Corrective Action Plans

Finding 20739 (2022-006)

Significant Deficiency 2022

MD

Questioned Costs Subrecipient Monitoring Reporting § 200.303

U.S. Department of Treasury 2022-006 COVID-19 ? Coronavirus State and Local Relief Funds (CSLRF)? Assistance Listing No. 21.027 Recommendation: The Town should review and enhance its reporting procedures and controls to ensure that quarterly performance reports are submitted no later the last day ...

U.S. Department of Treasury 2022-006 COVID-19 ? Coronavirus State and Local Relief Funds (CSLRF)? Assistance Listing No. 21.027 Recommendation: The Town should review and enhance its reporting procedures and controls to ensure that quarterly performance reports are submitted no later the last day of the month after the end of each quarter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Subsequent reports were filed by the due date and this is expected to continue. Name(s) of the contact person(s) responsible for corrective action: Steven Repole Planned completion date for corrective action plan: Completed for all subsequent reports. If the U.S. Department of Treasury, Office of Recovery Programs has questions regarding this plan, please call Steven Repole at 410-398-4170.

View Audit 21205

Finding 20737 (2022-004)

Material Weakness 2022

Town of Elkton, Maryland

MD

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.318 § 200.319 § 200.320

U.S. Department of Treasury 2022-004 COVID-19 ? Coronavirus State and Local Relief Funds (CSLRF)? Assistance Listing No. 21.027 Recommendation: The Town should review and enhance controls and procedures to ensure that it follows procurement policy for all goods and services charged to the program....

U.S. Department of Treasury 2022-004 COVID-19 ? Coronavirus State and Local Relief Funds (CSLRF)? Assistance Listing No. 21.027 Recommendation: The Town should review and enhance controls and procedures to ensure that it follows procurement policy for all goods and services charged to the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Town's procurement policy will be reviewed and updated to ensure compliance with federal requriements. Name(s) of the contact person(s) responsible for corrective action: Steven Repole Planned completion date for corrective action plan: 6/30/2023 If the U.S. Department of Treasury, Office of Recovery Programs has questions regarding this plan, please call Steven Repole at 410-398-4170.

View Audit 21205

Finding 20689 (2022-101)

Significant Deficiency 2022

Pinal County, Arizona

AZ

Reporting Subrecipient Monitoring § 200.327

Finding 2022-101 - Improve the Timeliness and Accuracy of Financial and Programmatic Reports (Significant Deficiency) FAL Numbers: 17.258, 17.259, 17.278 Program Title: Workforce Investment Opportunities Act (WIOA) Cluster Condition and Context: Two of three monthly programmatic reports teste...

Finding 2022-101 - Improve the Timeliness and Accuracy of Financial and Programmatic Reports (Significant Deficiency) FAL Numbers: 17.258, 17.259, 17.278 Program Title: Workforce Investment Opportunities Act (WIOA) Cluster Condition and Context: Two of three monthly programmatic reports tested were submitted past the deadline for the WIOA Cluster. Specifically, the January 2022 and June 2022 reports were submitted 9 days late and 26 days late, respectively. Recommendation: The auditors recommend that Pinal County improve controls over grant reporting that includes a process for identifying reporting requirements and monitoring the timely grant reporting. The system of control should include evaluating and documenting the reporting requirements of each grant and, assignment of both the employees responsible for preparation of the grant reports and a secondary employee assignment for overall monitoring of the timeliness of all grant reports. Contact Name: Joel Millman, WIOA Program Manager Corrective Action Planned: Although there are no excuses for untimely filing of financial reports, the issue found regarding the 2022 finding has been addressed. During the audit period, the Accountant position was in a state of transition with the previous Accountant leaving the position in June 2022. Since this staff departure, a new Accountant has been hired and subsequently underwent significant training provided by the Pinal County Budget and Finance Department as well as the Arizona Department of Economic Security?s Division of Employment and Rehabilitation?s (DES/DERS) Financial and Business Operations Administration. In order to ensure timely submittal of financial reports, new procedures have been implemented, these include cross training of the Pinal County Economic and Workforce Development Departments Administrative Specialist in monitoring financial report submittal dates. Additionally, the Accountant and Pinal County Economic and Workforce Development Department?s Workforce Development Manager meet upon receipt of contractor invoices to review and approve payment to ensure timely submittal of associated reports to DES/DERS. Of note, a fiscal review of the Workforce Innovation and Opportunity Act (WIOA), Title 1B program was conducted November 8th-10th, 2022 by the DES/DERS Business and Operations Administration. The periods selected for their testing were the periods of January 1, 2022, through April 30, 2022. The purpose of this review was to determine compliance with WIOA Title IB regulations and procedures, Department of Labor (DOL) guidelines and State policies. The review covered the areas of internal controls, general operation procedures, cash receipts and disbursements, accrued expenditures, program income, cash management, and miscellaneous items as outlined in the Fiscal Monitoring Guide. Documents reviewed within these general categories included disbursements journals, payroll journals, paid expense invoices, receipts journals, and payroll time sheets. No findings were submitted. Anticipated Completion Date: June 30, 2023

View Audit 28393

Finding 20628 (2022-004)

Significant Deficiency 2022

Municipality of Coamo

PR

Subrecipient Monitoring Reporting Significant Deficiency

COMMONWEALTH OF PUERTO RICO MUNICIPALITY OF COAMO Corrective Action Plan For the Fiscal Year Ended June 30, 2022 _____________________________________________________________________________________________________________________ Audit Report: Reports on Compliance and Internal Control in Acc...

COMMONWEALTH OF PUERTO RICO MUNICIPALITY OF COAMO Corrective Action Plan For the Fiscal Year Ended June 30, 2022 _____________________________________________________________________________________________________________________ Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and OMB Super Circular Uniform Guidance Audit Period: July 1, 2021 ? June 30, 2022 Fiscal Year: 2021-2022 Principal Executive: Hon. Juan C. Garcia Padilla, Mayor Contact Person: Mrs. Miraisa David Esparra, Finance and Budget Director Phone: (787) 825-1150 Original Finding Number: 2022-004 Statement of Concurrence or Non concurrence: We concur with the finding. Corrective Action: The new Program Director is aware about the compliance requirement. We gave instructions to the Program Director to maintain a dateline control sheet to ascertain that required reports were submitted within the due date. Implementation Date: April 30, 2023 Responsible Person: Mr. Hector R. Sanjurjo Rodriguez Federal Programs Director See Corrective Action Plan for chart/table

View Audit 27451

Finding 20562 (2022-001)

Material Weakness 2022

Battle Creek Housing Commission

MI

Questioned Costs Subrecipient Monitoring Material Weakness

Compliance with Laws and Regulations (Material Weakness) 2022-001 Public and Indian Housing ? CFDA 14.850 Recommendation: The Commission should require its financial institutions to provide documentation of collateral at a minimum on a quarterly basis. The Commission should also adopt policies a...

Compliance with Laws and Regulations (Material Weakness) 2022-001 Public and Indian Housing ? CFDA 14.850 Recommendation: The Commission should require its financial institutions to provide documentation of collateral at a minimum on a quarterly basis. The Commission should also adopt policies and procedures to monitor its cash and investments continuously to verify that the collateral provided by the financial institutions is adequate throughout the year. Action Taken: Management will implement a new process that will require the banks to provide proof of insurance coverage on a quarterly basis, at minimum. Anticipated Completion Date of Action: September 30, 2023

View Audit 26661 Questioned Costs: $1

Finding 20560 (2022-001)

Material Weakness 2022

The St. Luke's-Roosevelt Hospital Center and Affiliates

NY

Subrecipient Monitoring Eligibility Questioned Costs § 200.303

Current Year Audit Findings and Corrective Action Plan For the Year Ended December 31, 2022 Finding 2022-001 ? Eligibility Internal control deficiency over the reassessment requirement to determine eligibility Identification of the federal program: Assistance Listing Number 93.914 ? Program ...

Current Year Audit Findings and Corrective Action Plan For the Year Ended December 31, 2022 Finding 2022-001 ? Eligibility Internal control deficiency over the reassessment requirement to determine eligibility Identification of the federal program: Assistance Listing Number 93.914 ? Program Name: HIV Emergency Relief Project Grants ? Grantor: Department of Health and Human Services (HHS) ? Federal award identification number: Not Applicable Views of responsible officials and planned corrective actions: Management agrees with the finding. Management will develop internal controls to implement effective internal controls regarding 1) Review and retention of income and residency verification at program Intakes, and 2) Real time documentation of participants? income and residency eligibility at the required frequency (typically during 6 month Reassessments) with accepted supporting documentation for each participant. 3) This documentation will be entered into our EMR (EPIC) for each patient, outlining our eligibility verifications done at Intakes, Reassessments or Reassessment Attempts, along with screen shots from ePACES and/or other eligibility documents used. This will enable our program team and our funders and auditors to be able to more easily review our documented ongoing program eligibility for each patient. This will also improve our quality controls and will enable program staff to more effectively monitor annual eligibility checks. Contact person: Diane Tider Expected Completion Date: Implementing immediately 10/2/23

View Audit 26659

Finding 20548 (2022-004)

Material Weakness 2022

Jac-Cen-Del Community School Corporation

IN

Matching / Level of Effort / Earmarking Subrecipient Monitoring Special Tests & Provisions § 200.303 § 200.334

FINDING 2022-004 Contact Person Responsible for Corrective Action: Trina Huff Contact Phone Number:812-689-4114 Views of Responsible Official: We concur with the finding; however, if there was not a problem with the finances of this grant could this not have been a comment. There is not any one of u...

FINDING 2022-004 Contact Person Responsible for Corrective Action: Trina Huff Contact Phone Number:812-689-4114 Views of Responsible Official: We concur with the finding; however, if there was not a problem with the finances of this grant could this not have been a comment. There is not any one of us involved with this grant that would have known about the prevailing wages part of it. Description of Corrective Action Plan: Projects requiring prevailing wage are complete, so we can't change this one, but will review grant agreements and try to remember to ask grantor if prevailing wage applies if any new grants are received, so we can develop controls and monitor compliance. Anticipated Completion Date: 02/27/2023

View Audit 21805

Finding 20544 (2022-003)

Material Weakness 2022

Jac-Cen-Del Community School Corporation

IN

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303

FINDING 2022-003 Contact Person Responsible for Corrective Action: Trina Huff Contact Phone Number:812-689-4114 Views of Responsible Official: We concur with the finding; however, we were not aware that these funds participated in the public transfer. We know Title I does and we communicate with the...

FINDING 2022-003 Contact Person Responsible for Corrective Action: Trina Huff Contact Phone Number:812-689-4114 Views of Responsible Official: We concur with the finding; however, we were not aware that these funds participated in the public transfer. We know Title I does and we communicate with the other schools but we were not informed about ESSER I following these guidelines. Again, we will probably not receive these grants again and I feel they could have been comments instead of findings. Description of Corrective Action Plan: I can?t do anything about this but if we receive money like this again I will make sure and ask about the public transfer. Anticipated Completion Date: 02/27/2023

View Audit 21805

Finding 20543 (2022-002)

Material Weakness 2022

Jac-Cen-Del Community School Corporation

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.303

FINDING 2022-002 Contact Person Responsible for Corrective Action: Trina Huff Contact Phone Number:812-689-4114 Views of Responsible Official: We concur with the finding; however, these documents were reported by more than one person I just forgot or didn?t think about having someone sign off on it....

FINDING 2022-002 Contact Person Responsible for Corrective Action: Trina Huff Contact Phone Number:812-689-4114 Views of Responsible Official: We concur with the finding; however, these documents were reported by more than one person I just forgot or didn?t think about having someone sign off on it. Again, we will probably not receive these kinds of grants again and something this simple could be a comment and not a finding. I feel that if there are no issues with the actual funding and finances that it could be a comment. Description of Corrective Action Plan: I will document who helped with their portion of the report and have them sign off on it. Anticipated Completion Date: 02/27/2023

View Audit 21805

Finding 20540 (2022-004)

Material Weakness 2022

City of Cambridge Massachusetts

MA

Subrecipient Monitoring § 200.303 § 200.332

The City has established an Audit Review Certification form that will be completed by employees to formally document the review of subrecipient agencies? audit reports.

View Audit 19296

Finding 20533 (2022-003)

Material Weakness 2022

City of Cambridge Massachusetts

MA

Subrecipient Monitoring § 200.303 § 200.332

The City has established an Audit Review Certification form that will be completed by employees to formally document review of subrecipient agencies? audit reports.

View Audit 19296

Finding 20532 (2022-002)

Material Weakness 2022

City of Cambridge Massachusetts

MA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

The City will establish the following procedures to ensure payment requests received from subrecipients are paid within 30 days of receipt of a complete request for reimbursement: 1. Department of Human Service Programs (DHSP) Contract Manager reviews invoices within 5 business days of receipt of re...

The City will establish the following procedures to ensure payment requests received from subrecipients are paid within 30 days of receipt of a complete request for reimbursement: 1. Department of Human Service Programs (DHSP) Contract Manager reviews invoices within 5 business days of receipt of request for reimbursement from subrecipient. a. If invoice is complete, original date of receipt is recorded. b. If invoice is incomplete, subrecipient is notified of items or documentation that is missing and receipt date is updated to reflect date of receipt of complete invoice. 2. Contract Manager approves payment request and submits to DHSP Fiscal staff for processing. 3. Fiscal staff processes and submits to Auditing Department as Priority payment.

View Audit 19296

Finding 20531 (2022-001)

Material Weakness 2022

City of Cambridge Massachusetts

MA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

The City will update the subrecipient contract template to ensure the required language is included in all newly executed contracts certifying that the agency, its officers, and employees are not suspended or debarred from doing business with the federal government. Prior to entering into contracts ...

The City will update the subrecipient contract template to ensure the required language is included in all newly executed contracts certifying that the agency, its officers, and employees are not suspended or debarred from doing business with the federal government. Prior to entering into contracts with subrecipients, the City will check that each subrecipient is not included on the SAM.gov Exclusion List and will include a dated screenshot from the SAM.gov website documenting the review in each project file.

View Audit 19296

Finding 20511 (2022-001)

Significant Deficiency 2022

The Carle Foundation

IL

Subrecipient Monitoring Procurement, Suspension & Debarment § 200.303 § 200.332

Corrective Action Plan: Carle to proceed with publishing and implementing its Sub-Recipient Monitoring Policy. The Grants Administration Office has already created Sub-Recipient Orientation training session for Carle departments and prospective subrecipients and will work with Compliance to active...

Corrective Action Plan: Carle to proceed with publishing and implementing its Sub-Recipient Monitoring Policy. The Grants Administration Office has already created Sub-Recipient Orientation training session for Carle departments and prospective subrecipients and will work with Compliance to actively train stakeholders. Contact Person(s): Kathy Dams, Director, Grants Administration and Research Operations Anticipated Completion: 12/31/2023

View Audit 20202

Finding 20480 (2022-001)

Significant Deficiency 2022

City of Eveleth

MN

Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties

REPRESENTATION OF THE CITY OF EVELETH, MINNESOTA CORRECTIVE ACTION PLAN Year Ended December 31, 2022 Finding Number: 2022-001 Finding Title: SEGREGATION OF DUTIES Name of Contact Person Responsible for Corrective Action Jackie Monahan-Junek, City Administrator Corrective Action Planned The City Admi...

REPRESENTATION OF THE CITY OF EVELETH, MINNESOTA CORRECTIVE ACTION PLAN Year Ended December 31, 2022 Finding Number: 2022-001 Finding Title: SEGREGATION OF DUTIES Name of Contact Person Responsible for Corrective Action Jackie Monahan-Junek, City Administrator Corrective Action Planned The City Administrator will attempt to monitor transactions and structure the duties of office personnel to help ensure as much segregation of duties as possible within the City's staffing limitations and funding constraints. Anticipated Completion Date Ongoing. Finding Number: 2022.002 Finding Title: LACK OF CONTROL OVER FINANCIAL REPORTING PROCESS Name of Contact Person Responsible for Corrective Action Jackie Monahan-Junek, City Administrator Corrective Action Planned Management has determined that the cost and training involved to review or prepare the City's financial statements exceeds the benefit that would result. Anticipated Completion Date Ongoing. Jackie Monahan.Junek, City Administrator

View Audit 28327

Finding 20473 (2022-003)

None 2022

Morning Calm Apt

WA

HUD Housing Programs Questioned Costs Subrecipient Monitoring

Department of Housing and Urban Development Auditee identification number: 127-EE017 Name of audit firm: Squires Maddux & Company, PLLC Period covered by the audit: Year Ended June 30, 2022 Prepared by: S3800-160: Contact Person First Name: Marc S3800-170: Contact Person Middle Initial: ...

Department of Housing and Urban Development Auditee identification number: 127-EE017 Name of audit firm: Squires Maddux & Company, PLLC Period covered by the audit: Year Ended June 30, 2022 Prepared by: S3800-160: Contact Person First Name: Marc S3800-170: Contact Person Middle Initial: S3800-180: Contact Person Last Name: Busch Contact Email Address: marc.busch@coastmgt.com The finding from the June 30, 2022 schedule of findings and question costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDING NO. 2022-003 Recommendation: Management should institute a monitoring process to review approved HUD 9250?s ensuring that all withdrawals are made from the proper account. S3800-130: Response Indicator: Agree. S3800-140: Completion Date: March 24, 2023 S3800-150: Action Taken: Management agrees with the finding and plans to take corrective actions which include communication with the Project Accountant and Regional Manager about withdrawals, and will transfer $4,400 from the replacement reserve account to the residual receipts account..

View Audit 26498 Questioned Costs: $1

Finding 20472 (2022-002)

None 2022

Morning Calm Apt

WA

Questioned Costs Subrecipient Monitoring HUD Housing Programs

Department of Housing and Urban Development Auditee identification number: 127-EE017 Name of audit firm: Squires Maddux & Company, PLLC Period covered by the audit: Year Ended June 30, 2022 Prepared by: S3800-160: Contact Person First Name: Marc S3800-170: Contact Person Middle Initial: ...

Department of Housing and Urban Development Auditee identification number: 127-EE017 Name of audit firm: Squires Maddux & Company, PLLC Period covered by the audit: Year Ended June 30, 2022 Prepared by: S3800-160: Contact Person First Name: Marc S3800-170: Contact Person Middle Initial: S3800-180: Contact Person Last Name: Busch Contact Email Address: marc.busch@coastmgt.com The finding from the June 30, 2022 schedule of findings and question costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDING NO. 2022-002 Recommendation: Management should institute a monitoring process to ensure all required monthly deposits to the replacement reserve are made. Such process could include initiating automatic recurring monthly transfers with the financial institution that maintains the replacement reserve account. S3800-130: Response Indicator: Agree. S3800-140: Completion Date: March 24, 2023 S3800-150: Action Taken: Senior management has discussed the deficiency with the Project Accountant and Regional Manager. All future deposits the replacement reserve will be made as required in the regulatory agreement.

View Audit 26498 Questioned Costs: $1

Finding 20464 (2022-002)

Material Weakness 2022

Town of Edinburgh

IN

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

FINDING 2022-002 Contact Person Responsible for Corrective Action: Scott Finley Contact Phone Number: 812-526-3511 Contact E-mail: sfinley@edinburgh.in.us View of responsible official: The town concurs with the Section III finding identified. Description of Corrective Action Plan: For SRF disburseme...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Scott Finley Contact Phone Number: 812-526-3511 Contact E-mail: sfinley@edinburgh.in.us View of responsible official: The town concurs with the Section III finding identified. Description of Corrective Action Plan: For SRF disbursements related to construction, the town?s engineers review the pay applications and are sent to the town for review. The pay app is submitted to the council for review and approval. Upon approval, the Clerk-Treasurer signs the pay app and submits it to SRF for disbursement. Moving forward, the town council president will sign the pay app rather than the Clerk-Treasurer. For SRF Disbursements related to engineering, the invoice is reviewed by the Town Manager and Clerk- Treasurer and then submitted to SRF for disbursement. Moving forward, these invoices will be processed similarly to the construction pay apps. These invoices will be reviewed by the Town Manager and Clerk- Treasurer and then submitted to the council for approval. After council approval they will be submitted to SRF for disbursement. The town will also request that the engineers add a signature page to their invoices so they can be signed off on. Anticipated Completion Date: Process will be implemented immediately.

View Audit 24560

Finding 20460 (2022-005)

Material Weakness 2022

Jefferson County Government

CO

Matching / Level of Effort / Earmarking Questioned Costs Subrecipient Monitoring

FISCAL YEAR OF FINDING: 2022 AUDITOR FINDING: 2022-005 Eligibility. We noted the following issues in the 40 cases tested: 1. Four instances in which income was incorrectly calculated based on information maintained in case file. 2. One instance in which there was inadequate documentation to support ...

FISCAL YEAR OF FINDING: 2022 AUDITOR FINDING: 2022-005 Eligibility. We noted the following issues in the 40 cases tested: 1. Four instances in which income was incorrectly calculated based on information maintained in case file. 2. One instance in which there was inadequate documentation to support eligibility determination within the case file. 3. One instance in which the Colorado Works Referral form was not processed timely. 4. Two instances in which the County' eligibility authorization notes for the period selected did not agree to CHATS. Recommendation: We recommend that the County continue to strengthen the internal controls surrounding the eligibility process, specifically continuing the use and monitoring of case reviews to help identify potential areas for additional training. CLIENT PLANNED ACTION: Jefferson County agrees with the findings. There continues to be improvement each year in the overall findings, which demonstrates that the strategies previously implemented had the desired impact. However, the continued findings require additional action steps. Jefferson County will continue and implement the following actions to address and prevent future errors. ? The CCAP supervisor will continue reviewing available reports in CHATS to target untimely closures and follow up on potential erroneous case closures. Reports include the RE301, RE224, and RE115. Any case needing action will be assigned for completion within 5 business days and reviewed to ensure corrections were completed. ? Monthly case reviews will continue, at three levels, to assess case and payment accuracy. o The Jeffco Human Services Internal Quality Assurance (IQA) team will review 1% of the caseload monthly, utilizing the state mandated list. o The State Program Integrity Office will review cases monthly to monitor case and payment accuracy. o CCAP Supervisor and/or Lead Worker will review cases as follows: - The CCAP Supervisor will complete a minimum of two case reviews per worker per month. The number and type of review may be adjusted based on individual staff performance. Income and parent fee calculations will be targeted using the primary activity report in CHATS. The Lead Worker will fulfill this function if the Supervisor is out of the office. - 5% of all applications and redeterminations will be reviewed by the CCAP Supervisor or Lead Worker prior to approval. Jefferson County?s Internal Auditor has also been trained on the eligibility process and may review cases prior to approval to support the team. Eligibility Specialists will utilize a pre-authorization checklist when submitting the selected cases for review. The checklist was developed and implemented to assist workers in accurately entering and checking their data entry and eligibility determination. New CCAP Eligibility Specialists will have 100% of cases reviewed prior to approval until accuracy rates reach 95%, at which point preauthorization reviews will be reduced incrementally based on performance. o All responses to IQA or State Program Integrity regarding corrections or resolutions to cases will be documented and provided to the CCAP Supervisor/Program Manager within 2-5 business days, depending on the identified deadline, and will include screen shots verifying corrections prior to submittal. o Monthly meetings between the Division Director, Program Integrity Manager, Program Integrity Supervisor, Quality Assurance Supervisor, CCAP Program Manager, and CCAP Supervisor will continue in order to discuss performance and progress related to quality assurance and program integrity. Prior to the meeting, the Internal Quality Assurance (IQA) team will provide monthly reports for review and analysis. During the meetings, data and trends will be reviewed utilizing the aforementioned reports, which include error type, accuracy, and error increase/reduction over the year. In addition, training needs for staff will be discussed based on the supervisory, Internal Quality Assurance (IQA), and State level review findings and monitoring strategies will be developed to address areas of concern. ? Monthly review data is incorporated into all individual and leadership performance milestones. Milestones are the county?s employee performance management system. Continued errors or lack of progress and improvement will be addressed via the county Employee Relations coaching and disciplinary framework. ? Effective January 1, 2023, Jefferson County launched an updated model for service delivery and workload management utilizing an internal system, GenApp. The utilization of GenApp: o Improved document storage, o Increased oversight related to workload and timeliness as all pending actions can be viewed by type, date received and due date, o Simplified workload coverage due to employee leave or vacancies, o Removed inconsistencies in customer service, o Improved available reports. ? The Colorado Works Referral inbox has been prioritized by the CCAP Supervisor/Lead Worker for review and timely completion. ? Supplementary income training will be developed and delivered starting in October 2023 and continue on a quarterly basis to provide a review of income rules, calculation, common errors, and answer questions. CLIENT RESPONSIBLE PARTY: Tara Noble (Program Manager) and Monie Salgado (CCAP Supervisor) COMPLETION DATE: October 2023

View Audit 22844

Finding 20459 (2022-006)

Significant Deficiency 2022

Jefferson County Government

CO

Eligibility Questioned Costs Subrecipient Monitoring

AUDITOR FINDING: 2022-006 Eligibility. We noted the following issues in the 25 cases tested: 1. One instance in which JCHS could not provide copy of the participant's Colorado Works Individualized Plan (IP), however case comments indicated an IP was completed. 2. One instance in which the Initial As...

AUDITOR FINDING: 2022-006 Eligibility. We noted the following issues in the 25 cases tested: 1. One instance in which JCHS could not provide copy of the participant's Colorado Works Individualized Plan (IP), however case comments indicated an IP was completed. 2. One instance in which the Initial Assessment was not completed timely. 3. One instance in which JCHS did not properly cure the sanction after the client began complying with Colorado Works eligibility requirements. 4. One instance in which case comments were missing to support action of JCHS eligibility technician. CLIENT PLANNED ACTION: Jefferson County agrees with the findings and has taken or plans to take the following steps to address the errors. The findings were caused by workers on both the eligibility and workforce teams so varying measures will be implemented based on the finding and responsible team. Jefferson County will continue and implement the following actions to address and prevent future findings. ? Eligibility Team Actions o Beginning in August 2023, new processes were implemented for Colorado Works, which will improve timeliness, customer service, and increase staff program knowledge: - Prioritizing Colorado Works applications for interview scheduling within 3 business days, - Restructuring teams to create an intake and ongoing team to better meet timeliness measures, - Offering Colorado Works training in the fall of 2023, - Completed hiring for all vacant positions. o Additional training will be provided by the end of October 2023 to include: - Continue to emphasize the importance of clearing the compliance screen in CBMS when processing new applications during new worker training, - Providing a training alert requiring that all staff who process Colorado Works cases check the compliance screen as part of the intake process, - Provide coaching to the eligibility worker who processed the case. o The sanction that was improperly advanced was reversed and appropriate case note entered on August 31, 2023. ? Workforce Development Team Actions o In addition to the State and Internal Quality Assurance reviews, Colorado Works Supervisors and/or Lead Workers will review cases as follows: - Complete a minimum of two case reviews per worker per month. The number and type of review may be adjusted based on individual staff performance. The Lead Worker will fulfill this function if the Supervisor is out of the office or as needed to the team. Areas of focus will include but are not limited to timely case comments, active Individual Plans, and CBMS data entry. o Updated standards implemented in July 2022 requiring documents be uploaded into the document storage system, GenApp, within 7 days. o Training delivered during new employee onboarding and starting in May 2023, offered on a quarterly basis for document uploading and best practices. o Finding related to missing case note was corrected on August 23, 2023. CLIENT RESPONSIBLE PARTY: CW Eligibility Team: Amy Brown (Program Manager), Stephanie Reese (Program Manager) and Jennifer Martinez (Quality Assurance & Systems Administrator) CW Workforce Development Team: Tara Noble (Program Manager), Kathryn Boyd-Cordova (CW Supervisor), and Erin Encinias (CW Supervisor) COMPLETION DATE: September 2023

View Audit 22844

Finding 20406 (2022-005)

Material Weakness 2022

Landmann-Jungman Memorial Hospital, Inc.

SD

Special Tests & Provisions Questioned Costs Subrecipient Monitoring § 200.303

Finding 2022-005 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: UMH did set aside a reserve amount within a saving account; however, the funds were not segregated in a separat...

Finding 2022-005 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: UMH did set aside a reserve amount within a saving account; however, the funds were not segregated in a separate bookkeeping account or bank account. Additionally, UMH entered into three debt arrangements during the fiscal year with a financial institution without obtaining prior written consent from the agency. Responsible Individuals: Melissa Gale, CEO; Erin Odens, CFO Corrective Action Plan: LJMH will have the USDA reserve money segregated as a separate line item in the financials. LJMH did submit proper information to the USDA for the three loans that were entered into without consent and USDA did reply back with post-loan approval concurrence. Future loans will be approved through the USDA prior to entering into them. Anticipated Completion Date: March 1, 2023

View Audit 24965

Finding 20389 (2022-005)

Significant Deficiency 2022

Wickenburg Community Hospital

AZ

Questioned Costs Student Financial Aid Subrecipient Monitoring

Finding 2022-005 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Compliance Requirement: Reporting Finding Summary: Management was unaware of the requirement to submit the annual proposed budget to the R...

Finding 2022-005 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Compliance Requirement: Reporting Finding Summary: Management was unaware of the requirement to submit the annual proposed budget to the Rural Development Area Office within 30 days of each year end. The Hospital approves the budget annually. However, the budget is not submitted to USDA. Responsible Individuals: Patti Clavette, Chief Financial Officer; Jackie Lundblad, Chief Executive Officer Corrective Action Plan: Management will put a process in place to ensure the approved budget is submitted to USDA within 30 days of year end. Anticipated Completion Date: December 31, 2023

View Audit 21564

Finding 20381 (2022-001)

Significant Deficiency 2022

Tri-County Community Health Council, Inc. (d/b/a Commwell Health)

NC

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

CORRECTIVE ACTION PLAN November 4, 2022 Health Resources and Services Administration Tri-County Community Health Council, Inc. (d/b/a CommWell Health) respectfully submits the following corrective action plan for the year ended March 31, 2022. _______________________________________________________...

CORRECTIVE ACTION PLAN November 4, 2022 Health Resources and Services Administration Tri-County Community Health Council, Inc. (d/b/a CommWell Health) respectfully submits the following corrective action plan for the year ended March 31, 2022. ____________________________________________________________________________________ CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: March 31, 2022 The findings from the March 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS ? FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Centers Program Cluster (Assistance listing number 93.224/93.527) Finding 2022-001 - Special Tests and Provisions SIGNIFICANT DEFICIENCY Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken CommWell Health concurs with the recommendation and has designed a series of enhancements to existing registration orientation and ongoing training. Additional training time will be dedicated with current front desk registration colleagues to ensure that they can determine household income from the documentation given to them by patients. This education will be completed by December 31, 2022. New hire orientation training will include a thorough review of the Front Desk Handbook and slide fee procedures. Post-test will be given to each front desk colleague upon completion of education. Scores of at least 90% will required or training and testing will be repeated. In addition, CommWell Health is moving to a new electronic health record (EHR), EPIC, beginning November 7, 2022. This system has much better controls built in to help ensure that slide fee is documented correctly. EPIC also does not have many of the system limitations our previous EHR had. Audits of 100% of slide fee records will be done every day by designated colleagues to ensure slide fee documentation is correct. Supervisors will review daily audit findings and ensure additional training is given accordingly. Corrective action will be taken on any errors noted during audits. Finance staff will conduct random internal audits of slide fee records each month to evaluate for compliance with applicable requirements. Results of internal audits will be reviewed monthly in Utilization Review Committee. If the Health Resources and Services Administration has questions regarding this plan, please call Cheryl Stanley, Chief Financial Officer, at 910-567-7008.

View Audit 20022

Finding 20322 (2022-002)

None 2022

City of Birmingham

AL

Special Tests & Provisions Subrecipient Monitoring Allowable Costs / Cost Principles

Corrective Action Plan: Management has arranged for grants training for relevant employees. Directors over the City's ESG federal program will develop procedures with the City's Finance Department in order to ensure that the City meets the award requirements for both ESG and ESG- CV funds. Perso...

Corrective Action Plan: Management has arranged for grants training for relevant employees. Directors over the City's ESG federal program will develop procedures with the City's Finance Department in order to ensure that the City meets the award requirements for both ESG and ESG- CV funds. Person Responsible: Dr. Meghan V. Thomas, Director of Community Development Aaron L. Saxton, Acting Director of Finance

View Audit 28073

Finding 20319 (2022-002)

Significant Deficiency 2022

Simpson Midtown INC

PA

Subrecipient Monitoring HUD Housing Programs Significant Deficiency

Views of Responsible Officials and Planned Corrective Actions: Management will ensure proper training is given to staff responsible for annual recertifications. Management will ensure monthly reconciliation of recertification is reviewed timely and all supporting documentation of the reconciliation ...

Views of Responsible Officials and Planned Corrective Actions: Management will ensure proper training is given to staff responsible for annual recertifications. Management will ensure monthly reconciliation of recertification is reviewed timely and all supporting documentation of the reconciliation is kept in the resident tenant files.

View Audit 28212

Corrective Action Plans

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