Corrective Action Plans

Finding 5764 (2022-001)

Significant Deficiency 2022

AK

Subrecipient Monitoring Reporting Significant Deficiency

Finding 2022-001 Significant Deficiency in Internal Control over Compliance, Noncompliance-Reporting Type of Finding: Significant Deficiency/Noncompliance Name of Contact: George Flynn Corrective Action Plan: Stebbins Community Association will strive to ensure that the future audits will be com...

Finding 2022-001 Significant Deficiency in Internal Control over Compliance, Noncompliance-Reporting Type of Finding: Significant Deficiency/Noncompliance Name of Contact: George Flynn Corrective Action Plan: Stebbins Community Association will strive to ensure that the future audits will be completed in time to file the form SD-SCA within the required nine months. We will schedule future audits to work with an accounting firm to occur within 100 days after fiscal year. Proposed Completion Date: December 4, 2023.

View Audit 7848

Finding 5708 (2022-001)

Material Weakness 2022

Potter County Housing Authority

PA

Cash Management Significant Deficiency Matching / Level of Effort / Earmarking

Department of Housing and Urban Development The Potter County Housing Authority respectively submits the following corrective action plan for the fiscal year ended June 30, 2022. Audit Period: July 1, 2021 – June 30, 2022 The finding from the schedule of findings and questions costs is discussed...

Department of Housing and Urban Development The Potter County Housing Authority respectively submits the following corrective action plan for the fiscal year ended June 30, 2022. Audit Period: July 1, 2021 – June 30, 2022 The finding from the schedule of findings and questions costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. Finding 2022-1 – Interfund Receivables and Payables Financial Statement Audit Recommendation The Authority should address the repayment of the interfund receivables and payables. The balances of the receivables and payables should be review by management on an annual basis to determine if repayment is expected in a reasonable time period. If repayment is not expected, the interfund balances should be reduced and the amount that is not expected to be repaid should be reported as a transfer from the fund that made the loan to the fund that received the loan. Response The Authority agrees with the Auditor that interfund balances should be reviewed on an annual basis. The Authority will continue to bring old interfund balances in front of our Board to approve write-off and donation transactions. Several interfund balances have been previously authorized and will remain on the financial accounts; The Authority should see a significant reduction in the need for interfund transfers in the future for project development.

View Audit 7713

Finding 5682 (2022-001)

Significant Deficiency 2022

Northwest Indiana Community Action Corporation

IN

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

Synopsis of Finding: Northwest Indiana Community Action Corporation (NWICA), experienced a delay in issuing the December 31, 2022, audited financial statements which were due September 30, 2023. The financial reporting and general ledger close-out process was not sufficient to provide accurate and t...

Synopsis of Finding: Northwest Indiana Community Action Corporation (NWICA), experienced a delay in issuing the December 31, 2022, audited financial statements which were due September 30, 2023. The financial reporting and general ledger close-out process was not sufficient to provide accurate and timely financial statements for timely filing of the audit in accordance with regulatory requirements. Management’s Response: Northwest Indiana Community Action Corporation (NWICA) concurs with the 2022-001: Fiscal Internal Controls finding. NWICA has taken the steps to address this finding by hiring new leadership within the Finance department and is evaluating internal processes to ensure timely completion of future audits. This will include starting the audit earlier in the year and periodic touch points with the auditors to ensure the established timeline for completion is achieved. Contact Person Responsible for Corrective Action: Jonathan Edwards Anticipated Completion Date: September 30, 2024

View Audit 7631

Finding 5656 (2022-002)

Significant Deficiency 2022

City of Wasilla, Alaska

AK

Reporting Subrecipient Monitoring Significant Deficiency

Finding 2022-002 – Reporting - Deadline for Federal Single Audit - Noncompliance and Internal Co ntrol over Compliance - Significant Deficiency Corrective Action Plan Due to the implementation of Governmental Accounting Standards Board (GASB) Number 87, there was a delay in closing the books and rec...

Finding 2022-002 – Reporting - Deadline for Federal Single Audit - Noncompliance and Internal Co ntrol over Compliance - Significant Deficiency Corrective Action Plan Due to the implementation of Governmental Accounting Standards Board (GASB) Number 87, there was a delay in closing the books and records in FY22. Management is working with the external auditors to ensure that the books and records will be closed in a timely manner to meet the deadline for filing Form SF-SAC in the future. Expected Completion Date: Fiscal Year 2024

View Audit 7570

Finding 5554 (2022-001)

Significant Deficiency 2022

Nursing and Therapy Services of Colorado

CO

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking

The Organization will review the special provIsIons of the disaster assistance loan and ensure that all provisions of the program are complied with. Management will ensure itemized receipts are tracked and submitted to the SBA, internal financial statements are submitted to the SBA, and the Equal Op...

The Organization will review the special provIsIons of the disaster assistance loan and ensure that all provisions of the program are complied with. Management will ensure itemized receipts are tracked and submitted to the SBA, internal financial statements are submitted to the SBA, and the Equal Opportunity Poster is posted where it will be ·clearly visible to employees, applicants for employment, and the general public.

View Audit 7385

Finding 5505 (2022-006)

Significant Deficiency 2022

Santa Fe Community Housing Trust

NM

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

The contractors hired to do the accounting and payroll functions are no longer under contract with the Housing Trust. All financial functions are now being taken care of in-house. The financials are already in the process of being adjusted and all numbers being accounted for with documentation. Thi...

The contractors hired to do the accounting and payroll functions are no longer under contract with the Housing Trust. All financial functions are now being taken care of in-house. The financials are already in the process of being adjusted and all numbers being accounted for with documentation. This will continue through 2023 and in 2024, the chart of accounts will be changed to reflect the current practices for a nonprofit organization. As the Executive Director prepares the 2024 budget, a reorganization of the business operations department has started. Staff changes will also need the Business Operations manager to provide a thorough monthly review. The current administrative assistant will take on the role of accounting technician to handle the day-to-day QuickBooks-related processes. Work has already started to develop checks and balances. Corrective Action Plan Timeline: Immediately Designated Employee Responsible for Corrective Action: Business Operations Manager

View Audit 7270

Finding 5502 (2022-003)

Significant Deficiency 2022

Santa Fe Community Housing Trust

NM

Reporting Procurement, Suspension & Debarment Cash Management

Response. Agreed. Where feasible, the Housing Trust will aim to improve management of all federal grants. A process of documentation verification prior to any requests made for financial draws will include employee, supervisor, business operations manager, and executive director level approvals to e...

Response. Agreed. Where feasible, the Housing Trust will aim to improve management of all federal grants. A process of documentation verification prior to any requests made for financial draws will include employee, supervisor, business operations manager, and executive director level approvals to ensure compliance and availability of funds. A monthly federal request for reimbursements with all grantee information will be used and reconciled monthly with QuickBooks. This report will mirror the SEFA form so auditors will receive the information in a timely manner. For any quarterly reports, the three months of reporting will again be reconciled prior to submission. All new processes and compliance will be updated in the policies and procedure manual. As the Executive Director prepares the 2024 budget, a reorganization of the business operations department will be sought. A new position to prepare and work on all federal grant tasks will be hired and report to the Business Operations Manager. In the meantime, the Business Operations Manager has started to develop checks and balances. Corrective Action Plan Timeline: Immediately Designation Of Employee Position Responsible For Meeting Deadline: Business Operations Manager

View Audit 7270

Finding 4958 (2022-007)

Significant Deficiency 2022

City of Medford

MA

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring § 200.214

Condition: Suspension and debarment compliance is not verified for all covered transactions. Corrective Action Planned: The School Comptroller will ensure that all vendors are checked using SAM for suspension and debarment for all covered transactions in compliance with federal laws. The School C...

Condition: Suspension and debarment compliance is not verified for all covered transactions. Corrective Action Planned: The School Comptroller will ensure that all vendors are checked using SAM for suspension and debarment for all covered transactions in compliance with federal laws. The School Comptroller will print out the support and include with each grant. Anticipated Completion Date: Completed Contact: Robert Dickinson, City Auditor

View Audit 7220

Finding 4038 (2022-002)

Significant Deficiency 2022

Granville Health System

NC

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System ensure that remaining statement balance for uninsured testing is not balance billed to the patient. Explanation of disagreement with audit finding: There is no di...

Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System ensure that remaining statement balance for uninsured testing is not balance billed to the patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We understand the finding. All balances remaining after HRSA payments will be reviewed and adjusted to zero. Name(s) of the contact person(s) responsible for corrective action: Adam McConnell, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2023

View Audit 6359 Questioned Costs: $1

Finding 4037 (2022-001)

Significant Deficiency 2022

Granville Health System

NC

Questioned Costs Cash Management Significant Deficiency

Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System review the submissions to HRSA to ensure that the patients they requested reimbursement for were in fact uninsured. Explanation of disagreement with audit finding...

Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System review the submissions to HRSA to ensure that the patients they requested reimbursement for were in fact uninsured. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We understand the finding. In future submissions, the System will review all patients to ensure that are uninsured. Name(s) of the contact person(s) responsible for corrective action: Adam McConnell, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2023

View Audit 6359 Questioned Costs: $1

Finding 3992 (2022-004)

Significant Deficiency 2022

City of Depere

WI

Reporting Significant Deficiency Internal Control / Segregation of Duties

Management has taken sufficient corrective action to resolve and does not believe this will be an issue in the future.

View Audit 6296

Finding 3979 (2022-001)

Significant Deficiency 2022

Hodgeman County, Kansas

KS

Subrecipient Monitoring Cash Management Significant Deficiency § 200.305

U.S. DEPARTMENT OF HOMELAND SECURITY KANSAS ADJUANT GENERAL 2022-001: Disaster Grants – Public Assistance CFDA No. 97.036 Grant period: Year Ended December 31, 2022 Condition and Context: The County does not have a complete set of written cash management policies and procedures as required by the U...

U.S. DEPARTMENT OF HOMELAND SECURITY KANSAS ADJUANT GENERAL 2022-001: Disaster Grants – Public Assistance CFDA No. 97.036 Grant period: Year Ended December 31, 2022 Condition and Context: The County does not have a complete set of written cash management policies and procedures as required by the Uniform Guidance. The lack of written procedures did not result in any material noncompliance, fraud or abuse with respect to the major program. Criteria: The Uniform Guidance requires Non-Federal entities other than States, including those operating Federal programs as subrecipients of States, to follow the cash management standards set out at 2 CFR section 200.305. The County must have a complete set of written cash management policies, which conform to applicable Federal statutes and the cash management requirements identified in 2 CFR part 200. Cause: The County was unaware of the written cash management policy requirements required by the Uniform Guidance. Effect: An important component of internal controls is the existence of operating policies and procedures and that they are clearly understood and communicated. Without clear written policies and procedures, there is a higher risk of noncompliance with program requirements. Recommendation: Management should determine the scope of written policies needed for compliance with all federal programs and develop policies and procedures to comply with the Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and recommendation. The County’s existing policies are currently under review by management and staff to determine what updates/changes are necessary in order to meet the Uniform Guidance requirements. Once any updates/changes are drafted, the policy will be presented to the Governing Body for review and approval.

View Audit 6270

Finding 3951 (2022-001)

Significant Deficiency 2022

Iowa Northland Regional Housing Authority

IA

Reporting Significant Deficiency Internal Control / Segregation of Duties

The corrective action plan was documented in our response to the auditor's comment. See the Schedule of Findings and Questioned Costs.

View Audit 6226

Finding 3876 (2022-006)

Significant Deficiency 2022

Camcare Health Corporation

NJ

HUD Housing Programs Special Tests & Provisions Significant Deficiency

Finding Numbers 2022-005 and 2022-006 Planned Corrective Action: Management plans to offer additional trainings, reminders to the Financial Screening Department, and institute a quarterly audit of completed applications to ensure compliance. Anticipated Completion Date: December 31, 2023 Responsib...

Finding Numbers 2022-005 and 2022-006 Planned Corrective Action: Management plans to offer additional trainings, reminders to the Financial Screening Department, and institute a quarterly audit of completed applications to ensure compliance. Anticipated Completion Date: December 31, 2023 Responsible Contact Persons: Jillian Hudspeth, CEO Christopher Bernardi, CFO

View Audit 6120

Finding 3655 (2022-004)

Significant Deficiency 2022

City of Eagle River

WI

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

The City has taken appropriate measures to resolve the finding in future years.

View Audit 5705

Finding 3517 (2022-002)

Significant Deficiency 2022

Northwestern Illinois Community Action Agency

IL

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

Action Taken: NICAA has parted ways with previous auditors, O’Connor & Brooks. NICAA has contracted with WIPFLI to standardize our internal controls and financial reporting. WIPFLI follows the Generally Accepted Accounting Principles (GAAP) standards more closely than previous auditors. In 2024, N...

Action Taken: NICAA has parted ways with previous auditors, O’Connor & Brooks. NICAA has contracted with WIPFLI to standardize our internal controls and financial reporting. WIPFLI follows the Generally Accepted Accounting Principles (GAAP) standards more closely than previous auditors. In 2024, NICAA will be working with WIPFLI to update internal controls and financial recording policies and procedures. Management and the Board of Directors will remain involved in the financial affairs of Northwestern Illinois Community Action Agency by providing oversight and independent review of financial reporting and accounting procedures.

View Audit 5528

Finding 3485 (2022-002)

Significant Deficiency 2022

Washington Association for Community Health

WA

Allowable Costs / Cost Principles Cash Management Reporting

Recommendation: The Association should ensure source documentation is maintained for all costs and elements of a cost calculation reimbursed by federal awards. Explanation or disagreement with audit finding: There is no disagreement with the audit finding from responsible officials that two out of ...

Recommendation: The Association should ensure source documentation is maintained for all costs and elements of a cost calculation reimbursed by federal awards. Explanation or disagreement with audit finding: There is no disagreement with the audit finding from responsible officials that two out of forty wage rate authorization forms requested were not located. Other documentation was submitted that supported the wage rates, including results of a salary survey performed by an HR consulting company. Actions taken in response to finding: In response to the finding, the Association generated detailed pay rate change history reports from the payroll system for these two employees and took a random sample of pay history for three other employees. Nothing unusual was identifiable. The Association will ensure source documentation is maintained for all federal award cost reimbursements by taking the following actions: • At least two Association leadership staff members will review all payroll changes and save documentation in secure, electronic personnel files and payroll processing files. • An improved human resources information and payroll system with more robust time tracking, reporting and document storage features is being implemented. • Detailed requirements for payroll changes will be added to revised finance and human resources policies and procedures (currently under revision). Name(s) or the contact person(s) responsible for correction action: Laura Dale, Director of Finance Bob Marsalli, CEO Planned completion date for corrective action plan: January, 2024

View Audit 5456

Finding 3376 (2022-004)

Significant Deficiency 2022

Bighorn Valley Health Center, Inc.

WA

Significant Deficiency Internal Control / Segregation of Duties

Health Center Program Cluster– Assistance Listing No. 93.224 & 93.527 Recommendation: Management should consider increasing the frequency of its internal audits over patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the coll...

Health Center Program Cluster– Assistance Listing No. 93.224 & 93.527 Recommendation: Management should consider increasing the frequency of its internal audits over patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection and verification of patient information for each patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The finding in the previous year’s audit was associated with lack of documentation of a slide application within the EMR, this was corrected. The current year’s finding was associated with the One Health EDR and was regarding an incorrect application of slide category. One Health has transitioned to an EDR that is interfaced and embedded into the current EMR and anticipates an automated process with slide application, which would correct the manual slide calculation by staff. Additionally, One Health is in the process of adjusting staff management to provide further oversight to intake personnel responsible for slide paperwork and documentation within the Electronic Health Record. One Health has already instituted additional internal audit oversight due to the EDR transition and plans to increase the frequency of review for those sliding scale patients. Name of the contact person responsible for corrective action: Colette Mild, VP Business Operations & Finance Planned completion date for corrective action plan: 12/31/2023

View Audit 5270

Finding 3162 (2022-002)

Significant Deficiency 2022

Boys and Girls Club of Livingston County

IL

Internal Control / Segregation of Duties Cash Management Significant Deficiency

The Organization will enhance its procedures and internal controls with respect to preparation and requests of funds. Grant agreements will be reviewed to confirm if expenditures being requested are allowed. The Organization will also hire an additional grant accountant to ensure proper controls are...

The Organization will enhance its procedures and internal controls with respect to preparation and requests of funds. Grant agreements will be reviewed to confirm if expenditures being requested are allowed. The Organization will also hire an additional grant accountant to ensure proper controls are in place.

View Audit 5166

Finding 3161 (2022-001)

Significant Deficiency 2022

Boys and Girls Club of Livingston County

IL

Internal Control / Segregation of Duties Cash Management Significant Deficiency

The Organization will enhance its procedures and internal controls with respect to preparation and requests of funds. Grant agreements will be reviewed to confirm if expenditures being requested are allowed. The Organization will also hire an additional grant accountant to ensure proper controls are...

The Organization will enhance its procedures and internal controls with respect to preparation and requests of funds. Grant agreements will be reviewed to confirm if expenditures being requested are allowed. The Organization will also hire an additional grant accountant to ensure proper controls are in place.

View Audit 5166

Finding 3034 (2022-005)

Significant Deficiency 2022

Lodge Grass School District No. 27 & 2

MT

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

Finding 2022-005 – Reporting (Compliance; Internal Control Over Compliance) Condition: The School District did not complete and submit their audit to the Federal Audit Clearinghouse by the due date of March 31, 2023. Recommendation: We recommend the School District become familiar with reportin...

Finding 2022-005 – Reporting (Compliance; Internal Control Over Compliance) Condition: The School District did not complete and submit their audit to the Federal Audit Clearinghouse by the due date of March 31, 2023. Recommendation: We recommend the School District become familiar with reporting requirements for each award and implement procedures to begin audit preparation work earlier in the fiscal year to ensure reports are filed within the nine-month reporting deadline set forth by Uniform Guidance. Views of Responsible Officials: The District was notified late by their audit firm that they would no longer be providing audit services. The District hired a replacement firm but was unable to complete the audit in accordance with the Clearinghouse guidelines. The District is retaining the current audit firm with anticipation of the report for the 2022-23 fiscal year being issued and filed on a timely basis.

View Audit 4984

Finding 3032 (2022-004)

Significant Deficiency 2022

Lodge Grass School District No. 27 & 2

MT

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

Finding 2022-004 – Internal Control Over Disbursements (Allowable Costs/Activities) Condition: During our testing of internal controls over nonpayroll disbursements we reviewed 20 transactions, noting there was no supporting documentation for 2 transactions. No additional documentation was present ...

Finding 2022-004 – Internal Control Over Disbursements (Allowable Costs/Activities) Condition: During our testing of internal controls over nonpayroll disbursements we reviewed 20 transactions, noting there was no supporting documentation for 2 transactions. No additional documentation was present to show that approval was obtained through other means, such as by email, verbally or follow-up signature approval from the program director. The sampling was not a statistically valid sample. Recommendation: We recommend that the School District strengthens internal control policies and procedures over disbursements and employees indicate their review and approval for all transactions to ensure they are properly authorized. We further recommend no disbursement be processed without all necessary supporting documentation being obtained. Views of Responsible Officials: The District concurs with the recommendation. The Superintendent is working with finance staff on the review process so as to provide documentation for each expenditure incurred by the District. The review is completed by the Business Manage then submitted to the Supt and Board of Trustees on a periodic basis.

View Audit 4984

Finding 3019 (2022-001)

Significant Deficiency 2022

Monroe County Board of Education

GA

School Nutrition Programs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

FA 2022-001 Strengthen Controls over Special Reporting Compliance Requirement: Reporting Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of Education Assis...

FA 2022-001 Strengthen Controls over Special Reporting Compliance Requirement: Reporting Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 10.553 - School Breakfast Program 10.555 - National School Lunch Program Federal Award Number: 225GA324N1199; 225GA324N1199 Questioned Costs: None Identified Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over the monthly Claims for Reimbursement process. Corrective Action Plans: The School District has returned to collection Free and Reduce applications and recording the student meals accordingly. Estimated Completion Date: July 1, 2022 Contact Person: Chris Johnson, CGFM, Director of Financial Services Telephone: 478-994-2031 Email: chris.johnson@mcschools.org

View Audit 4890

Finding 2965 (2022-004)

Significant Deficiency 2022

Thurston County Economic Development Council

WA

Questioned Costs Internal Control / Segregation of Duties Significant Deficiency § 200.430

Significant Deficiency in Internal Control over and Compliance over Programs Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No.21 .027 Recommendation: CLA recommends that the program manager and a member of the finance committee knowledgeable about 2 CFR § 200.430(i)(1) revie...

Significant Deficiency in Internal Control over and Compliance over Programs Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No.21 .027 Recommendation: CLA recommends that the program manager and a member of the finance committee knowledgeable about 2 CFR § 200.430(i)(1) review the executive director costs charged to the Coronavirus State and Local Recovery Funds program. Action planned in response to finding: Executive Director's time and effort reports will be reviewed by a member of the Finance Committee, who also serves as an Officer of the Board, on a quarterly basis to insure correct assignment of hours. Names of the contact persons responsible for corrective action: Michael Cade, Michael McGauly, and Matt Stacey Planned completion date for corrective action plan: November 14, 2023

View Audit 4859 Questioned Costs: $1

Finding 2964 (2022-003)

Significant Deficiency 2022

Thurston County Economic Development Council

WA

Questioned Costs Internal Control / Segregation of Duties Significant Deficiency § 200.430

Significant Deficiency in Internal Control over and Compliance over Programs Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027 Recommendation : CLA recommends increased payroll training and reconciliation procedures. Action planned in response to finding : Classificat...

Significant Deficiency in Internal Control over and Compliance over Programs Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027 Recommendation : CLA recommends increased payroll training and reconciliation procedures. Action planned in response to finding : Classification of payroll hours assigned to Coronavirus State and Local Fiscal Recovery Funds, and all others, are to be reviewed and signed off on by accounting or administrative staff before submission of payroll. Names of the contact persons responsible for corrective action: Maria Hemmen, Brooke Johnson or Matt Stacey. Planned completion date for corrective action plan: October 27, 2023

View Audit 4859 Questioned Costs: $1

Corrective Action Plans

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