Corrective Action Plans

Finding 34716 (2022-001)

Significant Deficiency 2022

Coos County Family Health Services, Inc.

ME

Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties

Finding Number: 2022-001 Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Individual(s) Responsible for Corrective Action: Brenda Ladd-Front Office Manager Brandon Gilbert-Compliance Officer Corrective Ac...

Finding Number: 2022-001 Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Individual(s) Responsible for Corrective Action: Brenda Ladd-Front Office Manager Brandon Gilbert-Compliance Officer Corrective Action Planned: 1. The Front Office Manager will provide additional training to the Front Desk/Reception Staff. 2. Assign the Compliance Officer the task of performing monthly audits on 25 random sliding fee charges to verify patient eligibility and discount. The results of the monthly audits will be reported to the Chief Executive Officer, Chief Financial Officer, and the Revenue Cycle Manager. Anticipated Completion Date: 1. Retraining of Front Desk/Reception will begin immediately. 2. Monthly audits of 25 random sliding fee charges will begin immediately.

View Audit 32420

Finding 34711 (2022-002)

Material Weakness 2022

Fresno Pacific University and Subsidiaries

CA

Student Financial Aid Subrecipient Monitoring Material Weakness

Untimely Returns to Title IV (R2T4) Planned Corrective Action: We have trained and implemented processes to correctly determine period lengths and the earned and unearned percentages. We have increased the number of reports used to identify potential withdrawals. To correctly and timely process ...

Untimely Returns to Title IV (R2T4) Planned Corrective Action: We have trained and implemented processes to correctly determine period lengths and the earned and unearned percentages. We have increased the number of reports used to identify potential withdrawals. To correctly and timely process R2T4s, we outsourced the determination and calculation processes to a third-party vendor in November 2022 (this took longer than we anticipated). In March 2023, we were granted additional staffing resources and are in the process of hiring for those positions. To reduce the number of R2T4 calculations required, we also plan to switch from being an institution required to take attendance to a non-attendance taking institution for the 2023-2024 aid year. Person Responsible for Corrective Action Plan: Bryan Taylor, Associate Director of Student Financial Services Anticipated Date of Completion: May 2023

View Audit 37763

Finding 34707 (2022-006)

None 2022

City of South San Francisco

CA

Subrecipient Monitoring § 200.332 § 200.501

Finding Reference Number: SA2022-006 - Subrecipient Monitoring Assistance Listing Number: 21.027 Assistance Listing Title: COVID-19 ? Coronavirus State and Local Fiscal Recovery Funds Name of Federal Agency: Department of the Treasury Federal Award Identification Number: EES4XJFTXC28...

Finding Reference Number: SA2022-006 - Subrecipient Monitoring Assistance Listing Number: 21.027 Assistance Listing Title: COVID-19 ? Coronavirus State and Local Fiscal Recovery Funds Name of Federal Agency: Department of the Treasury Federal Award Identification Number: EES4XJFTXC28 ? Name(s) of the contact person: Karen Chang, Finance Director ? Corrective Action Plan: City will incorporate this information in our grant policy to ensure the program staff is aware of this requirement. ? Anticipated Completion Date: July 1, 2023

View Audit 36521

Finding 34704 (2022-005)

Material Weakness 2022

City of South San Francisco

CA

Questioned Costs Cash Management Subrecipient Monitoring § 200.305

Finding Reference Number: SA2022-005 - Cash Management ? Draw Down of Community Development Block Grant Funds in Advance of Expenditures Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant ? Entitlement Grant COVID-19 - Community Development Bloc...

Finding Reference Number: SA2022-005 - Cash Management ? Draw Down of Community Development Block Grant Funds in Advance of Expenditures Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant ? Entitlement Grant COVID-19 - Community Development Block Grants/ Entitlement Grants-CV Name of Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-21-MC-06-0042 COVID-19 ? B-20-MW-06-0042 CDBG Daly City Pass Through #Not Available Name of Pass-through Entity: City of Daly City ? Name(s) of the contact person: Karen Chang, Finance Director ? Corrective Action Plan: The CDBG grant seldom involves a contract that has included a retention payable. Going forward, staff will double check contracts that have retention clauses and ensure the reimbursement submission does not include an unpaid retention. Staff will also check with the grantor to see if the City needs to reimburse the interest earned on the grant funds advanced. ? Anticipated Completion Date: December 31, 2023

View Audit 36521 Questioned Costs: $1

Finding 34698 (2022-003)

Material Weakness 2022

City of South San Francisco

CA

Subrecipient Monitoring Procurement, Suspension & Debarment Eligibility

Finding Reference Number: SA2022-003 - Monitoring of CDBG Program Activities For Compliance with Program Rules and Regulations Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant ? Entitlement Grant COVID-19 - Community Development Block Grants/ ...

Finding Reference Number: SA2022-003 - Monitoring of CDBG Program Activities For Compliance with Program Rules and Regulations Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant ? Entitlement Grant COVID-19 - Community Development Block Grants/ Entitlement Grants-CV Name of Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-21-MC-06-0042 COVID-19 ? B-20-MW-06-0042 CDBG Daly City Pass Through #Not Available Name of Pass-through Entity: City of Daly City ? Name(s) of the contact person: Nell Selander, ECD Director/ Karen Chang, Finance Director ? Corrective Action Plan: It should be noted that the City does not agree with all of the findings made by HUD and is actively evaluating whether findings will be disputed or corrective action taken. For example, Finding 2023-01-B may be disputed, as the City?s CDBG Committee and City Council meet to evaluate requests for funding. These meetings are captured in audio (and in some cases video) recordings, minutes produced, and recommendations summarized in staff reports. Additionally, staff do not agree with Finding 2023-02-A, that a grant-based accounting system must be used to manage CDBG. There is currently a system in place to track and report revenue and expenditures for CDBG. Finance will bolster this system by using the project accounting module in Eden to manage future CDBG projects to increase efficiency and promote transparency. Given the extensiveness of the findings made in the HUD monitoring letter and the need to coordinate with multiple subgrantees and internal departments, the City has requested an extension to respond, which was granted by HUD to extend the response date to June 8, 2023. To address any corrective action needed as a result of HUD?s findings, ECD is in the process of updating the CDBG grant management manual, in coordination with Finance. During the past several years, both ECD and Finance have experienced staff turnover. Both departments are working closely to ensure staff are familiar with the latest CDBG program procedural manual, purchasing guidelines, and financial management policy to ensure record keeping is done properly and transparently. ? Anticipated Completion Date: July 1, 2023

View Audit 36521

Finding 34695 (2022-002)

Material Weakness 2022

City of South San Francisco

CA

Subrecipient Monitoring Reporting

Finding Reference Number: SA2022-002 - Federal Funding Accountability and Transparency Act (FFATA) Reporting Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant ? Entitlement Grant COVID-19 - Community Development Block Grants/ Entitlement Grants...

Finding Reference Number: SA2022-002 - Federal Funding Accountability and Transparency Act (FFATA) Reporting Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant ? Entitlement Grant COVID-19 - Community Development Block Grants/ Entitlement Grants-CV Name of Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-21-MC-06-0042 COVID-19 ? B-20-MW-06-0042 CDBG Daly City Pass Through #Not Available Name of Pass-through Entity: City of Daly City ? Name(s) of the contact person: Karen Chang, Finance Director ? Corrective Action Plan: Staff were not aware of this requirement. The city is going to incorporate this requirement in the grant procedural manual to ensure the grant program manager understands the reporting requirements under the FFATA. ? Anticipated Completion Date: July 1, 2023

View Audit 36521

Finding 34693 (2022-002)

Material Weakness 2022

Josephine County, Oregon

OR

Subrecipient Monitoring § 200.331

Management of Josephine County has acknowledged that evidence of subrecipient monitoring and risk assessments were not retained in the file. While vetting was done on subrecipients a risk assessment form was not formally written. We have addressed it by providing training to central staff as well as...

Management of Josephine County has acknowledged that evidence of subrecipient monitoring and risk assessments were not retained in the file. While vetting was done on subrecipients a risk assessment form was not formally written. We have addressed it by providing training to central staff as well as department staff who have responsibility over grants. Further, a dedicated staff member will be responsible for monitoring grant compliance and completing risk assessments that were not done based on the vetting process that did occur. Anticipated Completion date is June 30, 3023. The responsible contact person is Sandy Novak, Finance Director.

View Audit 36520

Finding 34682 (2022-003)

Significant Deficiency 2022

Suffolk County, New York

NY

Questioned Costs Eligibility Student Financial Aid

REFERENCE # 2022-003 ELIGIBILITY FOR INDIVIDUALS ? NONCOMPLIANCE Program ADOPTION ASSISTANCE TITLE IV-E (Assistance Listing # 93.659) Identification Number(s) 18000 Finding New York State has enacted legislation which allows payments to be made for the care and maintenance of children when they are ...

REFERENCE # 2022-003 ELIGIBILITY FOR INDIVIDUALS ? NONCOMPLIANCE Program ADOPTION ASSISTANCE TITLE IV-E (Assistance Listing # 93.659) Identification Number(s) 18000 Finding New York State has enacted legislation which allows payments to be made for the care and maintenance of children when they are adopted. Suffolk County Department of Social Services (the ?Department?) provides a monthly adoption subsidy payment mandated by law for the care, maintenance, and/or medical needs of a child who fits the definition of handicapped or hard-to-place as defined by New York State law and regulations. Subsidy payments are available to all eligible children until the age of 21 regardless of the adoptive parent?s income. These payments are discontinued only when it is determined by a social service official that the adoptive parent(s) is no longer legally responsible for the support of the child or that the child is no longer receiving any support from the parent(s). Of the sixty (60) files selected for testing: ? Five (5) case file did not include the Home Studies narrative; and one (1) case file did not include the Criminal check form. Therefore, we were not able to determine if the eligible participants met all the eligibility criteria. Questioned Costs Cannot be determined. Recommendation We recommend the Department strengthen its monitoring controls over the adoption assistance case files to ensure the timely and accurate determination of eligibility. Corrective Action Plan With regards to the Criminal check form: Corrective Action Plan: It was found that one (1) case file did not include the criminal check form. The criminal check forms for this case was conducted when the children were in Foster Care and the results were included in the Foster Home record. Foster Home records are purged after eight (8) years of the home closing and no longer available. Currently: The criminal record check is included in the Adoption Subsidy file upon adoption as well as maintained in our Adoption vendor files. With regards to the Home Study narrative: Corrective Action Plan: It was found that five (5) cases did not include the Home Study narrative. The Home Study narratives for these case files were conducted when the homes were first certified as Foster Homes and were included in the Foster Home case record. Foster Home records are purged after eight (8) years of the home closing and no longer available. Currently: The Home Study narrative is included in the Adoption Subsidy file upon adoption as well as maintained in our Adoption vendor files. Action Date Record Check ? 2018 Home Study ? 2021 Final Implementation Date Record Check ? 2039 Home Study ? 2042 Name And Phone # Of Person Responsible For Implementation Carleen Newlands, Division Administrator 631-854-9626

View Audit 31089 Questioned Costs: $1

Finding 34680 (2022-004)

Significant Deficiency 2022

Suffolk County, New York

NY

Questioned Costs Eligibility Subrecipient Monitoring

REFERENCE # 2022-004 ELIGIBILITY FOR INDIVIDUALS ? NONCOMPLIANCE Program LOW-INCOME HOME ENERGY ASSISTANCE (ALN # 93.568) Identification Number(s) 21-LCM-15, 21-LCM-23, 22-LCM-06, and 23-LCM-01 Finding The New York State Office of Temporary and Disability Assistance is responsible for Low-Income Ene...

REFERENCE # 2022-004 ELIGIBILITY FOR INDIVIDUALS ? NONCOMPLIANCE Program LOW-INCOME HOME ENERGY ASSISTANCE (ALN # 93.568) Identification Number(s) 21-LCM-15, 21-LCM-23, 22-LCM-06, and 23-LCM-01 Finding The New York State Office of Temporary and Disability Assistance is responsible for Low-Income Energy assistance programs that provide assistance and support to eligible families and individuals. The Home Energy Assistance Program (HEAP) helps eligible New Yorkers heat and cool their homes. An eligibility family may receive one regular HEAP benefit per program year and could also be eligible for emergency HEAP benefits if you are in danger of running out of fuel or having utility service shut off. Of the sixty (60) files selected for testing: ? One (1) case file did not include the required documentation to support eligibility for HEAP. Therefore, we were not able to determine if the eligible participants met all the eligibility criteria. Questioned Costs Cannot be determined. Recommendation We recommend the Department strengthen its monitoring controls over the Low-Income Home Energy case files to ensure the timely and accurate determination of eligibility. Corrective Action Plan Staff will be reminded of the importance of scanning all applications and required documentation into the Imaging and Enterprise Document Repository to ensure that a complete and accurate case file is kept electronically for all cases. Action Date 9/20/2023 Final Implementation Date 2024 Name And Phone # Of Person Responsible For Implementation Loreta Keller 631-854-9920

View Audit 31089 Questioned Costs: $1

Finding 34669 (2022-003)

None 2022

Boys & Girls Clubs in Tennessee

TN

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.414 § 200.502

Name of Responsible Individual(s): Jason Penegar, BGCA Vice President ? Controller Shelby Mahoney, Accounting Manager - State Alliances Corrective Action: Management will review grant agreements to confirm whether funding received from private entities are federal funds that should be reported on th...

Name of Responsible Individual(s): Jason Penegar, BGCA Vice President ? Controller Shelby Mahoney, Accounting Manager - State Alliances Corrective Action: Management will review grant agreements to confirm whether funding received from private entities are federal funds that should be reported on the SEFA. Anticipated Completion Date: December 31, 2023

View Audit 34598

Finding 34667 (2022-002)

Significant Deficiency 2022

Boys & Girls Clubs in Tennessee

TN

Subrecipient Monitoring Cash Management Reporting

Individual Responsible for Corrective Action Plan: Whitney Holliday, Director of Club Financial Services Corrective Action: Previous Process: The previous process was created prior to the current admin becoming the dedicated Financial Services leader on the Boys & Girls Clubs in TN/TN Alliance admi...

Individual Responsible for Corrective Action Plan: Whitney Holliday, Director of Club Financial Services Corrective Action: Previous Process: The previous process was created prior to the current admin becoming the dedicated Financial Services leader on the Boys & Girls Clubs in TN/TN Alliance admin team. All changes took place over the 2022/2023 grant cycles. Current Process: The previous process was overhauled to our current process in Q1 of 2022. Training and updates to the process were performed with 20 organizations throughout the year. We also implemented better direct communication with admin/staff 1:1s and a quarterly financial update call to continue training and best practice sharing. Process Update: A process update will be implemented beginning with July 2023 reimbursement requests/submissions to funders. These updates will be shared with individual Clubs with an expectation of full implementation by the end of Q3 2023. The admin will enhance its policies and procedures over sub-recipient monitoring to ensure accurate invoicing. -All reimbursement requests due from the Clubs by the 15th of each month o Previous Process: ? Requests were either loaded in the shared drive or emailed directly to the admin. Requests were consistently late and admin would communicate with each Club to see if they submitted something but it was missed. o Current Process: ? Calendar reminders are disbursed to all financial contacts with the deadlines clearly defined ? All submissions must be made in the shared drive. No email reimbursement requests are allowed. ? Admin no longer reached out to Clubs if nothing is loaded in the shared drive to process by the deadline ? Direct communication opened and established between Club financial leaders and admin financial leader to ensure all deadlines are met o Process Update: ? No update is needed ? Reimbursement Request/Cover Sheet o Previous Process: ? Submissions were processed based on a spreadsheet that the Clubs tracked in the shared drive. ? Manual verification of lines requested o Current Process: ? A cover sheet detailing the calculations of each line in the reimbursement request is required with each submission. Acknowledgment by Clubs that they have included/not included (timesheets signed in 3 places, receipts with no sales tax or other unallowable expenses, request submitted by the 15th of each month) via check boxes prior to authorized signature and date. ? All salary and benefit calculations must be completely detailed in the supporting documentation. This has remained difficult with all 20 organizations having different pay structures, paycheck layouts, benefit providers, etc. ? All supporting documentation must be present at the time of processing or line item requests are removed from overall submission. ? All submissions are compiled and sent to funders by their deadline on a monthly basis o Process Update: ? Additional calculation details will now be required for all submissions. We will add a separate box for the percentage breakdown to be charged to each grant to match supporting documentation exactly. ? All communication of errors will be in writing and detailed notes will be kept. No more phone conversations about corrections unless also documented in writing. ? If there are any unclear calculations in the request, it will be sent back to the Club to submit the following month. This will take the liability for the error off the admin and place it back with the Club. ? We will no longer allow miscellaneous benefits (other than payroll taxes) as an allowable expense for reimbursement as they are difficult to verify. ? 1:1 training will be conducted with each Club prior to their first reimbursement request for new grant cycles. With turnover and task sharing in our organization, this will ensure direct training and increase compliance. ? Quarterly financial update calls will be longer/more specific. ? We will no longer allow Clubs to combine requests over multiple months. This inconsistency tends to lead to errors. ? Additional admin support has been added to decrease the number of requests being processed by one individual per month. We have hired an additional staff member. ? Status of Funds o Previous Process: ? Clubs kept up with their budgets/available balances themselves o Current Process: ? Admin updates a running spreadsheet in the shared drive after each month's submission to ensure Clubs are aware of their available balances for each grant o Process Update: No update is needed Anticipated Completion Date: September 30, 2023

View Audit 34598

Finding 34659 (2022-002)

Significant Deficiency 2022

Dallas County

TX

Reporting Subrecipient Monitoring Significant Deficiency

Finding 2022-02: Control and Compliance Finding ? Significant Deficiency Coronavirus State and Local Fiscal Recovery Funds ? Reporting ALN #21.027 ? Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Recommendation? Management should ensure that they have a mechanism for tracking the reporti...

Finding 2022-02: Control and Compliance Finding ? Significant Deficiency Coronavirus State and Local Fiscal Recovery Funds ? Reporting ALN #21.027 ? Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Recommendation? Management should ensure that they have a mechanism for tracking the reporting requirements and activity occurring in each reporting period. Management should also ensure all submitted reports are properly reviewed for all reporting requirements. Responsible Party?Charles Reed, Hector Faulk, and Darcy Cohen ? ARP Team Corrective Action Plan? The Department agrees with the finding of the single audit and will implement the following: 1. Increase frequency of meetings with Grants Audit staff from monthly to biweekly to ensure approved projects and budgeted amounts are in the General Ledger/PPM module, that is used to provide cumulative obligations and expenditures reports including discussion of any reconciliation items as regards to reporting. 2. Continue to ensure Grants Audit reviews and approves quarterly and annual reports for timely submission to the U.S. Treasury by ARP Team 3. There will be two preparers of each report- the Senior Policy Analyst and the Special Projects Manager- to help capture all grant activity, including the reporting period obligations and expenditures. 4. ARP Team Director (Assistant County Administrator) will review draft reports and document the review before submission to confirm they meet all reporting requirements and accurately reflect cumulative obligations and expenditures. 5. ARP Management will meet biweekly to discuss the tracking of grant activity for each reporting period and any updated or new reporting requirements.

View Audit 32407

Finding 34655 (2022-004)

Significant Deficiency 2022

Dallas County

TX

Subrecipient Monitoring Reporting

Finding 2022-04: Special Test ? Reporting ? Significant Deficiency in Controls over Compliance and Noncompliance ALN #14.218? Community Development Block/Entitlement Grants) Recommendation? Management should ensure that they have a mechanism for reporting subaward data in the FSRS. Responsible Party...

Finding 2022-04: Special Test ? Reporting ? Significant Deficiency in Controls over Compliance and Noncompliance ALN #14.218? Community Development Block/Entitlement Grants) Recommendation? Management should ensure that they have a mechanism for reporting subaward data in the FSRS. Responsible Party? Department of Planning and Development Corrective Action Plan?Planning and Development staff will contact its HUD field office representative for guidance and consultation on FFATA reporting requirements and will ensure compliance will be met by 9/30/2023. Planning and Development will begin to implement these corrective actions immediately or on the timeline identified in the corrective action itself. Responsible Party: Luis Tamayo, Director of Planning and Development

View Audit 32407

Finding 34628 (2022-018)

Material Weakness 2022

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT 2022-018 Low-Income Home Energy Assistance, COVID-19 ? Low-Income Home Energy Assistance ? Assistance Listing No. 93.568 ...

DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT 2022-018 Low-Income Home Energy Assistance, COVID-19 ? Low-Income Home Energy Assistance ? Assistance Listing No. 93.568 Action taken in response to the finding: Going forward, the FFATA will be submitted for LIHEAP by the DCS Fiscal Unit as required by FFATA instructions. Name of the contact person responsible for corrective action: Kristen Crowley Planned completion date for corrective action plan: Report will be filed in FSRS by the end of the month following the month in which the prime recipients are awarded. Next anticipated due date will be November or December 2023.

View Audit 31118

Finding 34625 (2022-017)

Significant Deficiency 2022

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION 2022-017 COVID-19 ? Elementary and Secondary School Emergency Relief...

DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION 2022-017 COVID-19 ? Elementary and Secondary School Emergency Relief Fund (ESSER), COVID-19 ? American Rescue Plan ? Elementary and Secondary School Emergency Relief (ARP ESSER) ? Assistance Listing No. 84.425D, 84.425U Action taken in response to the finding: DESE will review, enhance procedures and internal controls to ensure that all required subawards are reported timely to FSRS no later than the end of the month following the month of issuance. Specifically; (1) update procedures to ensure that DESE maintains all supporting documentation for report delays due to FSRS rejections and issues that arise during the reporting process that may cause delays in timely reporting; and (2) Incorporating other DESE units and staff in resolving reporting issues to avoid reporting delays. Name of the contact person responsible for corrective action: Robert Curtin, Associate Commissioner of DATA, Donna Shannon, Director of Financial Services, Robert McDonald, Federal Grants Manager, Jeffrey Benbenek, Director of Audit & Compliance Planned completion date for corrective action plan: July 1, 2023

View Audit 31118

Finding 34624 (2022-016)

Significant Deficiency 2022

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION 2022-016 COVID-19 ? Elementary and Secondary School Emergency Relief Fund (ESSER), COVID-19 ? American Rescue Plan ? Elementary and Secondary S...

DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION 2022-016 COVID-19 ? Elementary and Secondary School Emergency Relief Fund (ESSER), COVID-19 ? American Rescue Plan ? Elementary and Secondary School Emergency Relief (ARP ESSER) ? Assistance Listing No. 84.425D, 84.425U Action taken in response to the finding: DESE has enhanced policies and procedures to ensure the Annual Report has amounts reported are verified with supporting documentation. In addition, DESE corrected all 1st year reporting errors for both the Year 2 and Year 3 Annual Reports submitted to the U.S. Department of Education and all amounts were verified with supporting documentation for accuracy. Name of the contact person responsible for corrective action: Julia Jou, Director of Budget, Jeffrey Benbenek, Director of Audit & Compliance Planned completion date for corrective action plan: July 1, 2023

View Audit 31118

Finding 34620 (2022-014)

Material Weakness 2022

Commonwealth of Massachusetts

MA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

DEPARTMENT OF TRANSPORTATION 2022-014 Highway Planning and Construction Cluster, COVID-19 ? Highway Planning and Construction Cluster ? Assistance Listing No. 20.205, 20.219 ...

DEPARTMENT OF TRANSPORTATION 2022-014 Highway Planning and Construction Cluster, COVID-19 ? Highway Planning and Construction Cluster ? Assistance Listing No. 20.205, 20.219 Action taken in response to the finding: In response to the finding and per the guidance of 2 CFR section 180.215, the Department is coordinating between the Construction Contracts/Prequalification Office and the various District Offices to develop a method of formally checking the status of all subcontractors on each job in the Federal SAM database, as is currently done with prime contractors on all awards. Once a process is finalized, the step will be included in the standard operating procedure for approving subcontractors. This approval will be memorialized as part of each Subcontract Approval Form and stored in the contract file. Name of the contact person responsible for corrective action: Leo Mooney, Manager of Construction Contracts Planned completion date for corrective action plan: As this action involves the development of a new process and disseminating to all six District Offices, enactment may take some time. Once the procedure is approved by the Deputy Administrator/Chief of Construction Engineering, District Offices will be notified of the process. A letter outlining the approved directive will be drafted prior to July 1, with the goal of full implementation by September 1.

View Audit 31118

Finding 34611 (2022-013)

Significant Deficiency 2022

Commonwealth of Massachusetts

MA

Subrecipient Monitoring § 200.303 § 200.332

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-013 WIOA Cluster ? Assistance Listing No. 17.258, ...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-013 WIOA Cluster ? Assistance Listing No. 17.258, 17.259, 17.278 Action taken in response to the finding: Beginning with fiscal year 2023, MHDCS has revised all Financial/Fiscal related documentation (i.e., Budget Sheets, Contracts) for sub- awardees to include the FAIN identifier as recommended through this finding. Further, MDCS has revised and enhanced its internal controls processes for scheduling, notification, and reporting of subrecipient monitoring by including an additional senior level signoff to confirm that all related documentation, required information including annual reviews, has been stored in a designated backup SharePoint data file beginning with Fiscal year 2023. Name of the contact person responsible for corrective action: Michael Williams, Director of Monitoring and Oversight, MHDCS Planned completion date for corrective action plan: December 2022

View Audit 31118

Finding 34609 (2022-011)

Material Weakness 2022

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-011 WIOA Cluster ? Assistance Listing No. 17.258, 17.259, 17.278 ...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-011 WIOA Cluster ? Assistance Listing No. 17.258, 17.259, 17.278 Action taken in response to the finding: Reporting has been built to notify responsible parties of the award periods of performance and highlight any issues for corrective action in accordance to previously filed FFATA reporting. In addition, FFATA reporting has been created in EOLWD?s DataMart application. Actions taken are as follows: ? Performed FFATA training ? Created accounts for employee access to FFATA ? Filed existing outstanding and new grant FFATA reports ? Used new reporting to notify responsible parties that a new grant/modification has arrived and requires a FFATA Subaward report filed ? Training for existing staff complete and new staff will be trained accordingly as part of their onboarding. Name of the contact person responsible for corrective action: Malachy Rice, Director of Federal Grants, EOLWD Planned completion date for corrective action plan: June 30, 2023

View Audit 31118

Finding 34607 (2022-001)

Significant Deficiency 2022

Legal Aid of North Carolina, Inc.

NC

Subrecipient Monitoring HUD Housing Programs

CORRECTIVE ACTION PLAN April 28, 2023 Legal Services Corporation Legal Aid of North Carolina, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Romeo, Wiggins & Company, LLP, 8210 Creedmoor...

CORRECTIVE ACTION PLAN April 28, 2023 Legal Services Corporation Legal Aid of North Carolina, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Romeo, Wiggins & Company, LLP, 8210 Creedmoor Road, Suite 202, Raleigh, NC 27613 Audit Period: Year Ended December 31, 2022 The findings from the December 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARD FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCY 2022-001: Case File Documentation/CFDA 09.634032 Recommendation: We recommend that management re-emphasize the importance of maintaining adequate documentation of retainer determination for all LSC eligible cases. Periodic reviews of case files should be performed to ensure compliance. Action Taken: The largest number of errors were discovered in one office, which office has a relatively new managing attorney. Legal Aid of North Carolina, Inc.?s Compliance Officer will provide compliance training targeted to this manager and her staff, emphasize compliance in new hire onboarding training, and train managers and supervisors promoted to new leadership roles. Additionally, all advocacy staff (attorneys and paralegals) will have mandatory annual refresher training on when and how to execute retainers. The training will also include a review of LSC Regulation 1611.9, Retainer Agreements. To strengthen the compliance process and assure requirements are met, Legal Aid of North Carolina, Inc. will perform semi-annual internal self-inspections to include retainer monitoring. We also plan to perform retainer monitoring of field offices that this audit and future self-inspections identify as missing required case documentation, including retainer agreements. Finally, our case management system will be evaluated for opportunities to more systematic alert case closing approvers or report on potential missing required documents. Legal Services Corporation Page Two If Legal Services Corporation has questions regarding this plan, please call Jim Strand, LANC CFO at 984-263-9609. Sincerely yours, Ashley Campbell Chief Executive Officer

View Audit 36954

Finding 34602 (2022-003)

Significant Deficiency 2022

Community Unit School District No. 3

IL

Subrecipient Monitoring Cash Management Reporting

United States Department of Education Education Stabilization Fund ? CFDA #84.425D/84.425U/84.425W Corrective Action Plan ? Noncompliance with Reporting Requirements Finding: 2022-003 Condition: The District has inadequate controls over reviewing and approving quarterly ?historical expenditure repor...

United States Department of Education Education Stabilization Fund ? CFDA #84.425D/84.425U/84.425W Corrective Action Plan ? Noncompliance with Reporting Requirements Finding: 2022-003 Condition: The District has inadequate controls over reviewing and approving quarterly ?historical expenditure reports? filed with the Illinois State Board of Education. Plan: The superintendent will review and approve quarterly ?historical expenditure reports? and supporting documentation on a regular basis prior to electronic submissions. Corresponding documents will be manually signed and dated to indicate approval. Anticipated Date of Completion: January 1, 2023 Management Response: The District intends to implement the recommendations in FY 2023. Name of Contact Person: Jessica Sisil, District Superintendent

View Audit 36244

Finding 34578 (2022-001)

None 2022

City of Roanoke, Virginia

VA

Subrecipient Monitoring

D EPARTMEN T OF FINANCE Ci ty of Roanoke 215 Church Avenue, SW Roanoke, VA 240 11 (540) 853-28 24 www.roanok eva.gov CORRECTIVE ACTION PLAN March 29, 2022 The Federal Audit Clearinghouse: The City of Roanoke, Virginia respectfully submits the following corrective action plan for the year ended...

D EPARTMEN T OF FINANCE Ci ty of Roanoke 215 Church Avenue, SW Roanoke, VA 240 11 (540) 853-28 24 www.roanok eva.gov CORRECTIVE ACTION PLAN March 29, 2022 The Federal Audit Clearinghouse: The City of Roanoke, Virginia respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 319 McClanahan St. SW, Roanoke, VA 24014 Audit period: June 30, 2022 The findings from the June 30, 2022 Schedule of Findings and Questioned Costs (the "Schedule") are discussed below. The findings are numbered consistently with the number assigned in the Schedule. FINDINGS - FINANCIAL STATEMENT AUDIT CY - Financial Statement - None CY- Federal Major Program 2022-001: Workforce Investment Opportunitv Cluster #17.258/17.259/17.278, Subrecipient Monitoring Assistance Listing Condition: During our review of subrecipient monitoring, we noted that the City's semi-annual subrecipient monitoring scheduled for February 2022 was not performed. Criteria: According to the City's Program Participant Monitoring Plan, the City is supposed to conduct subrecipient monitoring on a semi-annual basis which should include desk reviews of payroll, disbursements, and other financial items. Cause: Staff turnover, particularly for the role of grant accountant, caused these procedures to be overlooked. Effect: Noncompliance with federal grant requirements with regard to subrecipient monitoring as well as risk of subrecipient misusing funds. Questioned Cost Amount: Not applicable. Perspective Information: Not applicable. Recommendation: We recommend performing subrecipient monitoring in accordance with the City's guidelines and following the procedures laid out in the Program Participant Monitoring Plan. View of Responsible Officials and Planned Corrective Action: Management concurs with the recommendation and will ensure that follow up occurs regarding information provided by business owners. Loss of staff in this accountability area resulted in an inquiry and reviews conducted via electronic means verses a physical. Delivered information was reviewed and acknowledged by Accounting Supervisor, however physical visit did not occur. The Accounting Supervisor and the Accounts Payable Co-coordinator, in the absence of a Grant Accountant, have conducted the first semi-annual visit for FY23. Follow-up information has been received upon request and the final physical review has been scheduled for Spring of 2023. CY - Commonwealth - Auditor of Public Accounts - Fire Program A required audit procedure is to obtain a copy of the locality's completed Annual Report and Disbursement Agreement forms submitted to the Department of Fire Programs for the applicable fiscal year under audit. The procedure includes ensuring that the Annual Report and Disbursement Agreement forms are properly completed in accordance with Fire Programs' requirements and reconciled amounts per the Annual Report to the locality's accounting records. It was noted in the current year that the amount of revenues and expenditures reported to the Department of Fire Programs did not agree to the underlying accounting records. We recommend the Annual Report be reviewed and reconciled to the general ledger before submission. ManagementJs response: Management concurs with the recommendation and wilt ensure that follow up occurs regarding information provided. Employee transition and lack of training resulted in discrepancy. The Fire Program reports were submitted in advance of finalization of the disbursement register. This finding will be duplicated for FY22 report as well. Training has been provided, a procedure has been developed and the Accounting Supervisor is included in review of reporting prior to submission. PY - Financial Statement Audit Adjustments (Significant Deficiency) - Cleared PY - Federal Major Program COVID Business Grants - Cleared PY - Commonwealth - still applicable Disclosure Statements Five of 83 disclosure statements were not filed timely. Management's response: Management concurs with the recommendation and will ensure that follow up occurs regarding information provided. Staffing vacancies resulted in this delay. Training has been provided to new employee and an expectation of this issue being cleared is anticipated for FY23. Highway Maintenance Testing Six of the ten time cards tested contained data that could not be allocated to a specific work order. We recommend all departments use the newly adopted time reporting software to ensure labor is charged to the correct work order. Management concurs with the recommendation and will ensure that follow up occurs regarding information provided. [this testing is one year behind so improvements implemented in FY22 will be reflected in FY23 testing] PY - Commonwealth - no longer applicable Social Services - Special Welfare- Treasurer Reimbursements Social Services - Special Welfare- Unexpended Funds If the Federal Audit Clearinghouse has questions regarding this plan, please call Brent Robertson, Chief Financial Officer at (540) 853-1556. Respectfully submitted, Brent Robertson ACM/Chief Financial Officer

View Audit 35952

Finding 34526 (2022-002)

Material Weakness 2022

Town of Clarksville

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Cash Management § 200.303

FINDING 2022-002 Contact Person Responsible for Corrective Action: Sherry Lockard Contact Phone Number: 812-283-1500 Views of Responsible Official: The Town concurs with the finding. Description of Corrective Action Plan: The Town has assigned the duties to request reimbursement (LPA Invoice Voucher...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Sherry Lockard Contact Phone Number: 812-283-1500 Views of Responsible Official: The Town concurs with the finding. Description of Corrective Action Plan: The Town has assigned the duties to request reimbursement (LPA Invoice Voucher) from the IN Dept of Transportation to the Office Manager of Public Works. The Office Manager will prepare the LPA Invoice Voucher for INDOT and one of the two ERC?s, Public Works Director, or Assistant Public Works Director, will review for accuracy and sign off on the LPA Invoice Voucher. Anticipated Completion Date: May 9, 2023

View Audit 35793

Finding 34524 (2022-004)

Material Weakness 2022

Monroe Fire Protection District

IN

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303 § 200.329

FINDING 2022-004 Subject: Staffing for Adequate Fire and Emergency Response (SAFER) - Reporting Contact Person Responsible for Corrective Action: Dustin Dillard Contact Phone Number: 812-331-1906 Views of Responsible Official: We agree with this finding and will make necessary changes. Description o...

FINDING 2022-004 Subject: Staffing for Adequate Fire and Emergency Response (SAFER) - Reporting Contact Person Responsible for Corrective Action: Dustin Dillard Contact Phone Number: 812-331-1906 Views of Responsible Official: We agree with this finding and will make necessary changes. Description of Corrective Action Plan: The District has contacted our FEMA representative for guidance on how to complete the Programmatic Performance Reports which currently are past due. We were informed it was not on her priority list and it would be a while before she could help. This has often been an issue in submitting these reports. We have contacted a second representative who was slightly more helpful, but suggested we contact the next level of management for assistance. We hope to hear back from a Mr. Jones in the next week or two regarding our request. Once we have submitted all delinquent reports, we will create calendar reminders to check the portal for all grants monthly to ensure there are no missing or delinquent reports. Anticipated Completion Date: 12-31-2023 More information about this finding is available in the Supplemental Report. Monroe Fire Protection District 25

View Audit 32668

Finding 34509 (2022-002)

None 2022

Ryder Assisted Care, Inc.

PR

HUD Housing Programs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding Number: 2022-2 Deposit to residual Receipts Account was deposited over 60 days following the end of the fiscal year. The full amount of the required Residual Receipt deposits was made. The Project Administrator and Project Accountant was oriented to comply with this important requirement.

View Audit 30771

Corrective Action Plans

Filters