Corrective Action Plans

Finding 524399 (2021-006)

Material Weakness 2021

WA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.303

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limit...

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limited to essential staff and activities. Due to the limited staff reports were not always documented or certified. Further, prior to the emergency order key positions in the finance and administration departments were vacant. Currently all finance and administrative positions are staffed. Training will be provided to staff responsible for Federal reporting. Implementation date: June 30, 2025

View Audit 343636

Finding 524396 (2021-004)

Material Weakness 2021

Quileute Tribal School

WA

Equipment & Real Property Management Subrecipient Monitoring Material Weakness § 200.303 § 200.313

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limit...

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limited to essential activities. The taking of physical inventories was not considered essential. Training relating to the Federal physical inventory requirements will be provided. A physical inventory will be completed in the 2024-2025 fiscal year. Implementation date: June 30, 2025

View Audit 343636

Finding 524394 (2021-003)

Material Weakness 2021

Quileute Tribal School

WA

Allowable Costs / Cost Principles Subrecipient Monitoring Material Weakness § 200.303

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limit...

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limited to essential staff and activities. Due to the limited staff not all documentation and certifications were obtained. Further, prior to the emergency order key positions in the finance and administration departments were vacant. Currently all finance and administration departments are staffed. The School has implemented electronic procurement and timekeeping systems. These systems provide clarity in the approval process of procurement and timekeeping transactions. The transition from paper to digital formats provides enhanced internal controls to ensure that transactions are documented and approved. Training relating to the Federal and School procurement and timekeeping requirements will be provided. Implementation date: June 30, 2025

View Audit 343636

Finding 522453 (2021-003)

Significant Deficiency 2021

Monticello Housing Authority

NY

HUD Housing Programs Eligibility Significant Deficiency

The Board of Commissioners has recently hired an Executive Director (ED) who will actively oversee all financial aspects of the agency. Additionally, it is the intent of the ED to hire a CPA as fee accountant, as soon as financially feasible, to keep finances current and accurate monthly. With the a...

The Board of Commissioners has recently hired an Executive Director (ED) who will actively oversee all financial aspects of the agency. Additionally, it is the intent of the ED to hire a CPA as fee accountant, as soon as financially feasible, to keep finances current and accurate monthly. With the added assistance of the existing bookkeeper, all financial systems should be operable and accurate going forward. Planned Implementation Date of Corrective Action: December 31, 2024 Person Responsible for Corrective Action: Pat Croslan, Executive Director

View Audit 341730

Finding 519156 (2021-003)

Significant Deficiency 2021

22nd District Agricultural Association

CA

Questioned Costs Reporting Significant Deficiency

Reference Number: 2021-003 Name of Contact Person: Carlene Moore, CEO Corrective Action: The 22nd DAA has procured new accounting (Activity HD) and human resources (BambooHR) software for proper electronic data retention and safekeeping. Electronic records are now backed up daily by the IT staff....

Reference Number: 2021-003 Name of Contact Person: Carlene Moore, CEO Corrective Action: The 22nd DAA has procured new accounting (Activity HD) and human resources (BambooHR) software for proper electronic data retention and safekeeping. Electronic records are now backed up daily by the IT staff. Proposed Completion Date: December 31, 2022

View Audit 337708 Questioned Costs: $1

Finding 507806 (2021-005)

Significant Deficiency 2021

Tazewell County, Illinois

IL

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles

The County engaged an outside consultant to assist with compliance and reporting of the CSLFRF grant. Moving forward, management will ensure that a County employee, if working with a consultant or otherwise, be responsible for verifying compliance with all aspects of all federal grants.

View Audit 328309 Questioned Costs: $1

Finding 503666 (2021-001)

Significant Deficiency 2021

Public Defender Association

WA

Allowable Costs / Cost Principles Subrecipient Monitoring Significant Deficiency

Significant deficiency in internal control over compliance for allowable costs related to adequate documentation. Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: • This is primarily related to the absence of receipts for expen...

Significant deficiency in internal control over compliance for allowable costs related to adequate documentation. Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: • This is primarily related to the absence of receipts for expense items under $75. There are three items contributing to this finding: 1) Receipts that were not able to be located related to employees who had left the organization and did not provide receipts prior to departure - $96.12 of sample list. 2) Receipts that were simply not able to be found - $18.86 from sample list. 3) In general, PDA relies on our credit card platform for the repository of credit card receipts. The forum used during 2021 was “Elan”. Elan only retains receipts up to a maximum of 12 months from the date of spending. Due to the timing of the audit, in most cases 7-12 months had passed when the receipts were requested, and we were not able to extract from that system and therefore relied on employees’ records (see #1-2 above). • PDA’s policy is to retain and upload receipts for all spending, no minimum. • In May of 2022, PDA moved to a new credit card platform (“Center”), which retains receipts into perpetuity. Anticipated completion date: Quarter 1, 2024 Name(s) of the contact person(s) responsible for corrective action: Co-Executive Directors, Finance team

View Audit 325873

Finding 503647 (2021-001)

Significant Deficiency 2021

Hughes Village Council

AK

Subrecipient Monitoring Reporting Significant Deficiency

Finding 2021-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Jennifer Babcock Corrective Action Plan: Hughes Village Council is now compliant with all past due audits. In order to ensure audits are completed on time, HVC wi...

Finding 2021-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Jennifer Babcock Corrective Action Plan: Hughes Village Council is now compliant with all past due audits. In order to ensure audits are completed on time, HVC will schedule the audit at least 3 months prior to the March deadline. Proposed Completion Date: 10/5/2024

View Audit 325852

Finding 502216 (2021-004)

Significant Deficiency 2021

American Association of Physics Teachers, Inc.

MD

Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment Significant Deficiency § 200.303

Finding 2021-004: 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: 1624185 (9/16/2016...

Finding 2021-004: 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: 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. Of the 31 individual payroll payments tested to 7 separate individuals, totaling $63,848, we identified 16 total payments to 4 separate individuals, totaling $14,907 charged to federal grants, where the timesheet was approved by the CFO, who we do not consider to be knowledgeable of the employee’s activities during a given pay period. One of these four individuals was a full-time employee and the other three were part-time employees. Views of Responsible Officials and Planned Corrective Actions: AAPT has made changes to correctly 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 324370

Finding 502204 (2021-001)

Significant Deficiency 2021

American Association of Physics Teachers, Inc.

MD

Reporting Significant Deficiency

Finding 2021-001: 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 2021-001: 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), 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), 80NSSC21K1560 (6/28/2021 – 6/27/2022 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: 10/15/2024 Responsible Official: Michael Brosnan, CFO

View Audit 324370

Finding 485614 (2021-001)

Significant Deficiency 2021

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 318387

Finding 480952 (2021-004)

Significant Deficiency 2021

Luna County

NM

Questioned Costs Subrecipient Monitoring Significant Deficiency

2021-004 – High Intensity Drug Trafficking Areas (HIDTA) Overtime Violation (Signficant Deficiency) (Repeated finding FS 2020-005) - During the FY 2020 audit process it was discovered that Luna County had one employees which did not adhere to the HIDTA Program Policy on limitations of overtime. Luna...

2021-004 – High Intensity Drug Trafficking Areas (HIDTA) Overtime Violation (Signficant Deficiency) (Repeated finding FS 2020-005) - During the FY 2020 audit process it was discovered that Luna County had one employees which did not adhere to the HIDTA Program Policy on limitations of overtime. Luna County management along with the Program Commander and Luna County Sheriff will monitor OT more closely to ensure that no employee exceeds the maximum allowable earnings. Luna County will be monitoring all Federal programs to ensure compliance with contract/award guidelines on combined OT limits. In addition, the one employee this affected is no longer employed, however Luna County will continue due diligence to ensure that OT limits are strictly adhered to.

View Audit 317065 Questioned Costs: $1

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

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