Corrective Action Plans

Finding 480856 (2021-004)

Significant Deficiency 2021

American Association of Physics Teachers, Inc.

MD

Matching / Level of Effort / Earmarking Significant Deficiency § 200.303

Finding 2021-004: Payroll Federal Programs: Research and Development Cluster: 47.0746 Condition: Payroll approvals for individuals are not always made by individuals who are the employee's supervisors or are otherwise knowledgeable about their level of effort during the payroll periods paid for. Vie...

Finding 2021-004: Payroll Federal Programs: Research and Development Cluster: 47.0746 Condition: Payroll approvals for individuals are not always made by individuals who are the employee's supervisors or are otherwise knowledgeable about their level of effort during the payroll periods paid for. Views of Responsible Officials and Planned Corrective Actions: AAPT has made changes to correclty reflect the employee's assigned supervisor based on the position and job duties of the employees. Anticipated Completion Date: 04/01/2024 Responsible Official: Michael Brosnan, CFO

View Audit 316985

Finding 480685 (2021-001)

Significant Deficiency 2021

Puerto Rico Office Management and Budget

PR

Subrecipient Monitoring Reporting Significant Deficiency

3 de julio de 2024 Section II – Federal Award Findings and Questioned Costs Finding Number: 2021-001 Agency: Puerto Rico Office of Management and Budget Federal Program: Coronaviru...

3 de julio de 2024 Section II – Federal Award Findings and Questioned Costs Finding Number: 2021-001 Agency: Puerto Rico Office of Management and Budget Federal Program: Coronavirus Relief Fund Assistant listing number: 21.019 Grant Number: N/AV Grant Period: July 1, 2020 through June 30, 2021 Compliance Requirement: Reporting Category: Significant Deficiency and noncompliance over federal program Condition: During our audit of June 30, 2021 financial statement, we noted that single audit report for fiscal year 2020-2021 was not submitted by September 30, 2022. Cause: Missing of internal controls over financial reporting to produce financial statement on timely basis to comply with OMB reporting deadlines. Effect: Non-compliance with the above-mentioned requirement could lead to administrative actions by the grantor. It could also be interpreted as a failure to manage federal awards in compliance with laws, regulations, and provisions of contracts and grant agreements. Recommendation: To improve, execute and monitors accounting periods end closings as planned in order to get a financial statement on time to comply with required deadlines. Also, keep track and communication of federal programs compliances with regulatory parties and among agency’s responsible departments involve and establish a program deadline calendar. Questioned Costs: None Perspective of the information: Single audit report was issued after due date. The information was not drawn from a statistical sample. Calle Cruz #254 Esq. Tetuán, San Juan, PR / PO Box 9023228, San Juan, PR 00902-3228 Management response: 3 de julio de 2024 Section II – Federal Award Findings and Questioned Costs Finding Number: 2021-001 Agency: Puerto Rico Office of Management and Budget Federal Program: Coronavirus Relief Fund Assistant listing number: 21.019 Grant Number: N/AV Grant Period: July 1, 2020 through June 30, 2021 Compliance Requirement: Reporting Category: Significant Deficiency and noncompliance over federal program Condition: During our audit of June 30, 2021 financial statement, we noted that single audit report for fiscal year 2020-2021 was not submitted by September 30, 2022. Cause: Missing of internal controls over financial reporting to produce financial statement on timely basis to comply with OMB reporting deadlines. Effect: Non-compliance with the above-mentioned requirement could lead to administrative actions by the grantor. It could also be interpreted as a failure to manage federal awards in compliance with laws, regulations, and provisions of contracts and grant agreements. Recommendation: To improve, execute and monitors accounting periods end closings as planned in order to get a financial statement on time to comply with required deadlines. Also, keep track and communication of federal programs compliances with regulatory parties and among agency’s responsible departments involve and establish a program deadline calendar. Questioned Costs: None Perspective of the information: Single audit report was issued after due date. The information was not drawn from a statistical sample. Calle Cruz #254 Esq. Tetuán, San Juan, PR / PO Box 9023228, San Juan, PR 00902-3228 Management response: The Puerto Rico Office of Management and Budget (OMB) acknowledges the finding and the importance of complying with the OMB Uniform Guidance for single audits. The following actions have been taken and will continue to be implemented to ensure compliance: 1. Contracting External Audit Firms: o Action Taken: OMB has contracted qualified external audit firms to conduct the single audits to ensure compliance with federal requirements. o Outcome: This measure has resolved the immediate issue of non- compliance by ensuring timely submission of audit reports. The OMB complied with instructions from the Puerto Rico Fiscal Agency and Financial Advisory Authority (AAFAF) regarding reports related to these funds. The OMB presumed that AAFAF was responsible for the final report and audit to the federal government. The OMB will continue monitoring the use and disbursement of federal funds to comply with state and federal regulations. Responsible Officer: Mrs. Nivis González Rodríguez Estimated Completion Date: July 2024

View Audit 316913

Finding 478867 (2021-005)

Significant Deficiency 2021

Detroit Central City Cmh, Inc.

MI

Questioned Costs Program Income Subrecipient Monitoring § 200.307

FINDINGS - FEDERAL AWARDS Finding Number: 2021005 Finding Type: Significant Deficiency Condition: Program income was not used by DCCCMH to meet their matching requirements. DCCCMH reported allowable net program costs in excess of actual net allowable program costs of $15,569 and $3,446 for grants...

FINDINGS - FEDERAL AWARDS Finding Number: 2021005 Finding Type: Significant Deficiency Condition: Program income was not used by DCCCMH to meet their matching requirements. DCCCMH reported allowable net program costs in excess of actual net allowable program costs of $15,569 and $3,446 for grants M10071L5F011912 and Ml0439L5F011903, respectively. Management Response: Management acknowledges that program income generated from specific programs is to be used to cover net allowable program costs or to meet matching requirements. DCCCMH will implement measures to track program income for grant programs and will use program income to offset allowable program costs when preparing financial status reports. A final review of the use of program income will be performed by the Finance team before the annual audit commences. These measures will be incorporated into the updates to the financial policies and procedures for grant programs.

View Audit 315464 Questioned Costs: $1

Finding 478306 (2021-002)

Material Weakness 2021

City of Compton

CA

HUD Housing Programs Material Weakness Reporting

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller's Office drafted a grants policy that is currently under review by City Management. Community development staff will ensure a succession plan is in pl...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller's Office drafted a grants policy that is currently under review by City Management. Community development staff will ensure a succession plan is in place for any staff turnover and for report preparation compliance. Planned Implementation Date: December 31, 2024 Responsible Person(s): City Manager, Community Development Director, and City Controller

View Audit 314981

Finding 406473 (2021-002)

Significant Deficiency 2021

Leech Lake Tribal College

AZ

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.328

The College will ensure that all grant reports are reviewed in detail and information reported will be traced to the source reports by the reviewer. The College also implemented policies and procedures to ensure all grant reports are submitted prior to the due date.

View Audit 311635

Finding 406447 (2021-006)

Significant Deficiency 2021

City of Jersey City

NJ

Internal Control / Segregation of Duties Cash Management HUD Housing Programs

Corrective Action: The Chief Financial Officer will oversee efforts to close out the old accounts in a timely manner and make sure all systems are reconciled. Internal controls have been set into place to ensure future compliance. The Municipal Comptroller will train and continue to work closely wi...

Corrective Action: The Chief Financial Officer will oversee efforts to close out the old accounts in a timely manner and make sure all systems are reconciled. Internal controls have been set into place to ensure future compliance. The Municipal Comptroller will train and continue to work closely with personnel in charge of reporting and processing IDIS and vouchers drawdowns. The Division of Accounts & Control will continue to maintain a sub-ledger to ensure IDIS and the City’s financial system tie out prior to the processing of any payments, and each payment request will require an IDIS activity reference number in order to be processed. Monthly reconciliation of funds has been implemented and copies are sent to US HUD on a monthly basis. In addition, the City has hired a 3rd party grant consultant to help navigate and strengthen our overall processes. Implementation Date: Ongoing

View Audit 311633

Finding 406040 (2021-003)

Significant Deficiency 2021

Hospital Damas INC

PR

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.512

Finding No. 2021-003 – Reporting - Late filing of data collection form and reporting package Corrective Action Plan Commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be the designated officer in charge of concluding all necessary procedures, including the audit of financial sta...

Finding No. 2021-003 – Reporting - Late filing of data collection form and reporting package Corrective Action Plan Commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be the designated officer in charge of concluding all necessary procedures, including the audit of financial statements and single audit, for the Hospital to file its reporting package within it´s due date, as required by the CFR. Also, Mr. Julio Colón, Chief Financial Officer, will be the designated officer in charge of supervising and monitoring compliance with timely submittance each year. Name (s) of the Contact Person (s) Responsible for Corrective Action Mr. Julio Colón, Chief Financial Officer Anticipated Completion Date December 2024

View Audit 311582

Finding 406039 (2021-002)

Significant Deficiency 2021

Hospital Damas INC

PR

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding No. 2021-002 - Reporting Corrective Action Plan On July 29, 2022, all pending reports were submitted to AAFAF. Also, commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be de designated officer in charge of submitting the report by its due date and Mr. Julio Colón, Chief ...

Finding No. 2021-002 - Reporting Corrective Action Plan On July 29, 2022, all pending reports were submitted to AAFAF. Also, commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be de designated officer in charge of submitting the report by its due date and Mr. Julio Colón, Chief Financial Officer, will be de designated officer in charge of supervising and monitoring compliance with timely submittance each month. Name (s) of the Contact Person (s) Responsible for Corrective Action Julio Colón, Chief Financial Officer Anticipated Completion Date Completed on July 29, 2022

View Audit 311582

Finding 406038 (2021-001)

Significant Deficiency 2021

Hospital Damas INC

PR

Eligibility Subrecipient Monitoring Significant Deficiency

Finding No. 2021-001 - Activities Allowed or Unallowed - Hazard Pay Eligibility Corrective Action Plan On March 2, 2022, payments to ineligible employees were recharacterized as additional compensation paid from the Entity’s own resources, instead of federal awards. Such federal awards remain availa...

Finding No. 2021-001 - Activities Allowed or Unallowed - Hazard Pay Eligibility Corrective Action Plan On March 2, 2022, payments to ineligible employees were recharacterized as additional compensation paid from the Entity’s own resources, instead of federal awards. Such federal awards remain available for use under other assistance programs provided by the CARES Act through December 2020. Name (s) of the Contact Person (s) Responsible for Corrective Action Julio Colón, Chief Financial Officer Anticipated Completion Date Completed on March 2, 2022

View Audit 311582

Finding 404909 (2021-005)

Significant Deficiency 2021

Iroquois Memorial Hospital

IL

Internal Control / Segregation of Duties Reporting Significant Deficiency

The CFO of Iroquois Memorial Hospital and Resident Home worked in fiscal year 2024 to catch up past audits and is working to catch-up account reconciliations and have proper support for balances within the general ledger and financial statements. This will also allow for timely filing of Uniform Gui...

The CFO of Iroquois Memorial Hospital and Resident Home worked in fiscal year 2024 to catch up past audits and is working to catch-up account reconciliations and have proper support for balances within the general ledger and financial statements. This will also allow for timely filing of Uniform Guidance audits in the future. The audits for the years ended September 30, 2023, 2022, and 2021, were completed and dated June 28, 2024; whereas under prior management of the hospital the last financial statement for the year ended September 30, 2020 was completed by the current management team in 2023 as was left uncompleted by prior hospital management. The team at the Organization plans to continue to be timely with audits in the future.

View Audit 311307

Finding 404908 (2021-004)

Significant Deficiency 2021

Iroquois Memorial Hospital

IL

Allowable Costs / Cost Principles Cash Management Reporting

The CFO and accounting team at Iroquois Memorial Hospital and Resident Home worked with its financial statement auditors and the HRSA audit support desk for Provider Relief Funds to identify a plan to update its documentation as well as update its internal records to reflect allowable costs under th...

The CFO and accounting team at Iroquois Memorial Hospital and Resident Home worked with its financial statement auditors and the HRSA audit support desk for Provider Relief Funds to identify a plan to update its documentation as well as update its internal records to reflect allowable costs under the program. One of the updates included utilization of additional lost revenue to cover nonallowable expenses under the first phases of reporting for Provider Relief Funds due to elimination of some expenses and reduction for Medicare cost reimbursement against expenses. Management developed a more detailed expense log and review those against current terms and conditions prior to any future portal submissions and took into account the use of additional lost revenue. The worksheets were mocked up internally as if these were submitted in the portal in Phase I reporting so that in the future for the next phases of reporting, these lost revenues are not utilized toward future Provider Relief Funding. One additional control being added for this reporting is that the CEO and CFO will be also completing a detailed review of the spreadsheets for entry into the portal and comparing this to the Compliance Supplement which governs the use of the Provider Relief Funds as to allowable costs as well as the Frequently Asked Questions (FAQs) available on HRSAs website. This may impact future reports, so management will ensure to take these updates into account on any future provider relief funds are they are released or future grant receipts if the Organization receives new grants in the future.

View Audit 311307

Finding 402882 (2021-001)

Significant Deficiency 2021

Aldersgate United Methodist Retirement Community, Inc.

NC

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Department of Health and Human Services Aldersgate United Methodist Retirement Community, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2021. Audit period: January 1, 2021 through December 31, 2021 The finding from the schedule of findings and questio...

Department of Health and Human Services Aldersgate United Methodist Retirement Community, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2021. Audit period: January 1, 2021 through December 31, 2021 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2021-001 Provider Relief Funding – Assistance Listing No. 93.498 Recommendation: We recommend the organization adopt a formal policy in which the documentation of expenditures is maintained and all expenditures are compared against source documentation to ensure appropriate recording. A review of these expenditures should be formally documented. This review should be performed by someone other than the preparer of the information. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Aldersgate is implementing a formal document retention policy including digital and email documentation to ensure documentation of expenditures is maintained for the appropriate period of time. Aldersgate is also implementing a formal policy for reviews and approvals for all transactions to ensure the reviews and posting are performed by someone other than the person initiating the transaction. Last, Aldersgate is implementing internal control audits to ensure the practices are compliant with the new policies. Name(s) of the contact person(s) responsible for corrective action: Cherie Grisso, Chief Financial Officer Planned completion date for corrective action plan: 8/31/24 If the Department of Health and Human Services has questions regarding this plan, please call Cherie Grisso, Chief Financial Officer, at 704-532-5222.

View Audit 310112 Questioned Costs: $1

Finding 402820 (2021-001)

Significant Deficiency 2021

Brownfield Regional Medical Center

NM

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.303 § 200.403 § 200.430

Recommendation: The Auditor recommends that the Entity implement controls for documenting and retaining information on expenditures charged to federal awards to follow the requirements over 2 CFR Section 200.430(g)(i) and in addition the Entity is properly paying employees at the approved pay rate. ...

Recommendation: The Auditor recommends that the Entity implement controls for documenting and retaining information on expenditures charged to federal awards to follow the requirements over 2 CFR Section 200.430(g)(i) and in addition the Entity is properly paying employees at the approved pay rate. Action Taken: 1. Policy Revision and Development: o Develop or revise existing policies to clearly define the processes for documenting and retaining expenditure information related to federal awards. These policies should explicitly follow the requirements over 2 CFR Section 200.430(g)(i), ensuring that all expenditures are properly documented and justified as per federal award conditions. Specifically, approval of differential rates will be added to those policies. o Ensure that the policy includes guidelines for regularly reviewing employee pay rates against approved rates for compliance with federal award conditions. 2. Training and Awareness Programs: o Implement comprehensive training programs for all staff involved in charging costs to federal awards. This training should cover the importance of compliance with federal regulations, specifically focusing on the documentation and retention of expenditure information and adherence to approved pay rates. o Schedule regular refresher training sessions to ensure ongoing compliance and awareness. 3. Enhanced Monitoring and Audit Trails: o Introduce monitoring mechanisms to regularly review expenditures charged to federal awards for compliance with documented policies and federal requirements. o Develop an audit trail system that allows for the easy retrieval of documentation supporting expenditures and payroll compliance. This system should enable auditors to trace the documentation back to the federal award and the approved budget items. 4. Internal Control Improvements: o Review and strengthen internal controls related to the processing of expenditures and payroll to ensure that all transactions are authorized, recorded accurately, and in compliance with federal award requirements. o Implement segregation of duties where possible, to reduce the risk of errors or fraud in the charging of costs to federal awards. 5. Regular Compliance Reviews and Updates: o Conduct periodic internal reviews to assess compliance with federal award requirements and the effectiveness of the implemented corrective actions. o Ensure that any changes in federal regulations or award-specific requirements are promptly incorporated into the hospital's policies and training programs. 6. Documentation and Communication: o Maintain comprehensive records of all actions taken to address the audit findings, including policy revisions, training sessions, and internal review outcomes. Specifically, records for those these expenditures will remain onsite and not sent to long-term storage if the employee or vendor no longer has a relationship with the facilities. o Communicate regularly with federal awarding agencies to update them on the corrective actions taken and to seek guidance on compliance matters as needed. Implementation Timeline and Responsibility Assignment: • Management positions including the CEO, CFO and CNO for the 2021 fiscal year are no longer employed by Terry Memorial Hospital District. Administration employed in 2023 acknowledges these deficiencies and accepts responsibility for developing, applying and maintaining this corrective action plan going forward. • Assign specific responsibilities to designated staff members or departments for each component of the corrective action plan. • Set clear deadlines for the completion of each action item, with an initial goal to address all significant deficiencies within one to three months from the date of the audit report. Monitoring and Reporting: • Establish a mechanism for ongoing monitoring of the effectiveness of the corrective action plan, with periodic reports to senior management and the board of directors. Feedback Loop: • Create a feedback loop with employees and management to continuously improve internal controls and compliance processes based on practical experiences and challenges encountered during implementation. Responsible Person: Whitney Wilson, CFO

View Audit 310010 Questioned Costs: $1

Finding 402380 (2021-015)

Significant Deficiency 2021

State of California

CA

Questioned Costs Reporting Special Tests & Provisions § 200.303

Health Care Services agrees with the recommendation. Effective September 1, 2021, System Development Notice (SDN) 20039 made updates to the Claims Processing Accounts Receivable System, requiring the Fiscal Intermediary (FI) to record the FFP rate including the Budget Program (i.e., Medicaid Assista...

Health Care Services agrees with the recommendation. Effective September 1, 2021, System Development Notice (SDN) 20039 made updates to the Claims Processing Accounts Receivable System, requiring the Fiscal Intermediary (FI) to record the FFP rate including the Budget Program (i.e., Medicaid Assistance Program vs. Children’s Health Insurance Program) for each overpayment account receivable set up after the effective date. The FFP rate and Budget Program information for each overpayment is provided on the Action Notices to the FI. The SDN also made updates to the California Omnibus Budget Reconciliation Act of 1985 (COBRA) system to enable the system to receive the FFP rate and Budget Program information for each overpayment set up by the FI and updated COBRA reports, thereby allowing Health Care Services to report the correct FFP rate for overpayments on the CMS-64 and CMS-21. Estimated Implementation Date: September 30, 2021 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services

View Audit 309913 Questioned Costs: $1

Finding 402372 (2021-012)

Significant Deficiency 2021

State of California

CA

Subrecipient Monitoring Reporting Significant Deficiency

The Department of Aging (Aging) is committed to rectifying this issue and coming into compliance with this reporting requirement effective now. Aging has reworked the roles and responsibilities within the Budget Operations Bureau to ensure that there is a dedicated staff person to enter all FFATA re...

The Department of Aging (Aging) is committed to rectifying this issue and coming into compliance with this reporting requirement effective now. Aging has reworked the roles and responsibilities within the Budget Operations Bureau to ensure that there is a dedicated staff person to enter all FFATA reporting within the required timeframe. This individual has been trained and made aware of the expectations. Aging has begun updating the FFATA records and will continue this effort through the month of March until all reporting has been completed. Moving forward, the dedicated staff person will update the FFATA for each new federal funding award within the required timeframe. Estimated Implementation Date: March 2023 Contact: Kim Elliott, Chief Budget Officer Division of Administrative Services California Department of Aging

View Audit 309913

Finding 402368 (2021-009)

Significant Deficiency 2021

State of California

CA

Cash Management Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303 § 200.305

Office of AIDS (OA) agrees with the finding and has implemented solutions to meet the auditor's recommendation. OA has already taken steps to remedy the issue by using its Support Branch to realign staff and responsibilities to allow for a greater focus on fiscal reporting and invoice processing. T...

Office of AIDS (OA) agrees with the finding and has implemented solutions to meet the auditor's recommendation. OA has already taken steps to remedy the issue by using its Support Branch to realign staff and responsibilities to allow for a greater focus on fiscal reporting and invoice processing. The Care Branch has also put an increased emphasis on tracking and reviewing invoices for payment to prevent similar delays. Subsequently, the Ryan White Grant closeouts had all invoices processed and paid prior to the Federal Financial Report closeout deadlines to ensure that drawn cash for invoices was not held for extended timeframes. Estimated Implementation Date: July 1, 2021 Contact: Joseph Gonzales, Branch Chief Office of AIDS Support Branch California Department of Public Health

View Audit 309913

Finding 401250 (2021-001)

Significant Deficiency 2021

Presbyterian Homes of Tennessee, Inc.

TN

Reporting Significant Deficiency Internal Control / Segregation of Duties

Department of Health and Human Services Presbyterian Homes of Tennessee, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2021. Audit period: January 1, 2021 through December 31, 2021 The finding from the schedule of findings and questioned costs is disc...

Department of Health and Human Services Presbyterian Homes of Tennessee, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2021. Audit period: January 1, 2021 through December 31, 2021 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2021-001 Provider Relief Funding – Assistance Listing No. 93.498 Recommendation: The organization updated the submission related to its Period 1 reporting, which included an updated lost revenue calculation to support all provider relief fund payments received. The organization should ensure the proper review procedures are in place for any future submissions to ensure accurate reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: An amended Period 1 submission report, using the lost revenues, was submitted. Appropriate review procedures will be put in place to ensure accurate reporting on any future submissions. Name of the contact person responsible for corrective action: Erik Hockman, CFO Planned completion date for corrective action plan: May 2, 2023 If the Department of Health and Human Services has questions regarding this plan, please call Erik Hockman at 865-243-3613.

View Audit 309260

Finding 401146 (2021-001)

Significant Deficiency 2021

Public Hospital District No. 1 of Skagit County

WA

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

Finding 2021-001 Responsible Official: Matthew Vaughn, Regional Director of Financial Planning & Analysis Views of Responsible Officials: The District believed they were in compliance with the reporting requirements at the time of submission based on the guidance available. Guidance among the differ...

Finding 2021-001 Responsible Official: Matthew Vaughn, Regional Director of Financial Planning & Analysis Views of Responsible Officials: The District believed they were in compliance with the reporting requirements at the time of submission based on the guidance available. Guidance among the different federal programs changed over the course of the Public Health Emergency in a manner that caused reconsideration of both the classification and estimate of expenses. Over the course of the pandemic, the district went through the process to more completely segregate the PRF support from other COVID-19 funding. While the allocations and classifications within the program reports would have changed based on that process, in total program expenditures for both periods in total were supported. All expenses under the Public Health Emergency period have currently been categorized in this manner, and any future expenses or expense adjustments will be kept with this categorization in-tact. This was completed over the course of the 2021 Single Audit review in November 2023

View Audit 309195

Finding 400880 (2021-001)

Significant Deficiency 2021

Indiana Senior Housing Health Care Properties, Inc.

IN

Reporting Significant Deficiency

Views of Responsible Officials and Planned Corrective Action – Management understands the due date for single audit reporting package submission to the Federal Audit Clearinghouse and will file the single audit reporting package as soon as possible.

View Audit 308908

Finding 398559 (2021-001)

Significant Deficiency 2021

Least of These, Inc.

MO

Questioned Costs Equipment & Real Property Management Special Tests & Provisions

Audit Finding Reference: 2021 – 001 Planned Corrective Action: We will implement a new inventory system and related controls that track USDA Foods inventory separately from non-federal inventory and at the appropriate values. We will ensure the cost per item values in the system are reviewed at leas...

Audit Finding Reference: 2021 – 001 Planned Corrective Action: We will implement a new inventory system and related controls that track USDA Foods inventory separately from non-federal inventory and at the appropriate values. We will ensure the cost per item values in the system are reviewed at least annually to ensure that inventory is appropriately valued. Name of Contact Person: Kristy Carter, Executive Director, kristy.carter@leastofthesefoodpantry.org Anticipated completion date: June 30, 2022

View Audit 307269 Questioned Costs: $1

Finding 396486 (2021-002)

Significant Deficiency 2021

The County of Lebanon, Pennsylvania

PA

Internal Control / Segregation of Duties Material Weakness Reporting

Segregation of Duties over Reporting: The Department was in need of additional accounting personnel and as of December 2023 a new employee was hired so adequate oversight will be corrected going forward.

View Audit 306097

Finding 396047 (2021-006)

Significant Deficiency 2021

Orutsararmiut Native Council

AK

Reporting Significant Deficiency Internal Control / Segregation of Duties

Federal Agency: US Department of the Interior Federal Program: BIA Compact Assistance Listing Number: 15.022 Award Number: GT-OSGT043-16 Award Year: 2021 Type of Finding: Significant deficiency in internal control over compliance. Name of Contact: Brian Henry, Executive Director Corrective Action...

Federal Agency: US Department of the Interior Federal Program: BIA Compact Assistance Listing Number: 15.022 Award Number: GT-OSGT043-16 Award Year: 2021 Type of Finding: Significant deficiency in internal control over compliance. Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Management will adhere to the internal control policies and formally approve changes to employee pay rates in all personnel files. Proposed Completion Date: June 30, 2024

View Audit 305670

Finding 396046 (2021-005)

Significant Deficiency 2021

Orutsararmiut Native Council

AK

Reporting Significant Deficiency Internal Control / Segregation of Duties

Federal Agencies: U.S. Department of the Treasury Federal Programs: Emergency Rental Assistance Program Assistance Listing Numbers: 21.023 Award Numbers: ERA0672 Award Years: 2021 Type of Finding: Significant deficiency in internal control over compliance. Name of Contact: Brian Henry, Executive Di...

Federal Agencies: U.S. Department of the Treasury Federal Programs: Emergency Rental Assistance Program Assistance Listing Numbers: 21.023 Award Numbers: ERA0672 Award Years: 2021 Type of Finding: Significant deficiency in internal control over compliance. Name of Contact: Brian Henry, Executive Director Corrective Action Plan: The online reporting portal for this program has closed and no further reports are accepted. Management has been following the annual reporting requirements for Treasury’s ongoing SLFRF program. Proposed Completion Date: Complete as of December 31, 2023

View Audit 305670

Finding 395065 (2021-009)

Significant Deficiency 2021

Housing Authority of Cass County

ND

Significant Deficiency

Contact Person Derek Johnson, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP December 31, 2022.

View Audit 304992

Finding 395064 (2021-008)

Significant Deficiency 2021

Housing Authority of Cass County

ND

Significant Deficiency

Contact Person Derek Johnson, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP December 31, 2022.

View Audit 304992

Corrective Action Plans

Filters