Corrective Action Plans

Finding 10683 (2022-002)

Significant Deficiency 2022

Neighborhood Health Association of Toledo, Inc.

OH

Special Tests & Provisions HUD Housing Programs Significant Deficiency

Recommendation: We recommend that management continue to work and educate front desk and intake staff on the importance of the required patient application documentation so that the required support is filed before applying a sliding fee discount to a patient account. In addition, we suggest that ma...

Recommendation: We recommend that management continue to work and educate front desk and intake staff on the importance of the required patient application documentation so that the required support is filed before applying a sliding fee discount to a patient account. In addition, we suggest that management establish a policy to perform regular monitoring of a sample of patient file sliding fee applications to ensure the sliding fees are applied correctly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We agreed with the above comment, and we are working with our intake and finance staff to ensure all documentation is maintained on file and scanned into the EMR system to maintain the required supporting documentation. During 2023 we have implemented a system of monitoring sliding fees applied to patient accounts. Name of the contact person responsible for corrective action: Doni Miller, President & Chief Executive Officer Planned completion date for corrective action plan: 2023

View Audit 14360

Finding 10682 (2022-001)

Significant Deficiency 2022

Neighborhood Health Association of Toledo, Inc.

OH

Cash Management Allowable Costs / Cost Principles HUD Housing Programs

Recommendation: We recommend that management prepare federal draw down schedules on a more timely basis to ensure the accuracy and completeness of the support for all grant expenditures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in ...

Recommendation: We recommend that management prepare federal draw down schedules on a more timely basis to ensure the accuracy and completeness of the support for all grant expenditures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We agreed with the above comment and the Organization has engaged consultants to assist in creating a more robust system to document the supporting expenditures that are charged to the grant to ensure the timing of grant expenditures and allowability are appropriate. Name of the contact person responsible for corrective action: Doni Miller, President & Chief Executive Officer Planned completion date for corrective action plan: 2023

View Audit 14360

Finding 10623 (2022-004)

Significant Deficiency 2022

The Food Trust

PA

Allowable Costs / Cost Principles Reporting Significant Deficiency

DEPARTMENT OF AGRICULTURE 2022-004 Food Insecurity Nutrition Incentive Grants Program – Assistance Listing No. 10.331 Recommendation: We recommend The Food Trust establish and implement controls that require employees to document their time and effort spent on various activities. Time and effort ce...

DEPARTMENT OF AGRICULTURE 2022-004 Food Insecurity Nutrition Incentive Grants Program – Assistance Listing No. 10.331 Recommendation: We recommend The Food Trust establish and implement controls that require employees to document their time and effort spent on various activities. Time and effort certifications should be regularly reviewed and approved by appropriate personnel to ensure accuracy and completeness of personnel cost documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement processes and tools to ensure that all employee time and effort charged to federal grants is appropriately documented. Name(s) of the contact person(s) responsible for corrective action: Regine Metellus, Vice President of Finance Planned completion date for corrective action plan:The planned corrective action will be completed by September 2024.

View Audit 14285

Finding 10599 (2022-011)

Significant Deficiency 2022

Langston University

OK

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

U.S. Department of Education 2022-011 COVID-19 Educational Stabilization Fund: HEERF Student Portion – Assistance Listing No. 84.425E HEERF Institutional Portion – Assistance Listing No. 84.425F Recommendation: We recommend the University implement procedures to ensure the information reported on th...

U.S. Department of Education 2022-011 COVID-19 Educational Stabilization Fund: HEERF Student Portion – Assistance Listing No. 84.425E HEERF Institutional Portion – Assistance Listing No. 84.425F Recommendation: We recommend the University implement procedures to ensure the information reported on the annual reports are complete and accurate. Action taken in response to finding: The University agrees with the finding and has developed the following corrective action plan. The University, if allowed by the U.S. Department of Education, will correct a previous entry in the HEERF prior year annual reporting. The University will obtain and retain support for all required disclosures at the time of reporting to verify accuracy and will document this review. Disclosure reports will be reviewed by someone independent of the preparer before they are filed, and the reviewer will reconcile the reports to supporting documentation to ensure accuracy and completeness. Name(s) of the contact person(s) responsible for corrective action: Robert Dixon, Director of Grants and Contracts Financial Administration at Oklahoma State University. Planned completion date for corrective action plan: January 2024

View Audit 14277

Finding 10562 (2022-017)

Significant Deficiency 2022

Langston University

OK

Subrecipient Monitoring Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recomme...

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend the University implement procedures to ensure that the risk assessment used to determine compliance with the Gramm-Leach-Bliley act is properly reviewed. Action taken in response to finding: The University agrees with the finding and has developed the following corrective action plan. The University is creating a GLBA management program to govern security of GLBA data and ensure compliance with associated requirements. Name(s) of the contact person(s) responsible for corrective action: Heath Hodges, A&M CIO. Planned completion date for corrective action plan: March 2024

View Audit 14277

Finding 10559 (2022-014)

Significant Deficiency 2022

Langston University

OK

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

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recomme...

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend that the student financial aid department work to ensure disbursements are reported to COD within 15 days of the disbursement date and that disbursements date reported in COD matches the disbursement date to the student. Action taken in response to finding: The University agrees with the finding and has developed the following corrective action plan. Updated procedures are in place to ensure disbursements are reported to COD in a timely manner in accordance with Federal guidelines. Name(s) of the contact person(s) responsible for corrective action: Sheila McGill Executive Director, Financial Aid & Scholarships, Langston University. Planned completion date for corrective action plan: January 2024

View Audit 14277

Finding 10535 (2022-001)

Significant Deficiency 2022

Plumas County Community Development Commission

CA

HUD Housing Programs Internal Control / Segregation of Duties Reporting

Management's Response: Fiscal year-end 2022 provided PCCDC with challenges. The Dixie fire left the agency without a Finance director for 6 weeks which ultimately increased the delay of deadlines. With the onset of new employees and management transitions, the agency has been able to effectively kee...

Management's Response: Fiscal year-end 2022 provided PCCDC with challenges. The Dixie fire left the agency without a Finance director for 6 weeks which ultimately increased the delay of deadlines. With the onset of new employees and management transitions, the agency has been able to effectively keep up with requirements and deadlines. The new finance personnel has increase the standards, adherence to policies, and consistency within the policies and procedures. This ensures timely and accurate data, allowing us to submit required reports diligently. Finance has also developed a calendar oriented approach to help ensure deadlines are being met. Finance has regular meetings scheduled to discuss upcoming tasks and will communicate the deadlines with other departments if necessary. All tasks are reviewed by the Finance Director and Analyst to ensure entries are accurate. Estimated Completion Date: 07/01/2023 Responsible Party: Cindy Ramsey - Finance Director

View Audit 14262

Finding 10489 (2022-001)

Significant Deficiency 2022

Fusion Parterships, Inc.

MD

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Significant Deficiency

We concur with the finding, and a corrective action plan was created and implemented on January 1, 2023. We have modified our Accounting Policies and Procedures and trained all finance staﬀ on reviewing the necessary backup for disbursements and have been loading this backup into our finance system....

We concur with the finding, and a corrective action plan was created and implemented on January 1, 2023. We have modified our Accounting Policies and Procedures and trained all finance staﬀ on reviewing the necessary backup for disbursements and have been loading this backup into our finance system. The creation and implementation of a google submission for disbursements has added the necessary review and approval of all expenses.

View Audit 14190

Finding 10359 (2022-001)

Significant Deficiency 2022

Hoopa Valley Public Utilities District

CA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Management's Reponse: the District is working with a CPA consultant on a monthly basis to assist with month end year end close out. The District and the consultant are confident that the work completed with result in audits submitted on time in the future. Estimated completion date: September 30, 20...

Management's Reponse: the District is working with a CPA consultant on a monthly basis to assist with month end year end close out. The District and the consultant are confident that the work completed with result in audits submitted on time in the future. Estimated completion date: September 30, 2023. Responsible party: Keterah Mitchell, Accountant; Sean McCabe, CPA - Consultant

View Audit 14012

Finding 9846 (2022-028)

Significant Deficiency 2022

State of Illinois

IL

Reporting Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

The IDES will implement an internal process, which will include a supervisory review.

View Audit 13503

Finding 9827 (2022-024)

Significant Deficiency 2022

State of Illinois

IL

Subrecipient Monitoring Internal Control / Segregation of Duties Significant Deficiency § 200.303

ICJIA will review its current site visit policy and adjust to ensure the timing of review and submission of site visit documentation is clearly stated. Upon making any updates, ICJIA will circulate the site visit policy and provide training to grant specialists and program managers.

View Audit 13503

Finding 9518 (2022-002)

Significant Deficiency 2022

Jefferson County Housing Authority

AL

HUD Housing Programs Eligibility Significant Deficiency

FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Housing and Urban Development 2022-002-Eligibility Public Housing - Assistance Listing No. 14.850 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month, to de...

FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Housing and Urban Development 2022-002-Eligibility Public Housing - Assistance Listing No. 14.850 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month, to determine if the tenant files were prepared in accordance with internal policies and until the compliance deficiencies have been corrected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Public Housing Property Managers will sample a percentage of monthly recertifications to ensure that tenant files contain the necessary updated HUD forms. Name(s) of the contact person(s) responsible for corrective action: Hannah Gore, ED and Public Housing Property Managers Planned completion date for corrective action plan: December 31, 2023 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call the Executive Director at (205) 244-1348

View Audit 13164

Finding 9504 (2022-001)

Significant Deficiency 2022

Karen Organization of Minnesota

MN

Significant Deficiency Internal Control / Segregation of Duties

Internal Control over Revenue Process – Significant Deficiency Name of contact person: Alexis Walstad, Co-Executive Director Corrective Action Plan: Management and its contracted accounting staff will monitor financial reports and activities of Karen Organization of Minnesota to ensure proper record...

Internal Control over Revenue Process – Significant Deficiency Name of contact person: Alexis Walstad, Co-Executive Director Corrective Action Plan: Management and its contracted accounting staff will monitor financial reports and activities of Karen Organization of Minnesota to ensure proper recording. Proposed completion date: Management and the Board of Directors will implement the above procedures immediately.

View Audit 13088

Finding 9322 (2022-003)

Significant Deficiency 2022

Eastern Plains Community Action Agency, Inc.

NM

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

Auditor's Recommendation: We recommend the Entity follow their policy and procedures related to purchases. Action Taken: The Organization understands the importance of following current, written policies and procedures for both employees and members of management. Policies and procedures will be rev...

Auditor's Recommendation: We recommend the Entity follow their policy and procedures related to purchases. Action Taken: The Organization understands the importance of following current, written policies and procedures for both employees and members of management. Policies and procedures will be reviewed to ensure the appropriate approvals and signatures are obtained. Responsible Official: John Clemons, Chief Financial Officer Timeline for Implementation: July 31, 2023

View Audit 12797

Finding 9321 (2022-002)

Significant Deficiency 2022

Eastern Plains Community Action Agency, Inc.

NM

Equipment & Real Property Management Internal Control / Segregation of Duties Reporting § 200.303

Auditor's Recommendation: We recommend the Entity implement adequate controls to ensure the accuracy of the information reported to the Grantor Agency in a timely manner. Action Taken: The Organization will create an electronic calendar with reminders for all reporting requirements and respective du...

Auditor's Recommendation: We recommend the Entity implement adequate controls to ensure the accuracy of the information reported to the Grantor Agency in a timely manner. Action Taken: The Organization will create an electronic calendar with reminders for all reporting requirements and respective due dates. Responsible Official: John Clemons, Chief Financial Officer Timeline for Implementation: July 31, 2023

View Audit 12797

Finding 9031 (2022-006)

Significant Deficiency 2022

Nazlini Community School, Inc.

NM

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

Management Response: Management agrees with the auditors' finding. Internal controls did not exist during the audit period due to lack of staff in the business office and lack of understanding in the administration staff. The school has since hired a consulting firm to assist with following the exis...

Management Response: Management agrees with the auditors' finding. Internal controls did not exist during the audit period due to lack of staff in the business office and lack of understanding in the administration staff. The school has since hired a consulting firm to assist with following the existing policies and procedures. The school also has hired an experienced principal to oversee the operations of the business office. Anticipated completion date: June 30, 2023. Responsible party: Delores Noble, principal. Amber Wauneka, Consultant with Homeland Business Services.

View Audit 12351

Finding 8887 (2022-007)

Significant Deficiency 2022

Municipality of Guayanilla

PR

Reporting Significant Deficiency Internal Control / Segregation of Duties

We will improve our internal controls procedures related to record keeping and year adjustments in order to ensure compliance with the March 31 federal requirement. Implementation Date: During the 2023-2024 fiscal year Responsible Persons: Mr. Luis A. Ramos Feliciano Finance Director

View Audit 12154

Finding 8713 (2022-006)

Significant Deficiency 2022

Cardiovascular Center Corporation of Puerto Rico and the Caribbean

PR

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.512

Finding No. 2022-006 - Audit Requirements for Auditees - Report Submission Condition The data collection form and the reporting package for the year ended on June 30, 2022, was not submitted to the Federal Audit Clearinghouse within the timeframe prescribed by the Uniform Guidance. Corporation resp...

Finding No. 2022-006 - Audit Requirements for Auditees - Report Submission Condition The data collection form and the reporting package for the year ended on June 30, 2022, was not submitted to the Federal Audit Clearinghouse within the timeframe prescribed by the Uniform Guidance. Corporation response The Corporation agrees with the finding. Corrective Action Plan Upon receipt of the audit findings, we initiated an immediate review of our reporting procedures. We have identified specific areas that require attention and are implementing quick corrective actions to address the identified deficiencies. ■ Policies and Procedures Review - Simultaneously, we are reviewing our existing policies and procedures related to federal awards reporting. This includes a reassessment of reporting tirnelines, data validation processes, and the overall framework for ensuring accuracy and completeness in our reports. ■ Staff Training and Development - Recognizing the critical role of our personnel in the reporting process, we are providing additional training to the individuals involved. This training will emphasize the importance of adherence to reporting guidelines, accurate data entry, and the significance of meeting established deadlines. ■ Communication Protocol Enhancement - We recognize the importance of effective communication regarding reporting processes. To address this, we are enhancing our communication protocols to ensure that all relevant stakeholders are informed of reporting requirements, timelines, and any changes to procedures. ■ Monitoring - The Corporation designated the Financial Planning and Analysis Associate Director in charge of monitoring the compliance with the federal awards reporting requirements. Names of the contact persons responsible for corrective action plan Jesus A. Rodriguez Aviles - Financial Planning and Analysis Associate Director Cecilia Robles Kakiuchi - Financial Planning and Analysis Director Anticipated Completion Date Fiscal Year 2024

View Audit 11856

Finding 8703 (2022-008)

Significant Deficiency 2022

Dakota County

MN

Allowable Costs / Cost Principles Significant Deficiency § 200.303

2022-008– EMERGENCY RENTAL ASSISTANCE – ENFORCEMENT – ACTIVITIES ALLOWED AND UNALLOWED U.S. Department of Treasury Emergency Rental Assistance Assistance Listing Number: 21.023 Direct Payment Award Period: 2022 Recommendation: We recommend the County review its procedures and controls related to ...

2022-008– EMERGENCY RENTAL ASSISTANCE – ENFORCEMENT – ACTIVITIES ALLOWED AND UNALLOWED U.S. Department of Treasury Emergency Rental Assistance Assistance Listing Number: 21.023 Direct Payment Award Period: 2022 Recommendation: We recommend the County review its procedures and controls related to emergency rental assistance general expenditures to ensure the accuracy of all payments going forward. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will ensure a proper review of all payments that the correct amount is paid. Name of the contact person responsible for corrective action: Peter Skwira, Finance Director Planned completion date for corrective action plan: December 31, 2023

View Audit 11849

Finding 8700 (2022-007)

Significant Deficiency 2022

Dakota County

MN

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties § 200.303 § 200.420 § 200.476

2022-007 – SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM CLUSTER, TEMPORARY ASSISTANCE FOR NEEDY FAMILIES, & CHILD SUPPORT ENFORCEMENT – ACTIVITIES ALLOWED AND UNALLOWED U.S. Department of Agriculture & U.S. Department of Health and Human Services Supplemental Nutrition Assistance Program Cluster, Temp...

2022-007 – SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM CLUSTER, TEMPORARY ASSISTANCE FOR NEEDY FAMILIES, & CHILD SUPPORT ENFORCEMENT – ACTIVITIES ALLOWED AND UNALLOWED U.S. Department of Agriculture & U.S. Department of Health and Human Services Supplemental Nutrition Assistance Program Cluster, Temporary Assistance for Needy Families & Child Support Enforcement Assistance Listing Number: 10.561, 93.558, 93.563 Passed Through Minnesota Department of Human Services Pass Through Number: H55210010, H55214077 & H55214004 Award Period: 2022 Recommendation: We recommend that the County retain documentation of review and approval of all expenditures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: EEA has reviewed existing policies for purchases using federal funds. If using federal funds, these policies and procedures will be followed. Name of the contact person responsible for corrective action: Daren Nyquist, Administration Manager Planned completion date for corrective action plan: December 31, 2023

View Audit 11849

Finding 8641 (2022-005)

Significant Deficiency 2022

Kandiyohi County

MN

Eligibility Reporting Significant Deficiency

2022.005 CASEFILE REVIEW Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Recommendation: It is recommended the County perform internal casefile reviews of Medical Assistance Casefiles. Action taken in response to finding: The County will continue to w...

2022.005 CASEFILE REVIEW Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Recommendation: It is recommended the County perform internal casefile reviews of Medical Assistance Casefiles. Action taken in response to finding: The County will continue to work at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2023

View Audit 11795

Finding 8293 (2022-005)

Significant Deficiency 2022

East Central Regional Development Commission

MN

Reporting Cash Management Significant Deficiency

CASEFILE REVIEW Federal Agency: U.S. Department of Commerce Federal Program Name: COVID-19 Economic Adjustment Assistance(Economic Development Cluster) Assistance Listing Number: 11.307 Pass-Through Agency: N/A - Direct Federal Award Identification Number and Pass-Through Number: ED20CHI3070088/06-...

CASEFILE REVIEW Federal Agency: U.S. Department of Commerce Federal Program Name: COVID-19 Economic Adjustment Assistance(Economic Development Cluster) Assistance Listing Number: 11.307 Pass-Through Agency: N/A - Direct Federal Award Identification Number and Pass-Through Number: ED20CHI3070088/06-79-06222/06-79-06392; 2021 Compliance Requirement Affected: Reporting Award Period: Year Ended June 30, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: We recommend the Commission implement procedures to ensure all reports have proof of review and submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Commission will ensure that all report reviews are documented in the future, as well as being submitted timely. Name of the contact person responsible for corrective action: Darcy Rylander, Finance Officer Planned completion date for corrective action plan: June 30, 2024

View Audit 11091

Finding 8203 (2022-007)

Significant Deficiency 2022

Hubbard County

MN

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Finding Number: 2022-007 Finding Title: Reporting – LCTS Spending Report Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Brian Ophus, Social Services Director Corrective Action Planned: LCTS recipients have been given education on the importance ...

Finding Number: 2022-007 Finding Title: Reporting – LCTS Spending Report Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Brian Ophus, Social Services Director Corrective Action Planned: LCTS recipients have been given education on the importance of timely reporting, Hubbard County has provided recipients with the proper tools and timelines in order to meet the deadlines. DHS was notified of the tardiness from recipients and issued a warning to them. Anticipated Completion Date: October 1, 2023

View Audit 10780

Finding 8022 (2022-002)

None 2022

Harrisonburg Redevelopment and Housing Authority

VA

Reporting Significant Deficiency

The Authority continues to monitor and fine-tune financial processes to ensure program ledgers are correctly maintained and updated to ensure compliance with submission of all required data collection form and audit by the required deadline.

View Audit 10515

Finding 7971 (2022-002)

Significant Deficiency 2022

Clay County

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2022-002 Finding Title: Eligibility Program: Temporary Assistance for Needy Families (AL No. 93.558) Name of Contact Person Responsible for Corrective Action: Rhonda Porter, Director and Karen Syverson, Supervisor Corrective Action Planned: All five cases found to have errors are bei...

Finding Number: 2022-002 Finding Title: Eligibility Program: Temporary Assistance for Needy Families (AL No. 93.558) Name of Contact Person Responsible for Corrective Action: Rhonda Porter, Director and Karen Syverson, Supervisor Corrective Action Planned: All five cases found to have errors are being reviewed and will be corrected as appropriate. All case errors will be reviewed with staff who are involved in administering this program. Case file reviews will continue to occur, and any errors found will continue to be reviewed with staff and training provided. Anticipated Completion Date: The five cases found in error will be corrected by December 31, 2023. Family Team will review these errors on Dec. 14, 2023. Case file reviews will continue monthly.

View Audit 10394

Corrective Action Plans

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