Corrective Action Plans

Finding 469 (2022-004)

Material Weakness 2022

PA

Subrecipient Monitoring

Preparation of the SEFA and supplementary schedules has been permanently assigned to a Senior Accountant who is responsible for all grants payable and receivables with DHCD. The accountant will be responsible for updating a custom report in Microsoft Dynamics which generates the annual SEFA and the ...

Preparation of the SEFA and supplementary schedules has been permanently assigned to a Senior Accountant who is responsible for all grants payable and receivables with DHCD. The accountant will be responsible for updating a custom report in Microsoft Dynamics which generates the annual SEFA and the supplementary schedules will be manually prepared in excel. Documents will be manually adjusted if necessary and sent to Assistant Director of Finance or VP of Finance for review.

View Audit 1021

Finding 427 (2022-001)

None 2022

Metropolitan Transit Authority

TN

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

Management’s Corrective Action Plan 2022-001 – PROCUREMENT AND SUSPENSION AND DEBARMENT Corrective Action The Corrective Action Plan to resolve this finding was to have the vendor in question register with SAMS for future verifications and also submit the required notarized self-certification of...

Management’s Corrective Action Plan 2022-001 – PROCUREMENT AND SUSPENSION AND DEBARMENT Corrective Action The Corrective Action Plan to resolve this finding was to have the vendor in question register with SAMS for future verifications and also submit the required notarized self-certification of eligibility documentation. The finding was corrected on September 26, 2022 with the vendor submitting the required signed certifications as well as proof of registration on the SAMS website, which will be monitored by MTA to ensure the propriety of any future payments made to this vendor in question as well as to all other vendors. Anticipated Completion Date September 26, 2022 Name of Contact Person Ed Oliphant, Chief Financial Officer Metropolitan Transit Authority (615) 862-6129

View Audit 903 Questioned Costs: $1

Finding 426 (2022-003)

Significant Deficiency 2022

Hill County, Montana

MT

Procurement, Suspension & Debarment Subrecipient Monitoring

The County will update the Procurement Policy to address Suspension and Debarment when performed internally and will ensure that staff responsible for federal grant awards understands the requirement and will verify and document compliance.

View Audit 902

Finding 409 (2022-005)

Material Weakness 2022

Pioneercare

MN

Questioned Costs Special Tests & Provisions Subrecipient Monitoring § 200.303

Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: During testing, there were two debt covenants, net worth and the amount of capital expenditures, that w...

Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: During testing, there were two debt covenants, net worth and the amount of capital expenditures, that were not included in the monthly covenant report included in the financial packet for monitoring. There was also no control in place to seek approval prior to reaching the capital expenditure threshold of $100,000. Responsible Individuals: Nathan Johnson, CEO and Dan Stone, CFO Corrective Action Plan: We will update our monthly covenant report to include the net worth calculation and the amount of capital expenditures. We will actively seek lender approval prior to exceeding capital expenditures over $100,000. Anticipated Completion Date: December 31, 2023

View Audit 857

Finding 400 (2022-001)

None 2022

City of Hartwell, Georgia

GA

Questioned Costs Subrecipient Monitoring Cash Management § 200.502 § 200.510

RE: Single Audit Corrective Action Plan The City of Hartwell, Georgia respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Williamson and Company, CPAs 611 N Tennessee Street ...

RE: Single Audit Corrective Action Plan The City of Hartwell, Georgia respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Williamson and Company, CPAs 611 N Tennessee Street Cartersville, GA 30120 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 of findings and questioned costs. Findings – Financial Statement Audit MATERIAL WEAKNESS None Reported SIGNIFICANT DEFICIENCY None Reported Findings – Federal Award Programs Audit MATERIAL WEAKNESS None Reported SIGNIFICANT DEFICIENCY None Reported 2022-001 Clean Water State Revolving Fund – ALN: 66.458 Finding: Schedule of Expenditures of Federal Awards Preparation Recommendation: Procedures should be implemented to ensure completion of an entry to the Schedule of Federal Expenditures of Federal Awards to achieve a reliable reporting of total expenditures for an audit period. Action Taken: We acknowledge our responsibility to present the Schedule of Expenditures of Federal Awards and related notes in accordance with Uniform Guidance requirements. To ensure future implementation of this requirement, the City of Hartwell will record all expenditures on the schedule of federal expenditures going forward on for all federally funded projects. Please call or write if there are any questions/suggestions that you may have to help us further enhance the City’s operations. Sincerely, Audrey Segars Finance Director City of Hartwell, Georgia

View Audit 835

Finding 363 (2022-001)

Material Weakness 2022

East Liberty Family Health Care Center INC

PA

Questioned Costs Subrecipient Monitoring Reporting

Since taking over the financial management of ELFHCC in December 2022 we have reorganized the financial reporting process and have been able to ensure meaningful analysis on a regular basis. Policies and procedures have been created, changed, and board approved. All financial reporting is prepared, ...

Since taking over the financial management of ELFHCC in December 2022 we have reorganized the financial reporting process and have been able to ensure meaningful analysis on a regular basis. Policies and procedures have been created, changed, and board approved. All financial reporting is prepared, analyzed and presented each month without delay.

View Audit 750

Finding 360 (2022-001)

Material Weakness 2022

Franklin County

WA

Procurement, Suspension & Debarment Subrecipient Monitoring

This schedule presents the corrective action the County is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidan...

This schedule presents the corrective action the County is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2022-001 Finding caption: The County’s internal controls were inadequate for ensuring compliance with federal suspension and debarment requirements and reporting requirements. Name, address, and telephone of the County contact person: Tim Anderson, Director of Finance 1016 N. 4th Avenue Pasco, WA 99301, 509-545-3540 Corrective action the auditee plans to take in response to the finding: The county agrees with the State Auditor's Office finding on the SLFRF grant. The county takes this finding seriously and is taking steps to prevent it from happening again. Specifically, the county will: • Add language to contracts requiring vendors to certify that they are not suspended or debarred and/or conduct suspension and debarment checks online via SAM.gov and print the documentation. • Ensure that quarterly reporting is done timely and accurately. • Increase communication between the County Auditor's Office accounting department and the Commissioners' Office to ensure that all grant requirements are met. The county appreciates the State Auditor's Office's time and effort, and values the audit process as an opportunity to improve its controls and processes. Anticipated date to complete the corrective action: October 31, 2023

View Audit 728

Finding 322 (2022-002)

Material Weakness 2022

Lake County Crisis Center D/b/a A Safe Place

IL

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

Finding 2022-002 – Reporting-Control and Compliance Finding Personnel Responsible for Corrective Action: CFO and Accounting department staff Anticipated Completion Date: September 2023 Corrective Action Plan: A Safe Place will implement internal control procedures to ensure timely submission of all ...

Finding 2022-002 – Reporting-Control and Compliance Finding Personnel Responsible for Corrective Action: CFO and Accounting department staff Anticipated Completion Date: September 2023 Corrective Action Plan: A Safe Place will implement internal control procedures to ensure timely submission of all future reports. The CFO will review financial reporting prior to submission. Update: A Safe Place developed an infrastructure and implemented internal control procedures to ensure timely submission of all future reports. The CFO will review financial reporting prior to submission

View Audit 616

Finding 321 (2022-001)

Material Weakness 2022

Lake County Crisis Center D/b/a A Safe Place

IL

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

Finding 2022-001 – Reporting-Control and Compliance Finding Personnel Responsible for Corrective Action: CFO and Accounting department staff Anticipated Completion Date: September 2023 Corrective Action Plan: A Safe Place will implement internal control procedures to ensure timely submission of all ...

Finding 2022-001 – Reporting-Control and Compliance Finding Personnel Responsible for Corrective Action: CFO and Accounting department staff Anticipated Completion Date: September 2023 Corrective Action Plan: A Safe Place will implement internal control procedures to ensure timely submission of all future reports. The CFO will review financial reporting prior to submission. Update: A Safe Place developed an infrastructure and implemented internal control procedures to ensure timely submission of all future reports. The CFO will review financial reporting prior to submission.

View Audit 616

Finding 314 (2022-003)

Significant Deficiency 2022

Palmer Senior Citizens Center, Inc.

AK

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

Federal Award Finding: 2022-003 Significant Deficiency in Compliance and Internal Controls over Compliance - Reporting -Monitoring of Grant Budget and Expenditures Name and Contact Person: Heather Grato, Controller Corrective Action: The Controller with the help with of a hired consultant will gener...

Federal Award Finding: 2022-003 Significant Deficiency in Compliance and Internal Controls over Compliance - Reporting -Monitoring of Grant Budget and Expenditures Name and Contact Person: Heather Grato, Controller Corrective Action: The Controller with the help with of a hired consultant will generate a new policies and procedure that will help ensure the accounting is reviewed monthly and quarterly, and any errors are corrected before submission of grant reports. Once grant activity is adequately reviewed the Controller will create budget vs. actual financial reports to present to management and program managers or the Board. The accounting staff will file quarterly grant reports and drawdown funding before the deadline after transactions are prepared and reviewed. Proposed Completion Date: 6/30/2024

View Audit 588

Finding 303 (2022-001)

Significant Deficiency 2022

Caminar Latino Inc.

GA

Questioned Costs Subrecipient Monitoring Reporting § 200.303

Condition We reviewed all subawards made by the grantee during the audit period and found that 4 of them, totaling $224,000, were not reported to the FSRS. Correction action The FSRS will be submitted to the FFATA website. Responsible Person The Chief of Programs and Administration will submit the F...

Condition We reviewed all subawards made by the grantee during the audit period and found that 4 of them, totaling $224,000, were not reported to the FSRS. Correction action The FSRS will be submitted to the FFATA website. Responsible Person The Chief of Programs and Administration will submit the FSRS under the supervision of the Co-CEO. Anticipated completion date Within 30 days

View Audit 574

Finding 232 (2022-009)

Significant Deficiency 2022

Puerto Rico College of Physicians-Surgeons

PR

Subrecipient Monitoring Equipment & Real Property Management

The College must hire external providers with the necessary experience or skills in the management of federal grants. This must have knowledge in accounting and auditing procedures. In addition, must have experience in Uniform Guidance compliance requirements of internal policies and federal regulat...

The College must hire external providers with the necessary experience or skills in the management of federal grants. This must have knowledge in accounting and auditing procedures. In addition, must have experience in Uniform Guidance compliance requirements of internal policies and federal regulations.

View Audit 475

Finding 192 (2022-003)

Material Weakness 2022

Nulato Tribal Council

AK

Special Tests & Provisions Questioned Costs Subrecipient Monitoring § 200.305

Finding 2022-003 Lack of Internal Controls Over Cash Management Name of Contact: Martha Turner, Tribal Administrator Corrective Action Plan: We concur with the recommendation. Funds to transferred to NorthRim Bank on January 17, 2023 resulting in compliance with 2 CFR Section 200.305 advanced f...

Finding 2022-003 Lack of Internal Controls Over Cash Management Name of Contact: Martha Turner, Tribal Administrator Corrective Action Plan: We concur with the recommendation. Funds to transferred to NorthRim Bank on January 17, 2023 resulting in compliance with 2 CFR Section 200.305 advanced federal funding. The service being used to insure all deposits is called IntraFI Cash services. This is a sweep account that will automatically move all deposits to other financial institutions to assure that they are under the 250,000 limit. Funds are wholly available at any time. Proposed Completion Date: Already implemented.

View Audit 297

Finding 185 (2022-005)

Material Weakness 2022

Guam Housing and Urban Renewal Authority

GU

HUD Housing Programs Subrecipient Monitoring Reporting

Finding #2022-005 Housing Voucher Cluster Special Tests and Provisions – Rolling Forward Equity Balances Views of Responsible Officials and Planned Corrective Action Responsible accounting personnel will coordinate and prioritize with HUD to resolve the submission of its audited Fiscal Year 2020 a...

Finding #2022-005 Housing Voucher Cluster Special Tests and Provisions – Rolling Forward Equity Balances Views of Responsible Officials and Planned Corrective Action Responsible accounting personnel will coordinate and prioritize with HUD to resolve the submission of its audited Fiscal Year 2020 and 2021 financial information as required in the Financial Assessment Sub-System (FASS-PH) so that the Authority can meet the reporting requirement. Responsible Party: Frances Danieli, Controller Anticipated Date of Completion: Ongoing effort with HUD

View Audit 281

Finding 184 (2022-004)

Material Weakness 2022

Guam Housing and Urban Renewal Authority

GU

HUD Housing Programs Subrecipient Monitoring Reporting

Finding #2022-004 Housing Voucher Cluster Reporting Views of Responsible Officials and Planned Corrective Action Responsible accounting personnel will coordinate and prioritize with HUD to resolve the submission of its audited Fiscal Year 2020 and 2021 financial information as required in the Fina...

Finding #2022-004 Housing Voucher Cluster Reporting Views of Responsible Officials and Planned Corrective Action Responsible accounting personnel will coordinate and prioritize with HUD to resolve the submission of its audited Fiscal Year 2020 and 2021 financial information as required in the Financial Assessment Sub-System (FASS-PH) so that the Authority can meet the reporting requirement. Responsible Party: Frances Danieli, Controller Anticipated Date of Completion: Ongoing effort with HUD

View Audit 281

Finding 180 (2022-002)

Significant Deficiency 2022

Guam Housing and Urban Renewal Authority

GU

Subrecipient Monitoring Special Tests & Provisions Allowable Costs / Cost Principles

Finding #2022-002 Emergency Solutions Grant Program Special Tests and Provisions – Obligation, Expenditure and Payment Requirements Views of Responsible Officials and Planned Corrective Action GHURA agrees with the recommendation to review and process payment requests from subrecipients within the...

Finding #2022-002 Emergency Solutions Grant Program Special Tests and Provisions – Obligation, Expenditure and Payment Requirements Views of Responsible Officials and Planned Corrective Action GHURA agrees with the recommendation to review and process payment requests from subrecipients within the 30-day time frame. Responsible Party: Katherine Taitano, Chief Planner, and Jerricho Garcia, General Accounting Supervisor Anticipated Date of Completion: September 30, 2024

View Audit 281

Finding 178 (2022-001)

Material Weakness 2022

Guam Housing and Urban Renewal Authority

GU

Subrecipient Monitoring HUD Housing Programs Reporting

Finding #2022-001 CDBG – Entitlement Grants Cluster Reporting Views of Responsible Officials and Planned Corrective Action The Integrated Disbursement and Information System (IDIS) accounts for transactions using the cash basis method of accounting (real-time) while GHURA’s trial balance reflects ...

Finding #2022-001 CDBG – Entitlement Grants Cluster Reporting Views of Responsible Officials and Planned Corrective Action The Integrated Disbursement and Information System (IDIS) accounts for transactions using the cash basis method of accounting (real-time) while GHURA’s trial balance reflects transactions using the accrual basis method of accounting. Due to the differing accounting methods, variances are expected between reports extracted from IDIS and GHURA’s accounting system. The responsible party will prepare a reconciliation between GHURA’s trial balance and the IDIS reports to ensure the completeness and accuracy of the reported amounts. GHURA agrees with the recommendation to monitor subawards for reporting in FSRS. Responsible Party: Katherine Taitano, Chief Planner, and Jerricho Garcia, General Accounting Supervisor Anticipated Date of Completion: September 30, 2024

View Audit 281

Finding 66 (2022-001)

Material Weakness 2022

County of Madera

CA

Questioned Costs Subrecipient Monitoring HUD Housing Programs

The Community and Economic Development Planning Division has implemented the following procedures for the fiscal year ending June 30, 2023. For non-compliant loans that do not provide responses to annual residency and request for home insurance three letters will be sent by mail to grant recipient....

The Community and Economic Development Planning Division has implemented the following procedures for the fiscal year ending June 30, 2023. For non-compliant loans that do not provide responses to annual residency and request for home insurance three letters will be sent by mail to grant recipient. If a response is not received a certified letter will be sent with the request for information followed by a phone call to the number on file. The final step is to send a certified letter stating the loan is out of compliance and will become due and payable in full. For Economic Development loans an annual audit will be conducted June to ensure that the requirements of the grant are met. If audit finds any non-compliance issues are found three letters will be sent by mail to grant recipient. If a response is not received a certified letter will be sent with the request for information followed by a phone call to the number on file. The final step is to send a certified letter stating the loan is out of compliance and will become due and payable in full. We will update our loan receivables listing to include a compliance check box which indicate that the loan is complying and actually a receivable at the end of the year.

View Audit 61 Questioned Costs: $1

Finding 2 (2022-001)

Material Weakness 2022

City of Cheney

WA

Procurement, Suspension & Debarment Subrecipient Monitoring

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Cheney January 1, 2022 through December 31, 2022 This schedule presents the corrective action planned by the City for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 20...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Cheney January 1, 2022 through December 31, 2022 This schedule presents the corrective action planned by the City for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2022-001 Finding caption: The City lacked adequate internal controls for ensuring compliance with federal suspension and debarment requirements. Name, address, and telephone of City contact person: Cindy Niemeier, Finance Director 609 2nd Street Cheney, WA 99004 (509) 498-9215 Corrective action the auditee plans to take in response to the finding: The City of Cheney places a high priority to comply with all federal funding requirements and contract with legal and reputable contractors. The intent of the ARPA program SLFRF funds was to receive and disburse the funds into the community for aid and infrastructure projects in response to the COVID pandemic. The City’s received funds under the $10,000,000 threshold allowing the City to use the funds for a variety of purposes including water infrastructure and programs allowing citizens to conduct business with the City on a remote basis. Historically, federal funds have been received for use in Public Work projects where the Suspension and Debarment check is completed by our contracted engineers. Although the required check was completed, there was no policy or process to retain documentation. The software purchases were made under an existing contract with the software provider that is currently in good standing to receive federal funds, although no separate contract with the required suspension and debarment clause was issued. To comply with the required documentation, all 2022 contracts using SLFRF funds have now been verified as eligible to receive federal funds and all future contracts will now include the required federal suspension and disbarment clause. Anticipated date to complete the corrective action: September 26, 2023

View Audit 44

Finding 1241641 (2021-014)

Material Weakness 2021

Commonwealth Healthcare Corporation

MP

Reporting Subrecipient Monitoring § 200.303

Finding No.: 2021-014 AL Program: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Area: Reporting Questioned Costs: $0 Contact Person(s): Program Manager and Director of DGFI Corrective Action Plan: CHCC agrees with the Findings an...

Finding No.: 2021-014 AL Program: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Area: Reporting Questioned Costs: $0 Contact Person(s): Program Manager and Director of DGFI Corrective Action Plan: CHCC agrees with the Findings and will establish a stringent records retention policy, even for reports that were electronically completed and submitted using Grantor portals. These fiscal reports were done on the RedCap before 2023 and were readily accessible, hence ELC Program Staff did not maintain separate offline copies of the reports. When ELC transitioned to ELC CAMP, we lost access to the submitted and saved reports. Hence, we cannot provide supporting documents to our assertion that all reports have been submitted. Responsible Official: Program Administrator, Director of DGFI and Chief Financial Officer Proposed Completion Date: On-going

View Audit 415697

Finding 1241640 (2021-013)

Material Weakness 2021

Commonwealth Healthcare Corporation

MP

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.1 § 200.303 § 200.516

Finding No.: 2021-013 AL Program: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Area: Procurement Suspension and Debarment Questioned Costs: $79,194 Contact Person(s): Program Administrator, Director of DGFI and Chief Financial O...

Finding No.: 2021-013 AL Program: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Area: Procurement Suspension and Debarment Questioned Costs: $79,194 Contact Person(s): Program Administrator, Director of DGFI and Chief Financial Officer Corrective Action Plan: CHCC concurs with the compliance finding concerning the absence of documented, contemporaneous suspension and debarment verification but respectfully disagrees with the questioned costs of $79,194. Under 2 CFR 200.516(b)(5), the effect of an audit finding should establish a clear and logical link between the identified condition and its actual or potential impact. Although CHCC did not retain evidence that the vendors’ exclusion status was verified before entering into the covered transactions, the historical SAM.gov Exclusions reports confirm that this vendor was not suspended, debarred, or otherwise excluded during the relevant procurement periods. Accordingly, the procedural deficiency did not result in an award to an ineligible vendor. Additionally, 2 CFR 200.516(b)(6) requires questioned costs to be identified and their computation explained. The $79,194 represents the total expenditure under the seven covered transactions rather than costs demonstrated to be unallowable, unsupported, unreasonable, or incurred with an excluded vendor. The expenditures were supported, incurred for authorized program purposes, and resulted in goods or services received by CHCC. CHCC Division Grants and Financial Integrity (DGFI), updated our Suspension and Debarment procedure to comply with 2 CFR 180.300. Responsible Official: Director of Procurement and Supply, Director of DGFI and Chief Financial Officer Proposed Completion Date: 09/30/2026

View Audit 415697

Finding 1241639 (2021-012)

Material Weakness 2021

Commonwealth Healthcare Corporation

MP

Equipment & Real Property Management Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.313

Finding No.: 2021-012 AL Program: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Area: Equipment and Real Property Management Questioned Costs: -0- Undeterminable Contact Person(s): Director of Procurement and Supply and Chief Fin...

Finding No.: 2021-012 AL Program: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Area: Equipment and Real Property Management Questioned Costs: -0- Undeterminable Contact Person(s): Director of Procurement and Supply and Chief Financial Officer Corrective Action Plan: CHCC concurs with the findings. CHCC updated its Capital Assets policy on June 10, 2026, to comply with the requirements of 2 CFR 200.313. Pursuant to the revised policy, CHCC will update the fixed assets listing for all the required components and proper documentation reconciliation results. Responsible Official: Director of Procurement and Supply, Director of DGFI and Chief Financial Officer Proposed Completion Date: 12/31/2026

View Audit 415697

Finding 1241638 (2021-011)

Material Weakness 2021

Commonwealth Healthcare Corporation

MP

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.1 § 200.303 § 200.516

Finding No.: 2021-011 AL Program: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Area: Procurement Suspension and Debarment Questioned Costs: $352,470 Contact Person(s): Program Manager, Procurement, DGFI Corrective Action Plan: CHCC concurs with the compliance finding con...

Finding No.: 2021-011 AL Program: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Area: Procurement Suspension and Debarment Questioned Costs: $352,470 Contact Person(s): Program Manager, Procurement, DGFI Corrective Action Plan: CHCC concurs with the compliance finding concerning the absence of documented, contemporaneous suspension and debarment verification but respectfully disagrees with the questioned costs of $352,470. Under 2 CFR 200.516(b)(5), the effect of an audit finding should establish a clear and logical link between the identified condition and its actual or potential impact. Although CHCC did not retain evidence that the vendors’ exclusion status was verified before entering into the covered transactions, the historical SAM.gov Exclusions reports confirm that none of the vendors were suspended, debarred, or otherwise excluded during the relevant procurement periods. Accordingly, the procedural deficiency did not result in an award to an ineligible vendor. Additionally, 2 CFR 200.516(b)(6) requires questioned costs to be identified and their computation explained. The $352,470 represents the total expenditure under the seven covered transactions rather than costs demonstrated to be unallowable, unsupported, unreasonable, or incurred with an excluded vendor. The expenditures were supported, incurred for authorized program purposes, and resulted in goods or services received by CHCC. CHCC Division Grants and Financial Integrity (DGFI), updated our Suspension and Debarment procedure to comply with 2 CFR 180.300. Responsible Official: Director of Procurement and Supply, Director of DGFI and Chief Financial Officer Proposed Completion Date: 09/30/2026

View Audit 415697

Finding 1241637 (2021-010)

Material Weakness 2021

Commonwealth Healthcare Corporation

MP

Equipment & Real Property Management Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.313

Finding No.: 2021-010 AL Program: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Area: Equipment and Real Property Questioned Costs: $-0- Undetermined Contact Person(s): Procurement Director Corrective Action Plan: CHCC concurs with the findings. CHCC updated its Capital A...

Finding No.: 2021-010 AL Program: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Area: Equipment and Real Property Questioned Costs: $-0- Undetermined Contact Person(s): Procurement Director Corrective Action Plan: CHCC concurs with the findings. CHCC updated its Capital Assets policy on June 10, 2026, to comply with the requirements of 2 CFR 200.313. Pursuant to the revised policy, CHCC will update the fixed assets listing for all the required components and proper documentation reconciliation results. Responsible Official: Director of Procurement and Supply, Director of DGFI and Chief Financial Officer Proposed Completion Date: 12/31/2026

View Audit 415697

Finding 1241636 (2021-009)

Material Weakness 2021

Commonwealth Healthcare Corporation

MP

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

Finding No.: 2021-009 AL Program: 93.268 Immunization Cooperative Agreement Area: Special Tests and Provision – Record of Immunization Questioned Costs: -0- Contact Person(s): Program Administrator, Program Manager Corrective Action Plan: Since 2020, the CHCC has conducted the following steps to ens...

Finding No.: 2021-009 AL Program: 93.268 Immunization Cooperative Agreement Area: Special Tests and Provision – Record of Immunization Questioned Costs: -0- Contact Person(s): Program Administrator, Program Manager Corrective Action Plan: Since 2020, the CHCC has conducted the following steps to ensure that annual site visits for VFC providers are completed and documented appropriately to evaluate adherence to the VFC program requirements: - Worked with CDC Subject Matter Experts to ensure that data systems for site visit findings/reporting were accessible to the VFC Coordinator. Training on the system was also provided to the VFC Coordinator. This system is cloud based and accessible to anyone provided access. Therefore, should staff turnover occur, access to prior reports and the system for submitting new site visit reports will continue to be accessible to the organization and to team members who will take on the responsibility. - Ensure that Position Descriptions for the VFC Coordinator clearly specify responsibilities for implementing the VFC Program in accordance with the VFC Operations Guide, which outlines the requirements for annual provider compliance site visits, including the sampling of patient records to verify eligibility screening and administration of VFC vaccine only to eligible children. - Provided training/refresher to the staff member assigned/responsible (VFC Coordinator) for conducting site visits - Timeliness and completeness of site visit entries have been incorporated as part of the program’s activity workplan. Site visits were suspended per the CDC Project Officer during that time period due to the COVID-19 response. E-mail communication from the CDC Project Officer is attached. The Program continued to continuously monitor VFC Providers were maintaining proper storage of vaccines and verify that information on vaccination records was maintained by each VFC Provider despite not conducting a formal site visit. Responsible Official: Program Manager, Program Administrator, and Director of Public Health Services Proposed Completion Date: On-going

View Audit 415697

Corrective Action Plans

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