Corrective Action Plans

Finding 402363 (2021-007)

Significant Deficiency 2021

CA

Subrecipient Monitoring Reporting § 200.303 § 200.332 § 200.414 § 200.502

California Business, Consumer Services and Housing Agency (BCSH) The California Interagency Council on Homelessness (Cal ICH), an entity under the BCSH, would like to acknowledge a finding from the fiscal year 2020-21 Statewide Federal Compliance Audit of the State of California. This audit finding...

California Business, Consumer Services and Housing Agency (BCSH) The California Interagency Council on Homelessness (Cal ICH), an entity under the BCSH, would like to acknowledge a finding from the fiscal year 2020-21 Statewide Federal Compliance Audit of the State of California. This audit finding identifies lack of communication of required subaward information to Cal ICH subrecipients of the Coronavirus Relief Fund (CRF) program at the time of the subaward, or when the State became aware of changes in subaward information, including identification that the subaward funds represented federal funding. Cal ICH agrees with this finding and the recommendation to review all subawards provided which were funded using CRF program funds and determine whether the subrecipients properly reported their CRF awards and related expenditures in their respective schedule of expenditures of federal awards pursuant to Title 2 Code of the Federal Regulations 200.502. Additionally, while formal communication identifying that the subaward fund represented federal funding was not provided, many informal conversations were had with CRF grantees. These conversations were held during bi-weekly online Office Hours and through one-on-one calls with individual subrecipients and discussions of the substitution of federal awards with grantees originally provided with State funds could have occurred. Cal ICH will conduct review of the CRF subawards during mandatory desk reviews to verify that subrecipients properly reported their CRF awards and that expenditures of the federal awards were made pursuant to Title 2 Code of Federal Regulations 200.502. Additionally, Cal ICH has developed an improved communication system between leadership and program staff that will ensure changes are clearly communicated. This will also ensure the Council’s subrecipients are notified in a timely manner upon any changes in subaward information, such as identifying if subaward funds represent federal funding so that expenditures are spent in accordance with Federal statutes, regulations, and the terms and conditions of federal awards. Additionally, if in the future funding is changed, CDE will provide updated information to all recipients; this will ensure that expenditures are in line with the terms and conditions of the grant and/or funding source. Estimated Implementation Date: May 2023 Contact: Ellen Meuchel, Monitoring Unit Cal ICH Grant Operations and Suppor California Department of Education Concur. Education will review the relevant subawards funded under the CRF program and determine whether the subrecipients properly reported their CRF awards pursuant to 2 CFR 200.501. Estimated Implementation Date: July 31, 2023 Contact: Kelly Levario, External Audits Coordinator Audits and Investigations Division California Department of Social Services The California Department of Social Services (CDSS) acknowledges the Single Audit finding regarding the delayed communication of subaward information to the Department’s subrecipients of the Coronavirus Relief Fund (CRF) program. On December 21, 2022, CDSS released County Fiscal Letter 22/23-31 on the subject of “Federal Coronavirus Relief Funds That Replaced General Fund for COVID-19 Related Activities for Fiscal Years 2019-20 and 2020-21” to County Welfare Departments (CWDs) and federally recognized Tribal governments in California. This letter served as a formal documentation of the portion of expenditures that were funded with federal CRF. Additionally, although formal notice was not provided until December 21, 2022, informal notices and conversations took place between CDSS and the County Welfare Directors Association, as well as with CWDs, regarding possible situations in which the substitution of federal awards with grants originally provided with State funds could occur. On September 21, 2021, CDSS sent a notice to subrecipients requesting for their Data Universal Number System for the purpose of CRF federal subawards; thereby, communicating the use of CRF on the subrecipients’ behalf. CDSS will conduct a review of the CRF subawards during on-site fiscal monitoring reviews to verify that subrecipients properly reported their CRF awards and that expenditures of the federal awards were made pursuant to Title 2 Code of Federal Regulations 200.502. Moreover, CDSS will ensure that the Department’s subrecipients are notified in a timely manner upon any changes in subaward information, such as identifying if subaward funds represent federal funding so that expenditures are spent in accordance with Federal statutes, regulations, and the terms and conditions of federal awards. Estimated Implementation Date: April 2023 through June 2024 Contact: Elisa Tsujihara, Chief Fiscal Policy and Analysis Bureau

View Audit 309913

Finding 402354 (2021-002)

Material Weakness 2021

State of California

CA

Reporting Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303 § 200.502 § 200.510

Public Health’s Accounting Office will generate the FI$Cal Year End Close report (KK_12 expenditure) and collaborate with the ELC program to ensure that all expenditures captured are complete and accurate, ensuring timely reporting of the SEFA data for FY 2023-24 and beyond. Additionally, we will up...

Public Health’s Accounting Office will generate the FI$Cal Year End Close report (KK_12 expenditure) and collaborate with the ELC program to ensure that all expenditures captured are complete and accurate, ensuring timely reporting of the SEFA data for FY 2023-24 and beyond. Additionally, we will update the procedures to document the SEFA reporting for the ELC program.

View Audit 309913

Finding 401691 (2021-003)

Material Weakness 2021

Northwest Indian College

WA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Recommendation: We recommend the College implement a suspension and debarment policy and corresponding procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College currently follows its internal control ...

Recommendation: We recommend the College implement a suspension and debarment policy and corresponding procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College currently follows its internal control policies to document verification of vendors who may be listed in SAM for suspension and debarment. The College approved an updated procurement policy effective November 7, 2020, to adhere to Uniform Guidance. The College will strengthen (include) the suspension and debarment section to include a policy specific to Debarment and Suspension. Name of the contact person responsible for corrective action: Reatha Tom, Accounts Payable Specialist, and Clarissa Salhus, Finance Manager Planned completion date for corrective action plan: December 31, 2024

View Audit 309644

Finding 400966 (2021-004)

Material Weakness 2021

Gloversville Housing Authority

RI

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will ensure annual audits are conducted and timely electronic submissions of GAAP-based unaudited and audited financial information to HUD through the F...

Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will ensure annual audits are conducted and timely electronic submissions of GAAP-based unaudited and audited financial information to HUD through the FASS-PH system. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

View Audit 309030

Finding 400962 (2021-003)

Material Weakness 2021

Gloversville Housing Authority

RI

HUD Housing Programs Subrecipient Monitoring Eligibility

Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third party management company to ensure compliance with 24 CFP 982.516 in the future. Pl...

Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third party management company to ensure compliance with 24 CFP 982.516 in the future. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

View Audit 309030

Finding 400958 (2021-002)

Material Weakness 2021

Gloversville Housing Authority

RI

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Subrecipient Monitoring § 200.302

Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will maintain proper monitoring, communication and control activities to ensure adherence to the Authority’s key administrative policies including procu...

Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will maintain proper monitoring, communication and control activities to ensure adherence to the Authority’s key administrative policies including procurement, occupancy and the HCV administrative plan. Additionally, management will have the Board approve all policies and procedures adopted and communicate them with the third party company that manages the Authority’s Housing Choice Voucher and Mainstream Voucher programs. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

View Audit 309030

Finding 399911 (2021-001)

None 2021

Charles County Nursing and Rehabilitation Center Inc.

MD

Subrecipient Monitoring Reporting § 200.512

Finding 2021-001 – Reporting - Submission of the Data Collection Form Contact: Terry L. Weaver, CFO Telephone Number: (301) 539-3629 Estimated Completion Date: June, 2024 Charles County Nursing and Rehabilitation Center, Inc. hereby acknowledges the Organization’s audit reporting package was not ...

Finding 2021-001 – Reporting - Submission of the Data Collection Form Contact: Terry L. Weaver, CFO Telephone Number: (301) 539-3629 Estimated Completion Date: June, 2024 Charles County Nursing and Rehabilitation Center, Inc. hereby acknowledges the Organization’s audit reporting package was not submitted by the filing deadline of September 30, 2022. The Organization will file the reporting package shortly after issuance and ensure that any future audits are completed and filed timely, by working closely with our audit partner and frequently accessing the substantive status, stage of completion or any other pertinent aspect of the audit necessary to meet the filing deadline. Anticipated Completion Date The Organization anticipates submission of the audit and data collection form immediately upon completion on May 16, 2024.

View Audit 308054

Finding 399397 (2021-007)

Material Weakness 2021

Grant County

OK

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

The County will establish policies and procedures to create better communication between the Emergency Manager and the County Officers.

View Audit 307906

Finding 397059 (2021-006)

Material Weakness 2021

Open Cities Health Center, Inc. and Affiliate

MN

Eligibility Special Tests & Provisions Subrecipient Monitoring

Finding 2021-006 Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Material Weakness Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 U.S. Department of Human Services Condition: Supporting documents could not be located for four of...

Finding 2021-006 Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Material Weakness Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 U.S. Department of Human Services Condition: Supporting documents could not be located for four of the thirty patients selected for testing. As such, we were unable to determine eligibility. Action Planned in Response to the Finding: Effective immediately, the revenue cycle team will implement and monitor procedures to ensure that all supporting documents are kept for determining sliding fee discounts and patient eligibility. Official Responsible for Ensuring the CAP: Becky Howard Planned Completion Date: June 30th, 2024

View Audit 306434

Finding 396657 (2021-001)

None 2021

Employ Prince George's, Inc.

MD

Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking

MANAGEMENT’S CORRECTIVE ACTION PLANS Finding 2021-001: Noncompliance over Earmarking We agree with the auditors comments. Although much of the difficulty with establishing work-experience training for Youth was related to pandemic-driven restrictions on in-person work and slowdowns or freezes on ...

MANAGEMENT’S CORRECTIVE ACTION PLANS Finding 2021-001: Noncompliance over Earmarking We agree with the auditors comments. Although much of the difficulty with establishing work-experience training for Youth was related to pandemic-driven restrictions on in-person work and slowdowns or freezes on hiring that were commonplace during the period July 1, 2020 through June 30, 2021, our progress in improving performance against that target show it can be possible. (To that effect, note that Youth PY20 Total Program Expenditures at June 30, 2021 were $763,817 and Work Experience was $169,009 = 22.13%). Effective April 27, 2021, the Report Cards used by Local Board staff to evaluate sub-grantees and communicate their successes and deficiencies was modified to add Work Experience expenditures and make it worth 10/25 points in the financial section towards their final score. This made WEX spending part of the review every month and conversation every quarter and made it impossible to score in the top tier without also meeting the WEX target, which is set at 25% for each service provider. Additional technical assistance was provided June 24, 2021 for all youth service providers, led by EPG’s Director, Program Performance & Data Quality to clarify the requirements and provide guidance on how programs might be realigned to increase their focus on work experience activities. EPG believes these efforts will be reflected in program performance in fiscal year 2022. The above corrective action plans have been confirmed by management of Employ Prince George's, Inc. __________________________________ Jeffrey Dufresne Chief Financial Officer

View Audit 306272 Questioned Costs: $1

Finding 396248 (2021-003)

Material Weakness 2021

Pierre Indian Learning Center

SD

Reporting Subrecipient Monitoring

The School's SF 425 reports are currently up to date and are being submitted in a timely manner to our Superintendent for review then sent on to the BIE Grants Specialist.

View Audit 305901

Finding 396247 (2021-010)

Material Weakness 2021

California Fire Safe Council, Inc.

CA

Questioned Costs Subrecipient Monitoring Cash Management § 200.305

Finding 2021-010 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jessica Martinez, Program Director Joel Rusco, Chief Financial and Administrative Officer Jacy Hyde, Executive Director Contact Person: Jessica Martinez, P...

Finding 2021-010 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jessica Martinez, Program Director Joel Rusco, Chief Financial and Administrative Officer Jacy Hyde, Executive Director Contact Person: Jessica Martinez, Program Director Joel Rusco, Chief Financial and Administrative Officer Corrective Action Plan: • Clark Nuber has reviewed CFSC’s cash management policies and procedures. Clark Nuber’s proposed updates and revisions will be reviewed and approved by CFSC management and thereafter implemented by all CFSC staff. • CFSC will ensure the amount of advance payments requested from the funder are limited to the minimum amounts of funding needed and are timed to distribute in accordance with the actual cash requirements of CFSC or the subrecipient to carry out the approved program or project. • CFSC will review their subrecipient monitoring policy to determine and update where appropriate to ensure compliance with eh Unform Guidance. Payments made to subrecipients will be on a cost reimbursement basis unless subrecipients can show they have an adequate cash management policy in place. At that time, CFSC will make payments to subrecipients based on requests for advances; however, CFSC will continue to monitor the subrecipient to ensure it is minimizing the time lapse between the advance request by the subrecipient and the distribution of the grant funds. Anticipated Completion Date: CFSC will implement the above corrective actions by the end of Quarter 2 of 2024.

View Audit 305892 Questioned Costs: $1

Finding 396246 (2021-009)

Material Weakness 2021

California Fire Safe Council, Inc.

CA

Subrecipient Monitoring § 200.303 § 200.331 § 200.332

Finding 2021-009 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jessica Martinez, Program Director Joel Rusco, Chief Financial and Administrative Officer Jacy Hyde, Executive Director Contact Person: Jessica Martinez, P...

Finding 2021-009 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jessica Martinez, Program Director Joel Rusco, Chief Financial and Administrative Officer Jacy Hyde, Executive Director Contact Person: Jessica Martinez, Program Director Corrective Action Plan: • CFSC has retained Clark Nuber to assist in updating its policies and procedures to include a risk assessment for all subrecipients. The updated procedure includes a review of the subrecipients’ past audits and the development of a thorough monitoring plan based on an assessment of risk and/or audit findings pertaining to federal awards. • CFSC will update its policies and procedures to require subrecipients to report matching funds on a quarterly basis to ensure the matching requirement is met by the end of the grant period. Anticipated Completion Date: CFSC will implement these corrective actions by the end of Quarter 2 of 2024.

View Audit 305892

Finding 396245 (2021-008)

Material Weakness 2021

California Fire Safe Council, Inc.

CA

Subrecipient Monitoring § 200.331

Finding 2021-008 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jessica Martinez, Program Director Jacy Hyde, Executive Director Contact Person: Jessica Martinez, Program Director Corrective Action Plan: • CFSC will upd...

Finding 2021-008 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jessica Martinez, Program Director Jacy Hyde, Executive Director Contact Person: Jessica Martinez, Program Director Corrective Action Plan: • CFSC will update the subaward development procedure to include a review of the subaward agreement to ensure all applicable information and requirements are communicated to subrecipients at the time of the subaward in accordance with 2CFR 200.331(a). • Clark Nuber has reviewed the current subaward management policies and procedures as well as the subaward agreements. Clark Nuber has prepared an updated subaward agreement appendix that will be included with every new subaward. The subaward agreement will include all the necessary information to comply with the Uniform Guidance before the subaward agreement is provided to the subrecipient. After review and approval by CFSC management, the updated subaward shall be used by CFSC staff. Anticipated Completion Date: CFSC will update and implement its policies and subaward agreement by the end of Quarter 2 of 2024.

View Audit 305892

Finding 396243 (2021-006)

Material Weakness 2021

California Fire Safe Council, Inc.

CA

Subrecipient Monitoring Reporting Material Weakness § 200.328 § 200.329

Finding 2021-006 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jessica Martinez, Program Director Joel Rusco, Chief Financial and Administrative Officer Jacy Hyde, Executive Director Contact Person: Joel Rusco, Chief F...

Finding 2021-006 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jessica Martinez, Program Director Joel Rusco, Chief Financial and Administrative Officer Jacy Hyde, Executive Director Contact Person: Joel Rusco, Chief Financial and Administrative Officer Jessica Martinez, Program Director Corrective Action Plan: • CFSC retained Clark Nuber to review current reporting policy and procedures. Clark Nuber’s recommendations will be reviewed and approved by CFSC management and thereafter implemented by all CFSC staff. • CFSC will implement the updated policy, procedures, and tracking mechanisms to ensure all grant progress reports are submitted to managers prior to the due date for review, approval, and timely submission to the funding agency. • CFSC is conducting a full review of policies and procedures to ensure they are compliant with GAAP and Uniform guidance requirements. Anticipated Completion Date: CFSC will establish and implement the new policies and procedures by the end of Q2 2024.

View Audit 305892

Finding 396189 (2021-004)

Significant Deficiency 2021

City of Manteca

CA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding #SA2021-004: Allowable Subrecipient and Contract Costs Assistance Listing Number: 14.218 Assistance Listing Title: COVID-19 - Community Development Block Grants/Entitlement Grants Name of Federal Agency: Department of Housing and Urban Development Pass Through Entity: San Joaquin County Comm...

Finding #SA2021-004: Allowable Subrecipient and Contract Costs Assistance Listing Number: 14.218 Assistance Listing Title: COVID-19 - Community Development Block Grants/Entitlement Grants Name of Federal Agency: Department of Housing and Urban Development Pass Through Entity: San Joaquin County Community Development Department Federal Award Identification Number: A-93-916 • Name(s) of the contact person: Shay Narayan, Director of Finance; Carmen Gusman, Deputy Director of Finance • Corrective Action Plan: The City will develop procedures for grant management, accounting and reporting to ensure that only allowable subrecipient costs are claimed and are supported by contract. • Anticipated Completion Date: 06/30/24

View Audit 305817 Questioned Costs: $1

Finding 395789 (2021-005)

Material Weakness 2021

United Keetoowah Band of Cherokee Indians in Oklahoma

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.318 § 200.326

2021-005 Procurement Standards set out at 2 CFR sections 200.318 through 200.326 Management Response: The Tribe will update fiscal, payroll, HR, and procurement policies by the end of the year. Anticipated Completion Date: 12/31/2024 Responsible Party: Treasurer, Comptroller, Accounting Manager and ...

2021-005 Procurement Standards set out at 2 CFR sections 200.318 through 200.326 Management Response: The Tribe will update fiscal, payroll, HR, and procurement policies by the end of the year. Anticipated Completion Date: 12/31/2024 Responsible Party: Treasurer, Comptroller, Accounting Manager and Federal Programs Accounting Manager

View Audit 305423

Finding 395606 (2021-004)

Significant Deficiency 2021

Free Russia Foundation

DC

Cash Management Subrecipient Monitoring

2021-004 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...

2021-004 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, 2021. 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 2021, 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, 2022 Contact Person: Natalia Arno, President, 202-549-2417

View Audit 305213

Finding 394547 (2021-104)

Significant Deficiency 2021

Pancare of Florida, INC

FL

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.328

Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hired a new Chief Financ...

Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its reporting policy and implemented the changes. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented

View Audit 304417

Finding 394531 (2021-108)

Significant Deficiency 2021

Pancare of Florida, INC

FL

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.328

Lack of Documentation Related to Reporting Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within th...

Lack of Documentation Related to Reporting Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implement

View Audit 304417

Finding 394529 (2021-106)

Significant Deficiency 2021

Pancare of Florida, INC

FL

Subrecipient Monitoring HUD Housing Programs Significant Deficiency § 200.303

Missing Documentation to Support Payroll Authorizations Condition: The Organization could not provide one salary authorization form for sample selection of 40 employees under ALN #93.224 and 93.527 Health Care Center. The Organization could not provide one salary authorization form for sample sele...

Missing Documentation to Support Payroll Authorizations Condition: The Organization could not provide one salary authorization form for sample selection of 40 employees under ALN #93.224 and 93.527 Health Care Center. The Organization could not provide one salary authorization form for sample selection of eight employees under ALN #93.498 COVID-19 Provider Relief Fund. Corrective Action Planned: The Organization continues to engage the consulting services of a professional certified accounting firm. The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization will implement additional review procedures related to the salary authorization forms to verify accuracy of the information and review our procedures related to retention of documentation. The Organization will consider implementing additional procedures associated with employees agreeing to the salary as well as specifically identifying the revenue sources (e.g. specific grants, local funds, etc.) when applicable. The Organization implemented this corrective action during fiscal year 2023. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented

View Audit 304417

Finding 394528 (2021-105)

Material Weakness 2021

Pancare of Florida, INC

FL

Cash Management Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Use of Budgeted Versus Actual Costs for Reimbursements Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Corrective Action Planned: The Organization has hired a n...

Use of Budgeted Versus Actual Costs for Reimbursements Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented

View Audit 304417

Finding 394526 (2021-101)

Material Weakness 2021

Pancare of Florida, INC

FL

Subrecipient Monitoring Special Tests & Provisions Matching / Level of Effort / Earmarking § 200.303

Lack of Internal Controls Over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identi...

Lack of Internal Controls Over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization’s policies for the sliding fee scale were recently updated during fiscal year 2022, by management, based on findings during the monitoring by HRSA performed in 2022, but management will consider discussing potential improvements to their policy with the grantor to potentially update it to allow for certain exceptions. The Organization will also consider discussing the agreement with the local school district in more detail with the grantor to either structure their policies to allow for these visits to have different requirements or to see if the grantor would be willing to provide a waiver with regards to theses visits not being technically in compliance with other regular clinic visits. The planned corrective action for this finding is currently in the process of development, approval, and implementation. The Organization expects to have the corrective action implemented by July 1, 2024. The Organization will continue to engage the consulting services of the professional certified accounting firm to assist in this process through completion. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: July 1, 2024

View Audit 304417

Finding 394020 (2021-003)

Significant Deficiency 2021

Abilities Network, Inc.

MD

Subrecipient Monitoring Reporting Significant Deficiency § 200.303 § 200.328 § 200.329

U.S. Department of Health and Human Services 2021-003 Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend that the Organization design, implement and monitor internal controls over reporting as well as maintain source documentation to sup...

U.S. Department of Health and Human Services 2021-003 Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend that the Organization design, implement and monitor internal controls over reporting as well as maintain source documentation to support amounts reported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will maintain evidence of timely submission of reports, review of reports and documentation to support amounts reported. Additionally, management will implement a formal documentation retention policy. Name of the contact person responsible for corrective action: Lyn Elliot, CEO Planned completion date for corrective action plan: 3/1/2024

View Audit 304152

Finding 393845 (2023-003)

Significant Deficiency 2021

Hospital Comunitario Buen Samaritano, Inc.

PR

Questioned Costs Eligibility Subrecipient Monitoring

As discussed during the past couple of weeks we are lacking some detailed information that could have helped us clarify some of, or all of the questions and/ or doubts that you have raised, but unfortunately key people that generated the list are no longer employees (Finance Director, Human Resource...

As discussed during the past couple of weeks we are lacking some detailed information that could have helped us clarify some of, or all of the questions and/ or doubts that you have raised, but unfortunately key people that generated the list are no longer employees (Finance Director, Human Resource Director, and Payroll Manager). In regards to whom was eligible, this is a more difficult question to answer primarily due to the same reasons expressed above. But asking the team members that are still employed, they indicated that most of areas during this stage of the pandemic had direct or indirect contact with the patients visiting us, reason being that a significant percentage of our employees at the time were diagnosticated with COVID-19. In order to significantly improve future Federal funds receipts management processes, we will take the following steps: 1. Discuss, document and safe guard documentations regarding meetings that take place with all responsible parties on Federal requirements that must be followed to ensure compliance (Signatures required of all participants) 2. Depending on the nature of the funds and its intended utilization, the responsible parties will designate whom (Position/Department) will be the custodian of all the documentation 3. Ensure that each step of the implementation processes is well documented, with clear instructional details that are required to comply with the Federal requirements 4. Before submitting the required information, the responsible parties must meet to ensure that all requirements have been met, and that all required documentation is safe guarded for future reference (Signatures required of all participants) The plan will be approved by the Board and implemented no later than April 26th, 2024.

View Audit 304036 Questioned Costs: $1

Corrective Action Plans

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