Corrective Action Plans

Finding 401561 (2022-006)

Significant Deficiency 2022

Martin University

IN

Special Tests & Provisions Student Financial Aid Subrecipient Monitoring § 200.303

2022-006 Special Tests and Provisions – Return of Title IV Funding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the institution maintain proper documentation in accordance with federal grantor requirements and ensure that the docu...

2022-006 Special Tests and Provisions – Return of Title IV Funding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the institution maintain proper documentation in accordance with federal grantor requirements and ensure that the documents are readily available for review upon request, including monitoring of students with triggering events that require a return to Title IV calculation to be completed, reviewed, and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented policy and procedures that require a review of all official and unofficial withdrawals to have R2T4 calculations on a real time basis to ensure compliance with the Department of Education guidelines on a consistent and regular basis. Internal audits of the process will also be implemented for continuous improvement. Names of the contact persons responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration, and Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2024

View Audit 309593

Finding 401536 (2022-001)

Material Weakness 2022

K'ima:w Medical Center

CA

Eligibility Subrecipient Monitoring Material Weakness

Management’s Response – To ensure that K'ima:w Medical Center has all supporting documentation to confirm Native American eligibility, we will update our PRC policies to reflect a more standardized and robust procedure for collecting and storing patient eligibility documentation, including periodic ...

Management’s Response – To ensure that K'ima:w Medical Center has all supporting documentation to confirm Native American eligibility, we will update our PRC policies to reflect a more standardized and robust procedure for collecting and storing patient eligibility documentation, including periodic review of our patient records in compliance with IHS standards and requirements. Additionally, we have some understanding in our Medical Records Department, which we plan to fill by next fiscal year.

View Audit 309572

Finding 401429 (2022-006)

Significant Deficiency 2022

County of Columbia, Pennsylvania

PA

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

Federal Program: Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Condition/Context: The County’...

Federal Program: Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Condition/Context: The County’s required report for the quarter ended December 31, 2022 was due to be filed by January 31, 2023. The County filed its report on March 23, 2023, 48 days after the required due date. Recommendation: We recommend that the County revisit its policies and procedures related to reporting to ensure future reports are completed and submitted within the appropriate time period. Planned Corrective Actions: The County is current on all reporting. Name(s) of Contact Person(s) Responsible for Corrective Action: David Witchey, Chief Clerk

View Audit 309542

Finding 401426 (2022-005)

Material Weakness 2022

County of Columbia, Pennsylvania

PA

Subrecipient Monitoring

Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Ag...

Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Agency, Pass-Through Entity Identifying Numbers: C000071546, C000073444, C000075689, C000075284, C000080637, and PEMA-2022-007 Assistance Listing #21.023, COVID-19 Emergency Rental Assistance Program, U.S. Department of Treasury, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available Condition/Context: The County does not have a formal risk assessment or oversight program in place to monitor its subrecipients as required under the Uniform Guidance, including ensuring that financial information reconciles between the underlying expenditure reports and the subrecipient/County audit reports. Recommendation: We recommend that the County revisit its policies and procedures related to subrecipient monitoring and ensure that there are formal subaward agreements with all subrecipients, prepare a formal, initial, risk assessment of each potential subrecipient and document its monitoring activities of each subrecipient. Planned Corrective Action: Management understands that the organization receiving these funds receives a single audit also. We will continue to work with this agency ensuring that policies and procedures are understood and will follow the requirements. Name(s) of Contact Person(s) Responsible for Corrective Action: David Witchey, Chief Clerk

View Audit 309542

Finding 401421 (2022-004)

None 2022

County of Columbia, Pennsylvania

PA

Student Financial Aid Subrecipient Monitoring Reporting

Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Ag...

Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Agency, Pass-Through Entity Identifying Numbers: C000071546, C000073444, C000075689, C000075284, C000080637, and PEMA-2022-007 Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Assistance Listing #21.023, COVID-19 Emergency Rental Assistance Program, U.S. Department of Treasury, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available Assistance Listing #93.658, Foster Care - Title IV-E, U.S. Department of Treasury, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available Condition/Context: The County’s December 31, 2022 Single Audit was not completed and submitted within the required time period. Recommendation: We recommend that as the County gets up and running on the new accounting system, the audit be prioritized in future periods. Planned Corrective Action: Management understands that the organization receiving these funds receives a single audit also. We will continue to work with this agency ensuring that policies and procedures are understood and will follow the requirements. Name(s) of Contact Person(s) Responsible for Corrective Action: David Witchey, Chief Clerk Anticipated Completion Date: For the 2023 audit.

View Audit 309542

Finding 401416 (2022-003)

None 2022

County of Columbia, Pennsylvania

PA

Subrecipient Monitoring Cash Management

Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Ag...

Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Agency, Pass-Through Entity Identifying Numbers: C000071546, C000073444, C000075689, C000075284, C000080637, and PEMA-2022-007 Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Assistance Listing #21.023, COVID-19 Emergency Rental Assistance Program, U.S. Department of Treasury, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available Assistance Listing #93.658, Foster Care - Title IV-E, U.S. Department of Treasury, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available Condition/Context: While the County has informal policies and procedures surrounding the administration of its federal programs, these policies and procedures have not been formally documented to ensure compliance with the areas of allowability of costs, cash management or subrecipient monitoring as required under the Uniform Guidance. Recommendation: We recommend that County management prepare the required written policies/procedures related to allowability of costs, cash management and subrecipient monitoring outlined with the Uniform Guidance. Corrective Action Planned: The County is working to write and adopt procedures that are needed to meet compliance. Name(s) of Contact Person(s) Responsible for Corrective Action: David Witchey, Chief Clerk Anticipated Completion Date: For the 2023 audit

View Audit 309542

Finding 401269 (2022-003)

Significant Deficiency 2022

Alternatives, Inc.

IL

Cash Management Subrecipient Monitoring Reporting

Finding 2022-003 Adherence and Application of Financial Policies and Procedures for Vouchering Federal Agency: U.S. Department of Health and Human Services Pass-Through Entity: Illinois Department of Human Services Program Name: ...

Finding 2022-003 Adherence and Application of Financial Policies and Procedures for Vouchering Federal Agency: U.S. Department of Health and Human Services Pass-Through Entity: Illinois Department of Human Services Program Name: Social Services Block Grant Assistance Listing #: 93.667 Questioned Costs: None Corrective Action: We agree with the auditor’s comments and actions stated in the recommendation. The Organization is rewriting its accounting policies and procedures to ensure adherence to the proper procedures for vouchering, which will be completed in fiscal year 2024. In August 2022, the building at 4730 N. Sheridan was sold. During the move some documents were misfiled or otherwise missed place. This made it difficult to find vouchers for the audit. The new accounting system allows Alternatives to save a copy of the vouchers and necessary support within the software. The electronic filing of the backup documentation will prevent misplacement of vouchers in the future. Contact Person: Sonya Cook, Finance Director Anticipated Completion Date: December 15, 2023

View Audit 309281

Finding 401184 (2022-002)

Material Weakness 2022

Walla Walla County

WA

Procurement, Suspension & Debarment Subrecipient Monitoring

Noted, the County will work with the departments responsible for administering federal funds to create procedures requiring the review of the System Of Award Management (SAM) for suspended or debarred parties in accordance with Federal Regulation. We agree with the auditor's comments and the county ...

Noted, the County will work with the departments responsible for administering federal funds to create procedures requiring the review of the System Of Award Management (SAM) for suspended or debarred parties in accordance with Federal Regulation. We agree with the auditor's comments and the county recognizes the challenges with staffing, training, onboarding, and managing unforeseen large amounts of federal funds coming into the county during COVID response. The county will be utilizing a contractor to assist in establishing policies, procedures, training, and strategic improvements to allow quick onboarding of staff in policies, procedures and regulations outlined by CRF 200 for future emergency federal funding and routine federal funding. Walla Walla County is committed to the importance of managing federal funding.

View Audit 309209

Finding 401182 (2022-001)

Material Weakness 2022

Walla Walla County

WA

Subrecipient Monitoring Eligibility

We appreciate the auditor's assessment, analysis, and recommendations. However, we disagree with the conclusion reached and the finding. The auditor, during oral conversation discussing context, indicated the quantity of program beneficiaries reviewed for eligibility did not reach the auditor's expe...

We appreciate the auditor's assessment, analysis, and recommendations. However, we disagree with the conclusion reached and the finding. The auditor, during oral conversation discussing context, indicated the quantity of program beneficiaries reviewed for eligibility did not reach the auditor's expected quantity for adequate monitoring. As a management team, we assessed risk and determined the level of appropriate monitoring to consist of: 1) financial monitoring through review of reimbursement requests, which contained eligibility information necessary for oversight; 2) execution of regularly scheduled status and reporting meetings wherein we obtained ongoing programmatic data; and 3) review of audit reports, where applicable. We note neither our award agreement nor applicable federal regulations require a specific quantity of files to be reviewed as part of subrecipient monitoring. Accordingly, we do not concur with the presence of a finding. In addition, no instances of ineligible beneficiaries were identified by the auditor such that a material weakness classification does not appear reasonable or appropriate. That being said, we will assess our procedures and add greater clarity to help better tell this story going forward. We will also consider whether testing a specific number of beneficiaries is necessary and may be conducted efficiently.

View Audit 309209

Finding 400572 (2022-003)

Material Weakness 2022

Lutheran Family Services of Nebraska, Inc. and Affiliates

NE

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

Condition: Refugee case files, specifically related to the Afghan Placement and Assistance Program, lacked certain documentation required by the Cooperative Agreements. Planned Corrective Action Management is reviewing and improving internal controls over review of refugee case file documentation. T...

Condition: Refugee case files, specifically related to the Afghan Placement and Assistance Program, lacked certain documentation required by the Cooperative Agreements. Planned Corrective Action Management is reviewing and improving internal controls over review of refugee case file documentation. The Cooperative Agreement specific to the Afghan Placement and Assistance Program directed the Organization to focus on the provision of services and to include documentation of such activities to the extent possible. Furthermore, the Organization’s funding agencies have performed numerous monitoring reviews of the case files, including reviews specific to the Afghan Placement and Assistance Program. While the results of these reviews did note similar findings, subsequent to year-end, the Organization received written documentation that all such findings have satisfactorily been resolved and that the Organization is in compliance with the terms and conditions of the Cooperative Agreement. Contact Person: Amy Carolus, Chief Financial Officer Anticipated Completion Date: December 31, 2023

View Audit 308632

Finding 400260 (2022-002)

Material Weakness 2022

Red Wind Consulting INC

CO

Subrecipient Monitoring Material Weakness Reporting

Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of reporting. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document in wri...

Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of reporting. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document in writing, the process and review it with department leaders. Additionally, staff members working in areas concerning this process will be trained to ensure process adherence.

View Audit 308375

Finding 400152 (2022-007)

Significant Deficiency 2022

Puerto Rico Ports Authority

PR

Subrecipient Monitoring Procurement, Suspension & Debarment

None. This matter, as stated above, was properly addressed.

View Audit 308290

Finding 399999 (2022-009)

Material Weakness 2022

Lincoln-King Adams-Young Academy

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

The Academy signed a Promissory Note with Washington Parks Academy on February 8, 2024, to return all the ESSER dollars transferred to the Academy plus interest back to Washington Parks Academy over the next 60 months.

View Audit 308166

Finding 399993 (2022-003)

Material Weakness 2022

Lincoln-King Adams-Young Academy

MI

Subrecipient Monitoring

The necessary review and analysis of GL accounts will be completed according to the established month end and annual close procedure check lists. Audit engagement will begin no later than August for FY 2023. Any new, as well as current staff, will receive periodic in-service centered around the MI P...

The necessary review and analysis of GL accounts will be completed according to the established month end and annual close procedure check lists. Audit engagement will begin no later than August for FY 2023. Any new, as well as current staff, will receive periodic in-service centered around the MI Public School Accounting manual to ensure thorough understanding of the expectations and processes for school fund accounting.

View Audit 308166

Finding 399992 (2022-002)

Material Weakness 2022

Lincoln-King Adams-Young Academy

MI

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting

The Finance Director will review staffing resources and make appropriate adjustments to ensure that adequate levels of staffing and quality staff are recruited and retained. New ERP software has been purchased to facilitate input, reporting, and analysis of fund accounting and accurate GL classifica...

The Finance Director will review staffing resources and make appropriate adjustments to ensure that adequate levels of staffing and quality staff are recruited and retained. New ERP software has been purchased to facilitate input, reporting, and analysis of fund accounting and accurate GL classification.

View Audit 308166

Finding 399947 (2022-004)

Material Weakness 2022

University Physician Group

MI

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

The Organization does not plan on implementing written internal control policies over compliance with monitoring and reporting program performance, financial reporting, retention and access to records as the Organization has only received federal funding through the Covid-19 Provider Relief Fund whi...

The Organization does not plan on implementing written internal control policies over compliance with monitoring and reporting program performance, financial reporting, retention and access to records as the Organization has only received federal funding through the Covid-19 Provider Relief Fund which are no longer available. This finding is not relevant at this time.

View Audit 308099

Finding 399924 (2022-003)

Significant Deficiency 2022

County of Kings, California

CA

Subrecipient Monitoring Reporting § 200.332

The County should establish policies and procedures to ensure risk assessment is documented. The County should also obtain the single audit reports for their subrecipients and issue management decision letters as part of their monitoring. Atonya Moo...

The County should establish policies and procedures to ensure risk assessment is documented. The County should also obtain the single audit reports for their subrecipients and issue management decision letters as part of their monitoring. Atonya Moore Deputy Director – Fiscal Kings County Human Services Agency 559-852-2214

View Audit 308072

Finding 399303 (2022-004)

Significant Deficiency 2022

Free Russia Foundation

DC

Cash Management Subrecipient Monitoring

2022-004 Cash Management Federal Program – All federal programs Criteria – Advances received on federal awards should be expended within 30 days of being drawn down to comply with relevant cash management requirements. Condition and Context – During the performance of our audit, we noted that th...

2022-004 Cash Management Federal Program – All federal programs Criteria – Advances received on federal awards should be expended within 30 days of being drawn down to comply with relevant cash management requirements. Condition and Context – During the performance of our audit, we noted that the Organization had a significant amount of refundable advances on federal awards and had cash on hand that exceeded the anticipated expenses over the next 30 days. As a result of a conversion to a new accounting system, the impact of COVID-19, cash advances were not routinely reconciled during the year ended December 31, 2022. Questioned Costs – None. Effect – The Organization was not in compliance with the Uniform Guidance cash management requirements. Cause – With the conversion to a new accounting system, combined with the COVID-19, new accounting staff, refundable advances were not reconciled timely. Recommendation – The refundable advances of the Organization should be reconciled on a monthly basis, which will permit more accurate draws on federal awards. Views of Responsible Officials and Planned Corrective Actions Management partially agrees with this finding as, in certain instances, the Organization must comply with the payment schedules of our grantors, which typically are on a quarterly basis. In some cases, there are strict schedules of draws in our grant agreements and no requests to draw funds are made. In situations when the Organization has the ability to draw funds, we agree not to make additional draw requests until the Organization has expended the funds already received. In 2022, due to the pandemic and the uncertainty of when programs would continue, many programs were suspended while waiting for travel restrictions to be lifted so that the Organization’s programs could be implemented. We will take the following steps: We will improve procedures to ensure that the drawdown of funds, from those grantors who require drawdowns will not exceed the Organization’s immediate use and we will develop additional procedures, as necessary, to assist in monitoring cash management. Anticipated Completion Date: December 31, 2023 Contact Person: Natalia Arno, President, 202-549-2417

View Audit 307802

Finding 399179 (2022-006)

Material Weakness 2022

Elkhart County

IN

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

FINDING 2022-006 Finding Subject: Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (SED) ‐ Reporting Summary of Finding: As the designated pass‐through entity, the County’s administrative responsibilities, as outlined in the agreement, included the subm...

FINDING 2022-006 Finding Subject: Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (SED) ‐ Reporting Summary of Finding: As the designated pass‐through entity, the County’s administrative responsibilities, as outlined in the agreement, included the submission of the annual Federal Financial Report (FFR) (SF‐425) through the eRA Commons web‐based platform. The FFR (SF‐425) detailed cumulative balances of federal funds authorized and disbursed by the subrecipient during the grant period. In order to accumulate the required information for the FFR (SF‐425) the County Health Department Manager of Administration (Manager of Administration) worked in conjunction with subrecipient personnel. Subrecipient personnel submitted monthly financial information to the Manager of Administration which was then used to compile the FFR (SF‐425). The FFR (SF‐425) was then submitted by the Manger of Administration without evidence of an oversight, review, or approval process to ensure the report was complete and accurate. Recommendation We recommended that management of the County establish a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place to ensure reports are complete and accurate prior to submission. Contact Person Responsible for Corrective Action: Concetta Sanfilippo Contact Phone Number and Email Address: 574.523.2101 csanfilippo@elkhartcounty.com Views of Responsible Officials: Option 1: “We concur with the finding.” Description of Corrective Action Plan: The monthly financial information is submitted to both the Fiscal Manager and the Grants Administrator. Working in conjunction, both the Fiscal Manager and the Grants Administrator review and approve the financial information throughout the grant year. The Fiscal Manager compiles data for the FFR (SF-425) and receives the subrecipient’s report for cross reference and uploads the documentation into the FFR in collaboration with the Grant Administrator. Both parties review all data entered and confirm via email for dated communication which is retained. Two separate signatures are required on the SF425. Anticipated Completion Date: CAP was updated and implemented for the 2023 FFR for the period ending 8.30.23.

View Audit 307736

Finding 399178 (2022-005)

Material Weakness 2022

Elkhart County

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.303

FINDING 2022-005 Finding Subject: Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (SED) – Suspension and Debarment Summary of Finding: The County stated procedures were not in place to ensure vendors were not suspended or debarred prior to entering int...

FINDING 2022-005 Finding Subject: Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (SED) – Suspension and Debarment Summary of Finding: The County stated procedures were not in place to ensure vendors were not suspended or debarred prior to entering into covered transactions. One covered transaction for funds passed through to a subrecipient was identified during the audit period. The amount passed through to the subrecipient was $914,863. The identified transaction was examined to determine if the County verified the suspension and debarment status of the subrecipient prior to payment. Upon review we determined that the County entered into a Memorandum of Understanding (MOU) with the subrecipient on June 22, 2020. However, the County had not performed procedures to ensure the subrecipient was not suspended or debarred, or otherwise excluded or disqualified from participation in federal assistance programs or activities at the time of the initial MOU or at any time during the audit period. Recommendation We recommended that management of the County establish a proper system of internal controls and develop policies and procedures to ensure contractors and subrecipients, as appropriate, are not suspended, debarred, or otherwise excluded prior to entering into any contracts or subawards. We also recommended that supporting documentation be retained in order to be presented for audit. Contact Person Responsible for Corrective Action: Concetta Sanfilippo Contact Phone Number and Email Address: 574.523.2101 csanfilippo@elkhartcounty.com Views of Responsible Officials: We concur that suspension and debarment was not run within the audit period. However, it was not done under the direction of CLA Auditing team 2021 who instructed it was not necessary, rather the most current audit report should be run which Elkhart County did do and had on file for their subrecipient Oaklawn Psychiatric. Description of Corrective Action Plan: The Elkhart County Health Department and Auditor’s Office Grants Administrator are working collaboratively to administer this grant award with strong internal controls. The Grant’s Administrator has taken the role to routinely run Suspension and Debarment verification on this subrecipient. The date it is run is recorded and a pdf is retained for records. Anticipated Completion Date: This procedure is in place as of 2023 and correction is completed.

View Audit 307736

Finding 399177 (2022-004)

Material Weakness 2022

Elkhart County

IN

Internal Control / Segregation of Duties Cash Management Material Weakness § 200.303

FINDING 2022-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: The County Health Department was required to submit data through the online portal, National Electronic Disease Surveillance System Base System, monthly beginning in October...

FINDING 2022-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: The County Health Department was required to submit data through the online portal, National Electronic Disease Surveillance System Base System, monthly beginning in October 2022. The submitted data included program specific metrics related to patient case management of certified Elevated Blood Lead Levels. A Case Manager managed all aspects of an individual patient’s care. Once a patient’s care was complete, the case was closed by the Case Manager in the online portal. Completed cases were compiled by the Clinical Manager into a data sheet, which was then submitted to the Manager of Administration. The Manager of Administration based on the compiled data sheet prepared and submitted a reimbursement request to the State without an oversight, review, or approval process to ensure the reimbursement request was complete and accurate. Recommendation: We recommended that management of the County design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place to ensure reports are complete and accurate.” Contact Person Responsible for Corrective Action: Concetta Sanfilippo Contact Phone Number and Email Address: 574.523.2101 csanfilippo@elkhartcounty.com Views of Responsible Officials: Option 2: “We disagree with part of the finding.” Explanation and Reason for Disagreement: The County already has an established process of review and evaluation. The Case Manager’s reports on work are reported to their superior, the Clinical Manager. The Clinical Manager reviews data, enters report data into the program portal as required. A spreadsheet with case start date, patient ID number, home address and payment is submitted to the Manager of Administration who acts as secondary review and completes the invoice and submits it to the State where an additional process of review is then executed before approval and federal funds are drawn. Once the invoice is submitted, the Manager of Administration makes two copies of the invoice and the spreadsheet, one copy is sent to the Clinical Manager and the other to the Auditors office. This is an excellent procedure for checking and balance. Description of Corrective Action Plan: The Elkhart County Health Department receives elevated blood lead levels from the State. The Lead Case Manager determines if criteria are met to initiate a case. They conduct a home visit and make appropriate referrals. The lead case manager enters case information into NBS. INDIANA STATE BOARD OF ACCOUNTS 38 Ongoing case management for children with elevated blood leads levels includes coordination of blood lead tests, education, and appropriate referrals. The Lead Case Manager submits a list of cases each month to the Clinical Manager that meet the criteria for submission for reimbursement. The criteria are a completed home visit, a completed nutrition assessment, a referral for developmental assessment and documentation in NBS. The Clinical Manager reviews the cases in NBS and compiles a list and submits the data sheet to the Fiscal Manager. The Fiscal Manager prepares the invoice and submits it along with documentation to the State and Timothy Conley for review and approval. The Elkhart County Health Department will continue to have collaborative compilation of data which will be reviewed by field specialists before being submitted to the Manager of Administration for invoice reimbursement. The data and records are reviewed by the Manager of Administration and the invoice total will be confirmed and documented with the Clinical Manager prior to being submitted to the State for review and approval. Confirmation emails of secondary review will be retained as documentation. The State must approve invoices with supporting documentation and is the external party requesting reimbursement with Federal funds once approved. A copy of supporting documentation is supplied to the Elkhart County Auditor’s Office to be retained on file and to be used for receipting records once reimbursement is received and deposited into its unique 8000 series fund. Anticipated Completion Date: August of 2023 (Note: Provide the projected date of completion of major tasks for the planned corrective actions.)

View Audit 307736

Finding 398984 (2022-005)

Material Weakness 2022

Coastal Harvest

WA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Corrective Action: Coastal Harvest will begin tracking all inventory on hand by source, including receipts, distributions, waste/loss, and any other adjustments, and will perform periodic reconciliations of amounts recorded in the inventory system and amounts recognized in the general ledger to ensu...

Corrective Action: Coastal Harvest will begin tracking all inventory on hand by source, including receipts, distributions, waste/loss, and any other adjustments, and will perform periodic reconciliations of amounts recorded in the inventory system and amounts recognized in the general ledger to ensure accurate USDA food commodities inventory recordkeeping compliance. Further, Coastal Harvest will include specific inventory policies and procedure in the manual discussed in the corrective action for finding 2022-001. Anticipated Completion Date: June 30, 2024

View Audit 307582 Questioned Costs: $1

Finding 398980 (2022-004)

Material Weakness 2022

Coastal Harvest

WA

Special Tests & Provisions Subrecipient Monitoring Cash Management § 200.303

Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024

View Audit 307582

Finding 398468 (2022-005)

Significant Deficiency 2022

Yuma District Hospital

CO

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring § 200.303

Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Cluster Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliations for the federal program. In ...

Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Cluster Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliations for the federal program. In addition, there was lack of review of the quarterly internal monitoring of the Hospital’s debt covenants. Responsible Individuals: Rick Korf, CFO Corrective Action Plan: For the reserve fund reconciliations, a secondary review will be completed and documented. The Hospital will also ensure that the quarterly covenant calculations are completed and presented to the board for review with the financials. Anticipated Completion Date: 05/31/2024

View Audit 307192

Finding 398254 (2022-004)

Significant Deficiency 2022

City of Dunkirk Housing Authority

NY

HUD Housing Programs Subrecipient Monitoring Significant Deficiency

2022-004 Significant Deficiency: See finding 2022-004. Federal program: Public Housing Capital Fund CFDA 14.872 Recommendation: We recommend that management of the Authority work with its newly retained fee accountant to prepare an operating budget by AMP location. Action taken: We concur with t...

2022-004 Significant Deficiency: See finding 2022-004. Federal program: Public Housing Capital Fund CFDA 14.872 Recommendation: We recommend that management of the Authority work with its newly retained fee accountant to prepare an operating budget by AMP location. Action taken: We concur with the recommendation. The Authority has had some staff turnover over the past several years. A new executive director and a new account clerk were both hired within the past several years. Management was aware that its budget was not prepare by AMP location. Management engaged the services of a fee-accountant subsequent to year-end who will assist with the budgeting process starting in the 2024-2025 fiscal year.

View Audit 306946

Corrective Action Plans

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