to the auditors.

View Audit 20027

Finding 24104 (2022-001)

Significant Deficiency 2022

San Joaquin Health Centers

CA

Special Tests & Provisions Subrecipient Monitoring Cash Management

The Organization will continue to implement the following measures to ensure compliance with the sliding fee discount program, and consistently assess patient income and family size. The Organization will continue to provide on-going training to clinic staff who evaluate the sliding fee application ...

The Organization will continue to implement the following measures to ensure compliance with the sliding fee discount program, and consistently assess patient income and family size. The Organization will continue to provide on-going training to clinic staff who evaluate the sliding fee application at its clinic locations. The training consists of reviewing sliding fee program policies and procedures along with all applicable patient forms, sliding fee scale, and patient eligibility. The following quality control measures to ensure compliance will be implemented: 1. Front Desk Peer Review of sliding fee application and verification of patient income and family size. 2. Enhance training materials to support Front Desk Staff with assessing sliding fee applications. 3. Quarterly feedback to Front Desk Staff based on sliding fee applications reviewed. Person Responsible: Kristopher D. Zuniga Position of Responsible Party: Chief Financial Officer Anticipated Completion: April 30, 2023

View Audit 19923

Corrective Action Plans

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