Corrective Action Plans

Finding 531 (2021-005)

Significant Deficiency 2021

TX

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Deficiency in Special Tests and Provision Controls over Compliance with Training - Significant Deficiency Recommendation: The auditor recommends the Entity follow their employee policies and procedures related to mandatory trainings and retain documentation of all mandatory trainings held. Action Ta...

Deficiency in Special Tests and Provision Controls over Compliance with Training - Significant Deficiency Recommendation: The auditor recommends the Entity follow their employee policies and procedures related to mandatory trainings and retain documentation of all mandatory trainings held. Action Taken: EPHCC complied with all of the mandatory trainings, but in 2021 ther were held virtually due to COVID and there was no travel documentation. EPHCC is committed to continuing to follow our policy to ensure all mandatory trainings held are attended. Responsible Official: Chief Financial Officer, Lizabeth Romero Timeline for Implementation: Has already been implemented.

View Audit 1055

Finding 530 (2021-004)

Significant Deficiency 2021

El Paso Hispanic Chamber of Commerce

TX

Cash Management Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Deficiency in Cash Management Controls over Compliance - Significant Deficiency Recommendation: The auditor recommends that the Entity implement adequare controls for the bank reconciliation process to ensure the reconciliation is occurring on a timely basis and is reviewed by someone other than the...

Deficiency in Cash Management Controls over Compliance - Significant Deficiency Recommendation: The auditor recommends that the Entity implement adequare controls for the bank reconciliation process to ensure the reconciliation is occurring on a timely basis and is reviewed by someone other than the preparer. Action Taken: EPHCC will have an addendum to the bank reconciliation process to ensure that after it is reviewed by someone other than the preparer, the reconciliation is signed to have a documentation trail for verificationpurposes. Responsible Official: Chief Financial Officer, Lizabeth Romero. Timeline for Implentation: Effective by April 2023.

View Audit 1055

Finding 355 (2021-004)

Significant Deficiency 2021

Wicomico County Housing Authority

MD

HUD Housing Programs Special Tests & Provisions Significant Deficiency

Views of Responsible Officials: The Authority has addressed this finding. The Bank has signed the depository agreements effective March 30, 2022.

View Audit 724

Finding 352 (2021-001)

Significant Deficiency 2021

Wicomico County Housing Authority

MD

Allowable Costs / Cost Principles HUD Housing Programs Significant Deficiency

Views of Responsible Officials: The Authority will review and enhance our policies and procedures over payroll processing, to ensure all timesheets have visual approval by supervisor, and employee files obtain copy of the annual board approved salary worksheet.

View Audit 724

Finding 1165504 (2020-001)

Material Weakness 2020

New Directions, Inc.

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.

View Audit 376223

Finding 1161838 (2020-006)

Material Weakness 2020

City of Mount Vernon

NY

Reporting Significant Deficiency

Management Response: This issue is tied to the multi-year delay in completing audits. The City has implemented stricter internal controls to ensure timely submission of the Data Collection Form and reporting package to the Federal Audit Clearinghouse immediately after each year’s audit is finalized....

Management Response: This issue is tied to the multi-year delay in completing audits. The City has implemented stricter internal controls to ensure timely submission of the Data Collection Form and reporting package to the Federal Audit Clearinghouse immediately after each year’s audit is finalized. These improvements will be evident in the 2023 audit cycle.

View Audit 371774

Finding 1161636 (2020-003)

Material Weakness 2020

L.b.s.h. Housing Corporation

NY

Significant Deficiency

See 2020-001.

View Audit 371524

Finding 569332 (2020-010)

Significant Deficiency 2020

St. Croix Chippewa Housing Authority

CA

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

2020-010 Inventory Significant Deficiency Recommendation: Management should use a quarterly physical count as a starting point, track purchases and uses of inventory throughout the quarter in order to calculate the inventory balance that should be on hand at the end of the quarter. Management should...

2020-010 Inventory Significant Deficiency Recommendation: Management should use a quarterly physical count as a starting point, track purchases and uses of inventory throughout the quarter in order to calculate the inventory balance that should be on hand at the end of the quarter. Management should then compare the calculated ending inventory against the related quarterly physical count and determine if there are any large variances that require further investigation. Written policies and procedures should be adopted accordingly. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 360843

Finding 569323 (2020-001)

Significant Deficiency 2020

St. Croix Chippewa Housing Authority

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Significant Deficiency

2020-001 Segregation of Duties – Loan Program Significant Deficiency Recommendation: The Housing Authority’s fiscal policies should be revised to ensure that preventive controls are in place over check disbursements for loan disbursements, such that checks must be signed with live signatures at leas...

2020-001 Segregation of Duties – Loan Program Significant Deficiency Recommendation: The Housing Authority’s fiscal policies should be revised to ensure that preventive controls are in place over check disbursements for loan disbursements, such that checks must be signed with live signatures at least the signature of one Tribal Council member. Further, individuals who benefit from the loan program should not have complete discretion over recording and processing of advances and repayment. We recommend a complete list of outstanding balances be presented to the Tribal Council, or its designee, for continued monitoring. Action Taken: The SCCHA discontinued the Loan Program as of November 2019. A complete list of balances owed has been submitted to the Tribal Council with the outstanding balances of those whom had signatory authority forwarded to the St. Croix Tribal Court for further repayment actions.

View Audit 360843

Finding 505141 (2020-004)

Significant Deficiency 2020

Development Bank of American Samoa

AS

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

Segregation of Duties Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: HOME Investment Partnerships Program Assistance Listing Number: 14.239 Name of Contact Persons: Faaeteete Sio and Ruth Matagi Corrective Action: Due to the COVID-19 pandemic, DBAS had to wor...

Segregation of Duties Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: HOME Investment Partnerships Program Assistance Listing Number: 14.239 Name of Contact Persons: Faaeteete Sio and Ruth Matagi Corrective Action: Due to the COVID-19 pandemic, DBAS had to work a staggered schedule for the staff to include vulnerable employees who are 60+ year olds (management) to work remotely from home. Two of the signors fall under this category. DBAS will ensure and enforce proper segregation of duties will be followed. Loan approval and check signer controls will be reviewed and revised to ensure segregation of duties concerns are mitigated moving forward. Proposed Completion Date: Ongoing

View Audit 327808

Finding 505140 (2020-003)

Significant Deficiency 2020

Development Bank of American Samoa

AS

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking

General Disbursements Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: HOME Investment Partnerships Program Assistance Listing Number: 14.239 Name of Contact Persons: Faaeteete Sio and Venetta Holi Corrective Action: DBAS will establish a set procedure to follo...

General Disbursements Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: HOME Investment Partnerships Program Assistance Listing Number: 14.239 Name of Contact Persons: Faaeteete Sio and Venetta Holi Corrective Action: DBAS will establish a set procedure to follow both Finance Department and Loans Department and ensure approval procedures are followed through before loan disbursements are issued. Proposed Completion Date: Ongoing

View Audit 327808

Finding 502152 (2020-004)

Significant Deficiency 2020

American Association of Physics Teachers, Inc.

MD

Matching / Level of Effort / Earmarking Significant Deficiency § 200.303

Finding 2020-004: Payroll Federal Program: Research and Development Cluster (Education and Human Resources) Assistance Listing Number and Title: 47.076 STEM Education Name of Federal Agency, Pass Through Entity (when applicable), Award Number and Year: National Science Foundation: 1500529 (9/1/2015 ...

Finding 2020-004: Payroll Federal Program: Research and Development Cluster (Education and Human Resources) Assistance Listing Number and Title: 47.076 STEM Education Name of Federal Agency, Pass Through Entity (when applicable), Award Number and Year: National Science Foundation: 1500529 (9/1/2015 – 8/31/2022), 1624185 (9/16/2016 – 8/31/2022), 1726113 (8/1/2017 – 9/30/2023)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 324369

Finding 502144 (2020-001)

Significant Deficiency 2020

American Association of Physics Teachers, Inc.

MD

Reporting Significant Deficiency

Finding 2020-001: State Audit Law and Single Audit Reporting Federal Program: Research and Development Cluster (Education and Human Resources) Assistance Listing Number and Title: 47.076 STEM Education Name of Federal Agency, Pass Through Entity (when applicable), Award Number and Year: National Sci...

Finding 2020-001: State Audit Law and Single Audit Reporting Federal Program: Research and Development Cluster (Education and Human Resources) Assistance Listing Number and Title: 47.076 STEM Education Name of Federal Agency, Pass Through Entity (when applicable), Award Number and Year: National Science Foundation: 1431638 (9/1/2014 – 8/31/2022), 1524963 (11/1/2015 – 9/30/2021), 1500529 (9/1/2015 – 8/31/2022), 1624185 (9/16/2016 – 8/31/2022), 1640791 (9/15/2016 – 8/31/2022), 1720869 (5/15/2017 – 4/30/2022), 1726113 (8/1/2017 – 9/30/2023), 1645003 (3/15/2017 – 2/29/2020), 1821462 (7/1/2018 – 6/30/2024), 1812860 (9/1/2018 – 8/31/2020), 1940925 (1/15/2020 – 12/31/2023), 1907950 (7/1/2019 – 6/30/2024), 2015205 (4/1/2020 – 3/31/2022), 2021059 (10/1/2020 – 9/30/2024) Federal Program: Research and Development Cluster (Mathematical and Physical Sciences) Assistance Listing Number and Title: 47.049 Mathematical and Physical Sciences Name of Federal Agency, Pass Through Entity, Award Number and Year: National Science Foundation: 1821372 (10/1/2018 – 9/30/2024 pass through entity American Physical Society), 1834530 (9/1/2018 – 8/31/2025 pass through entity American Physical Society), 1938815 (8/1/2020 – 7/31/2024) Federal Program: Research and Development Cluster (Science) Assistance Listing Number and Title: 43.001 Science Name of Federal Agency, Pass Through Entity: National Aeronautics and Space Administration: NNX16AR36A (8/24/2016 – 8/23/2021 pass through entity Temple University of the Commonwealth System of Higher Education) Condition: AAPT did not timely file the audit with the annual financial report with the State of New York. AAPT did not timely file the single audit with the Federal Clearing House. Views of Responsible Officials and Planned Corrective Actions: AAPT has institute new policies and deadlines for staff to submit the required documentation in order for the accounting department to close the monthly books on a more timely and accurate financial statements. The polices include new staff repercussions for not following the new policies up to termination of employment. Anticipated Completion Date: October 15, 2024 Responsible Official: Michael Brosnan, CFO

View Audit 324369

Finding 501742 (2020-012)

Significant Deficiency 2020

Assiniboine and Sioux Rural Water Supply System

MT

Reporting Significant Deficiency

U.S. Department of Interior Fort Peck Reservation Rural Water System – CFDA No. 15.516 2020-012 Reporting Recommendation: CLA recommend more thorough accounting and review over financial reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Cond...

U.S. Department of Interior Fort Peck Reservation Rural Water System – CFDA No. 15.516 2020-012 Reporting Recommendation: CLA recommend more thorough accounting and review over financial reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Condition: During our audit testing, we noted that 1 of the quarterly reports SF-425 reports tested were inaccurate. Action taken in response to finding: In FY 2019, accounting services were provided by a company contracted for financial functions. In FY 2020 new positions were created and staff hired to perform all financial accounting in-house. Significant work has been done to provide accurate reports. Although not required, a spreadsheet was created to track cumulative revenue and expenditures with checks and balances to document the calculation of report amounts for each quarterly report. The SF-425 financial report is submitted the spreadsheet, financial records and reports from the accounting software such as the income statement, trial balance, cash report and monthly reconciliation reports. Strengthened internal controls include proper monthly reconciliation process that are reviewed and approved by the general manager, quarterly payroll liability review and adjustments, monthly review and approval of Finance reports by the Board of Directors, monthly and end-of-year adjustments by the Finance Officer and review for accuracy and approval by the General Manager will ensure accurate and timely reports. The knowledge and improved understanding of the new accounting software by the current finance staff and General Manager ensures proper accrual accounting and records are maintained. Name(s) of the contact person(s) responsible for corrective action: Ashleigh Weeks, General Manager, and Jodi Miller, Finance Officer Planned completion date for corrective action plan: Complete

View Audit 323813

Finding 501738 (2020-008)

Significant Deficiency 2020

Assiniboine and Sioux Rural Water Supply System

MT

Questioned Costs Procurement, Suspension & Debarment Significant Deficiency § 200.303

U.S. Department of Interior Fort Peck Reservation Rural Water System – CFDA No. 15.516 2020-008 Allowable Costs/Costs Principles – Nonpayroll Expenses Recommendation: CLA recommend that ASRWSS policies and procedures be followed consistently. We also recommend that supporting documentation be maint...

U.S. Department of Interior Fort Peck Reservation Rural Water System – CFDA No. 15.516 2020-008 Allowable Costs/Costs Principles – Nonpayroll Expenses Recommendation: CLA recommend that ASRWSS policies and procedures be followed consistently. We also recommend that supporting documentation be maintained and properly documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management agrees with this recommendation. Condition: During our testing of expenditures, it was noted that of the 60 samples tested, 1 purchase order was created after the invoice. Action taken in response to finding: Corrective action began in May 2019 with implementation of vouchers to document authorization of purchases by the signature or initial of the general manager. Supporting documentation for all purchases is now properly recorded and filed with each expense. Currently, purchase request forms are used rather than vouchers, but they serve the same purpose to document account coding and approval to initiate requisitions. Requisitions are entered by administrative staff, either the Administrative Officer or Secretary. Management reviews and will correct any errors in account coding before approval of requisitions in the accounting software. After requisitions are approved, they are made into purchase orders that encumbrance the accounts. Name(s) of the contact person(s) responsible for corrective action: Ashleigh Weeks, General Manager, and Jodi Miller, Finance Officer Planned completion date for corrective action plan: Complete

View Audit 323813 Questioned Costs: $1

Finding 501732 (2020-002)

Significant Deficiency 2020

Assiniboine and Sioux Rural Water Supply System

MT

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.303

U.S. Department of the Interior Bureau of Indian Affairs Facilities Operations and Maintenance – CFDA No. 15.048 2020-002 Allowable Costs/Costs Principles – Nonpayroll Expenses Recommendation: CLA recommend that ASRWSS policies and procedures be followed consistently. We also recommend that support...

U.S. Department of the Interior Bureau of Indian Affairs Facilities Operations and Maintenance – CFDA No. 15.048 2020-002 Allowable Costs/Costs Principles – Nonpayroll Expenses Recommendation: CLA recommend that ASRWSS policies and procedures be followed consistently. We also recommend that supporting documentation be maintained and properly documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management agrees with this recommendation. Condition: During our testing of expenditures, it was noted that of the 60 samples tested, 2 pay applications or invoices were not adequately supported or authorized. Action taken in response to finding: Corrective action began in May 2019 with implementation of vouchers to document authorization of purchases with the signature or initial of the general manager. Supporting documentation for all purchases are recorded and filed with each expense. New procedures were implemented during the last quarter of Fiscal Year 2020. Vouchers were replaced with purchase request forms. The purchase request forms serve the same objective as vouchers to document account coding and approval of purchase. The signed purchase request form then initiates the process to enter requisitions. Requisitions are entered by administrative staff, either the Administrative Officer or Secretary. Management reviews and will correct any errors in account coding before approval of requisitions in the accounting software. After requisitions are approved, they are made into purchase orders that encumbrance the accounts. Prior to payment, the Financial Officer reviews documentation of expenses for the approvals, allowable costs, correct coding, approved budgets. The Financial Officer then provides the General Manager with a Claims Report for final review and approval before posting expenses and making payments. The approval of the Claims Report is documented by the signature of the general manger on the report. This process provides internal controls that ensure pay applications and invoices will provide documentation of support and authorization. Name(s) of the contact person(s) responsible for corrective action: Ashleigh Weeks, General Manager; Jodi Miller, Finance Officer; and Tanya Bear, Administrative Officer Planned completion date for corrective action plan: Completed

View Audit 323813 Questioned Costs: $1

Finding 501710 (2020-003)

Significant Deficiency 2020

Housing Authority of the City of Tulsa

OK

HUD Housing Programs Eligibility Significant Deficiency

2020-003 Public and Indian Housing Recommendation: We recommend that management review their procedures for retrieving tenant information and establish a method that ensures compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken i...

2020-003 Public and Indian Housing Recommendation: We recommend that management review their procedures for retrieving tenant information and establish a method that ensures compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Affordable Housing Department has implemented a Management Analyst position to perform on-site file audits and to monitor compliance and accuracy in reporting to HUD. The Affordable Housing Department has discontinued the use of the general release form, however, the Management Analyst will be reviewing files for any missing signatures on the other various forms required. Name(s) of the contact person(s) responsible for corrective action: Jason Epperson, Assistant Vice President Planned completion date for corrective action plan: December 31, 2024

View Audit 323777

Finding 501708 (2020-002)

Significant Deficiency 2020

Housing Authority of the City of Tulsa

OK

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

2020-002 Housig Choice Voucher Program Recommendation: We recommend that the Authority should review their HQS inspection policies to ensure that all inspections are performed timely, and that all necessary documentation is maintained for each inspection. Explanation of disagreement with audit find...

2020-002 Housig Choice Voucher Program Recommendation: We recommend that the Authority should review their HQS inspection policies to ensure that all inspections are performed timely, and that all necessary documentation is maintained for each inspection. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Housing Inspections will incorporate additional reporting and monitoring into both their weekly and monthly routines. Additionally, they will collaborate with the Compliance Auditors monthly to review data and confirm all inspections are scheduled timely. Name(s) of the contact person(s) responsible for corrective action: Teresa Wolfe, Assistant Vice President Planned completion date for corrective action plan: December 31, 2024

View Audit 323777

Finding 496920 (2020-002)

Significant Deficiency 2020

Country Doctor Community Health Centers

WA

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

Views of responsible officials and planned corrective action: There is no disagreement with the audit finding from responsible officials. The passage of time and turnover in the department contributed to the oversight. Since 2020, we’ve separated Payroll functions from HR, to ensure there is a check...

Views of responsible officials and planned corrective action: There is no disagreement with the audit finding from responsible officials. The passage of time and turnover in the department contributed to the oversight. Since 2020, we’ve separated Payroll functions from HR, to ensure there is a check and balance, and that all personnel changes, to include changes to wage rate changes are reviewed by HR, submitted for Leadership/Executive approval, documentation is scanned, and kept with adjustments/updates to any wages. Further, we have since transitioned all personnel files to our HRIS system, which includes payroll, to ensure there is an audit trail of every action taken.

View Audit 319659

Finding 485612 (2020-001)

Significant Deficiency 2020

Great Redwood Trail Agency

CA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

Finding Numbers: 2021-1 & 2020-1 Lack of reporting under Financial and Project Reports requirement 4.6 (Significant Deficiency and Material Noncompliance) Planned Corrective Action: Pursuant to SB1029 (McGuire) as amended in August 2018, management of North Coast Railroad cooperated with the Califor...

Finding Numbers: 2021-1 & 2020-1 Lack of reporting under Financial and Project Reports requirement 4.6 (Significant Deficiency and Material Noncompliance) Planned Corrective Action: Pursuant to SB1029 (McGuire) as amended in August 2018, management of North Coast Railroad cooperated with the California State Transportation Agency (CalSTA) to discharge the debt obligation to the Federal Railroad Administration Railroad Rehabilitation and Improvement Program. Funds were included in the 2018-2019 State budget to discharge this debt and in July 2021, $2.4 million was paid to pay the RRIF loan in full. Person responsible for Corrective Action Plan: Great Redwood Trail Agency and Elaine Hogan, General Manager. Anticipated Date of Completion: This corrective action was completed in July 2021 with the repayment of the RRIF loan in full.

View Audit 318386

Finding 480785 (2020-004)

Significant Deficiency 2020

American Association of Physics Teachers, Inc.

MD

Matching / Level of Effort / Earmarking Significant Deficiency § 200.303

Finding 2020-004: 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 2020-004: 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 316959

Finding 406037 (2020-004)

Significant Deficiency 2020

Hospital Damas INC

PR

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.512

Finding No. 2020-004 – Reporting - Late filing of data collection form and reporting package Federal Program Condition For year ended December 31, 2020, the Hospital did not file on time the reporting package required by CFR § 200.512. Hospital’s Response The Hospital agrees with this finding. Corre...

Finding No. 2020-004 – Reporting - Late filing of data collection form and reporting package Federal Program Condition For year ended December 31, 2020, the Hospital did not file on time the reporting package required by CFR § 200.512. Hospital’s Response The Hospital agrees with this finding. 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 311581

Finding 406036 (2020-003)

Significant Deficiency 2020

Hospital Damas INC

PR

Subrecipient Monitoring Reporting Significant Deficiency

Finding No. 2020-003 – Recordkeeping Condition The federal grant expenditures recorded in the financial statements and reported monthly to the pass-through entity were not duly reconciled to source and other supporting documents, which resulted in performing such reconciliation during the single aud...

Finding No. 2020-003 – Recordkeeping Condition The federal grant expenditures recorded in the financial statements and reported monthly to the pass-through entity were not duly reconciled to source and other supporting documents, which resulted in performing such reconciliation during the single audit and also in changes to the major program expenditures during the completion of the single audit, to properly provide such supporting documents duly reconciled to the pass-through entity as part of the closeout process. As a result, the monthly reports of Use of Funds required by the grant agreement were amended and re-submitted to the pass-through entity on March 2, 2022. Hospital’s Response The Hospital agrees with this finding. Corrective Action Plan During the course of the audit, more information and educational material about the compliance with the major program’s requirements was made available and the Hospital was able to correct the amount of the expenditures recorded on the major program and on March 2, 2022 the Hospital submitted to the pass-through entity the monthly expenses report with the required changes for allowable expenditures, after reconciling all detailed supporting documents to the allowable expenditures. Also, commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be the designated officer in charge of submitting the report by its due date and Mr. Julio Colón, Chief Financial Officer, will be the 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 Mr. Julio Colón, Chief Financial Officer Anticipated Completion Date Completed on March 2, 2022.

View Audit 311581

Finding 406035 (2020-002)

Significant Deficiency 2020

Hospital Damas INC

PR

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

Finding No. 2020-002 - Reporting Condition Our audit procedures revealed instances where reports required to be filed under the grant agreement were either not filed at all or filed after the due date. The Hospital did not provide evidence of the June and July 2020 submission. Also, the expenses rep...

Finding No. 2020-002 - Reporting Condition Our audit procedures revealed instances where reports required to be filed under the grant agreement were either not filed at all or filed after the due date. The Hospital did not provide evidence of the June and July 2020 submission. Also, the expenses reports related to November and December 2020 were submitted on December 30, 2020 (15 days later) and February 5, 2021 (21 days later). Hospital’s Response The Hospital agrees with this finding. Corrective Action Plan On March 2, 2022, all pending reports were submitted to AAFAF. Also, commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be the designated officer in charge of submitting the report by its due date and Mr. Julio Colón, Chief Financial Officer, will be the 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 March 2, 2022

View Audit 311581

Finding 406034 (2020-001)

Significant Deficiency 2020

Hospital Damas INC

PR

Eligibility Subrecipient Monitoring Significant Deficiency

Finding No. 2020-001 - Activities Allowed or Unallowed - Hazard Pay Eligibility Condition During our test, we identified certain ineligible employees that were included as part of the Hazard Pay program incentive. Hospital’s Response The Hospital agrees with this finding. Corrective Action Plan On M...

Finding No. 2020-001 - Activities Allowed or Unallowed - Hazard Pay Eligibility Condition During our test, we identified certain ineligible employees that were included as part of the Hazard Pay program incentive. Hospital’s Response The Hospital agrees with this finding. 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 March 2, 2022

View Audit 311581

Corrective Action Plans

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