Corrective Action Plans

Finding 500281 (2023-004)

Significant Deficiency 2023

WA

Reporting § 200.303 § 200.329

Type of Finding: Significant Deficiency in Compliance and Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification ...

Type of Finding: Significant Deficiency in Compliance and Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year: H79TI083313 - 2020 Award Period: September 28, 2020, through September 27, 2025 Criteria or specific requirement: 2 CFR 200.303(a) states that a non-Federal entity must "Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO)." In addition, 2 CFR 200.329(c)(1) states that “the non-federal entity must submit performance reports at the interval required by the Federal awarding agency or pass-through entity to best inform improvements in program outcomes and productivity”. Per the award agreement for contract W912DW-20-2-0003, "Recipient shall submit to the Agreement Administrator (see paragraph 1.2.1) progress reports on a quarterly basis utilizing the form included in Attachment B of this agreement. Reports are due no later than 30 days following the end of each reporting period. A final performance progress report shall be submitted within 90 days after the expiration date of the award." Condition: During testing it was noted that 3 of the 6 financial reports tested did not include documentary evidence of Executive Director review and approval. In addition, 2 of the 2 performance reports tested were filed after the filing deadline. Questioned costs: None. Context: A sample of 6 was made from a population of 17 financial reports, and a sample of 2 was made from a population of 4 performance reports. Of the 6 financial reports sampled, 3 did not have documentary evidence of Executive Director review and approval. Of the 2 performance reports sampled, both were filed after the submission deadline date. Cause: Late filing is due to a lack of adherence to the due dates as defined within the contract terms. The Organization does not have adequate controls in place to document the Executive Director's review and approval of the Federal Financial Reports (SF-425). Effect: Not filing reports on a timely basis can present risks, such as outdated and unreliable information or the inability to detect potential fraud or irregularities. In addition, delayed reports can impede regulatory authorities' ability to monitor compliance, detect patterns or trends, and assess risks in a timely manner. Without adequate documentary evidence around the review of financial reports, there is an increased risk of errors and fraud in the reporting process, which could result in inaccurate financial reporting and misappropriation of funds. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2022-004. Recommendation: CLA recommends for the Organization to place emphasis on stronger controls around the timely filing of required reports, such as retaining a monthly checklist of required reconciliations and reports. CLA also recommends implementing a procedure that documents the Executive Director's review and approval of the Federal Financial Reports (SF-425s), whether that be via an email chain or retaining a copy that also includes the Executive Director's signature on the report. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Previous corrective actions were completed in April 2024 upon receipt of our FY 2022 Audit from CLA. We believe these corrective actions would have captured most, if not all, of the findings if they were in place for the entire FY23 period. That said we have further reviewed and strengthened our internal controls and training to all staff around the timely filing of required reports. This has included creating a calendar of required reconciliations and reports for all agreements. Further, we have updated our procedure for review, approval, and documentation of Federal Financial Reports. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/1/2024

View Audit 323064

Finding 500280 (2023-003)

Significant Deficiency 2023

Ecostudies Institute

WA

Internal Control / Segregation of Duties Cash Management HUD Housing Programs § 200.303

Type of Finding: Significant Deficiency in Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year:...

Type of Finding: Significant Deficiency in Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year: H79TI083313 - 2020 Award Period: September 28, 2020, through September 27, 2025 Criteria or specific requirement: The Organization, as part of their stated controls, require that expenditures must be approved by the ED, CFO, or program directors / managers. In addition, § 200.303(a) requires the Organization to establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition: During our testing, it was noted that 12 of 60 samples did not include sufficient records to substantiate approval of the disbursement. Questioned costs: None. Context: A sample of 60 was made from a population of over 250 disbursements charged to the major program. Of the 60 sampled costs, 12 did not have sufficient records to substantiate adequate approval. Cause: Approvals are not maintained for ACH transactions. Effect: Without adequate controls in place to ensure costs are reasonable and intended for the program charged, the Organization could incorrectly charge expenditures to the federal program, report fraudulent expenditures, or not request appropriate reimbursement that the Organization is entitled to under the terms of the grant. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2022-003. Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence should be obtained and retained by the Organization as proof of oversight of expenditure of federal funds. CLA would also recommend the use of an AP voucher, or similar, for each type of disbursement that leaves the Organization (check, ACH, EFT, credit card, etc.) to improve documentary evidence that costs are being reviewed and approved for appropriateness. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Previous corrective actions were completed in April 2024 upon receipt of our FY 2022 Audit from CLA. We believe these corrective actions would have captured most, if not all, of the findings if they were in place for the entire FY23 period. That said we have further reviewed and expanded our internal controls and training for all staff on documenting evidence of approvals, including obtaining and retaining necessary documentation and proof of expenditure oversight for federal funds to ensure there is adequate evidence that costs are being reviewed and approved for appropriateness. As noted above, we have added a procurement approval form and a standardized process for approval signature, quotes, sole source evidence and price analyses. We are also investigating an AP voucher process through our existing accounting software. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/1/2024

View Audit 323064

Finding 500275 (2023-006)

Material Weakness 2023

St. Vincent General Hospital District

CO

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303

Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, ...

Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, over the past 12 months we have started to reap the reward of the hard work through operationally increasing revenue, reducing costs, and being more strategic on service lines. This will allow for us to hit the reserve amounts in 2025, while maintaining the cash flow needed for operations.

View Audit 323053

Finding 500255 (2023-001)

Significant Deficiency 2023

King County Public Hospital District #2 Dba Evergreen Healthcare

WA

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303 § 200.403

AUDIT FINDINGS 2023-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, there was a system pr...

AUDIT FINDINGS 2023-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, there was a system pricing issue that resulted in an incorrect amount of expenses related to inventory that were submitted to FEMA for reimbursement. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: FEMA has been notified and the amount has been updated as part of the project closeout. Anticipated Completion Date: September 2024 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2023-001.

View Audit 323033 Questioned Costs: $1

Finding 500184 (2023-001)

Material Weakness 2023

Nationwide Children's Hospital

OH

Procurement, Suspension & Debarment § 200.214 § 200.303

Finding 2023-001 Grantor: Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Title: Suspension and Debarment Award Year: Fiscal year 2023 1/1/2023 – 12/31/2023 Award Number: None Corrective Action Plan and Anticipate Completion Date Nation...

Finding 2023-001 Grantor: Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Title: Suspension and Debarment Award Year: Fiscal year 2023 1/1/2023 – 12/31/2023 Award Number: None Corrective Action Plan and Anticipate Completion Date Nationwide Children’s Hospital (the Corporation) uses a third-party to perform its suspension and debarment checks on a monthly basis. However, we noted the following matters: • The Corporation did not retain the monthly supporting documentation related to the monthly suspension and debarment check. The suspension and debarment checks performed at year-end were retained. o Management Response: In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Upon finalization of the remediation details from the September 2023 finding, Management implemented remediation in Q4 2023 to address this finding. • The Corporation does not have a process to reconcile the vendor list provided to the third-party vendor with the results received from the third-party vendor after the suspension and debarment checks are performed to ensure the listing is complete. o Management Response: In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Upon finalization of the remediation details from the September 2023 finding, Management implemented remediation to address this finding for the annual screening that was performed in Q1 2024 for year 2023. Management also implemented a monthly reconciliation process as quickly as practicable, beginning with January 2024 data. • The third-party vendor does not have a SOC 1 (System and Organization Controls) Report. The Corporation relied on the results of the suspension and debarment checks performed by the third-party vendor without implementing an internal process to ensure the results provided by the third-party vendor were accurate. o Management Response: In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Management implemented a process to verify the accuracy of the results produced by the third-party vendor. Management implemented the remediation to address the finding in the first quarter of 2024 for 4th quarter 2023 results. Responsible Person: Kathleen Dunn, JD – VP and Chief Compliance Officer Completion Date: January 31, 2024 • In addition, the Corporation performs a suspension and debarment check of all new vendors prior to activating them in the procurement system. The Corporation did not consistently maintain supporting documentation to support the vendor was checked for suspension and debarment before the “new”-vendor was set up in the procurement system. o Management Response In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Management implemented an audit process to ensure that screening documentation is maintained. This audit process flagged 2 of these 3 deficient documentation results, and documentation was subsequently uploaded to the file. The third vendor was an insurance company, which prior to mid-2023 was not screened at the time of setup based on vendor type. As of mid-2023, all vendors regardless of vendor type, are being screened at setup. Responsible Person: Mary Beth Colatruglio, CPA – Director of Accounting Completion Date: January 31, 2024

View Audit 323032

Finding 500166 (2023-006)

Material Weakness 2023

Educare of Omaha, Inc.

NE

Cash Management Eligibility Material Weakness § 200.303

US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2022 – 6/30/2023 and 7/1/2023 – 6/30/2024 Cash Management Material Weakness in Internal Control Over Compliance Criteria...

US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2022 – 6/30/2023 and 7/1/2023 – 6/30/2024 Cash Management Material Weakness in Internal Control Over Compliance Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Organization is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. Condition: The Organization was unable to provide adequate documentation to support the number of meals claimed for reimbursement. Corrective Action Plan: Management is aware of the deficiency in internal control over compliance. Management is in the process of reviewing its existing controls over the tracking and submitting of its meal counts included in its attendance records for reimbursement. Individual Responsible for Corrective Action: Veronica Jones, Fiscal Services Director Anticipated Completion Date: December 31, 2024

View Audit 322999

Finding 500165 (2023-005)

Material Weakness 2023

Educare of Omaha, Inc.

NE

Procurement, Suspension & Debarment § 200.303

US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2022 – 6/30/2023 and 7/1/2023 – 6/30/2024 Procurement, Suspension and Debarment Material Weakness in Internal Control Over Co...

US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2022 – 6/30/2023 and 7/1/2023 – 6/30/2024 Procurement, Suspension and Debarment Material Weakness in Internal Control Over Compliance Material Noncompliance Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Organization is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. Condition: The Organization entered into purchase agreements with two vendors without complying with their purchasing and procurement policies and did not follow their internal policies related to debarment and suspension. Corrective Action Plan: Management is aware of the deficiency in internal control and compliance with its procurement policies. Management is reviewing its purchasing and procurement policies and controls to ensure compliance with Uniform Guidance requirements. Individual Responsible for Corrective Action: Veronica Jones, Fiscal Services Director Anticipated Completion Date: December 31, 2024

View Audit 322999

Finding 500163 (2023-003)

Material Weakness 2023

Educare of Omaha, Inc.

NE

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303

US Department of Health and Human Services Federal Financial Assistance Listing #93.600 Head Start Cluster Applicable Federal Award Number and Year – 07CH011832-04-00 11/1/2023 – 10/31/2024, 07CH011832-03-00 11/1/2022 – 10/31/2023, 07CH011832-02-00 11/1/2021 – 10/31/2022 Activities Allowed or Unallo...

US Department of Health and Human Services Federal Financial Assistance Listing #93.600 Head Start Cluster Applicable Federal Award Number and Year – 07CH011832-04-00 11/1/2023 – 10/31/2024, 07CH011832-03-00 11/1/2022 – 10/31/2023, 07CH011832-02-00 11/1/2021 – 10/31/2022 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control Over Compliance Material Noncompliance Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: The Organization requested drawdowns of grant funds in excess of amounts awarded for the grant years ended 10/31/2023 and 10/31/2022 that were denied by the passthrough agency, Omaha Public Schools, resulting in an overstatement in grant revenue and receivables, and federal awards expended included in the schedule of expenditures of federal awards. Corrective Action Plan: Management is in the process of reviewing its accounting policies and procedures over grant monitoring to ensure amounts are tracked appropriately. Management has hired a new fiscal services director to oversee this process. Individual Responsible For Corrective Action: Veronica Jones, Fiscal Services Director Anticipated Completion Date: December 31, 2024

View Audit 322999 Questioned Costs: $1

Finding 500153 (2023-002)

Material Weakness 2023

Collaborative Solutions for Communities

DC

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.308 § 200.430

Corrective Action: Name of Contact Person Wayne Moyer and Brenda Chandler To further prevent the issues regarding employee clearances, CSC HR department will have an in-depth discussion with the grantor at time of grant renewal to ensure that the contract language states that the clearances for hir...

Corrective Action: Name of Contact Person Wayne Moyer and Brenda Chandler To further prevent the issues regarding employee clearances, CSC HR department will have an in-depth discussion with the grantor at time of grant renewal to ensure that the contract language states that the clearances for hiring will be the responsibility of the grantor. While the grantor placed the instructions for clearances in the scope of work for Safe Passage, it was not clearly outlined in the grant under personnel requirements. Proposed Completion Date August 31, 2024

View Audit 322995 Questioned Costs: $1

Finding 500134 (2023-002)

Significant Deficiency 2023

1890 Universities Foundation

DC

Subrecipient Monitoring § 200.303 § 200.330

Finding 2023-002 Program: AL No. 10.523 Centers of Excellence at 1890 Institutions Significant Deficiency and Noncompliance over Subrecipient Monitoring Corrective Action Plan for Significant Deficiency and Noncompliance over Reporting The Foundation developed a matrix for subrecipient monitoring an...

Finding 2023-002 Program: AL No. 10.523 Centers of Excellence at 1890 Institutions Significant Deficiency and Noncompliance over Subrecipient Monitoring Corrective Action Plan for Significant Deficiency and Noncompliance over Reporting The Foundation developed a matrix for subrecipient monitoring and Single Audit reports/findings is a key attribute in our assessment of risk. Our subrecipient monitoring policy and procedure was completed on November 30, 2023. Additionally, we hired a Program Coordinator in June 2023. The Program Coordinator focuses on the interface work required by our organization to support our grants administration role including subrecipient monitoring The Foundation requires quarterly progress and financial reports from our subrecipients, and our current process is to increase scrutiny of reports and supporting documents, when risk is medium or high. The Foundation performed reviews of subrecipients in 2023, however, the time stamp was not effectively documented. The Foundation has implemented procedures to effectively time stamp the verification process using Sam.gov going forward. Contact Person: Calece Hilliard, CFAO 1890 Universities Foundation Completion Date: September 30, 2024

View Audit 322978

Finding 500118 (2023-002)

Material Weakness 2023

Centro Hispano, Inc.

WI

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.318

2023-002 Coronavirus State and Local Fiscal Recovery Funds — Assistance Listing No. 21.027 Recommendation: Procurements should follow the required methods per Uniform Guidance and document the full procurement history. Procurement procedures should be designed, implemented, and written consistent w...

2023-002 Coronavirus State and Local Fiscal Recovery Funds — Assistance Listing No. 21.027 Recommendation: Procurements should follow the required methods per Uniform Guidance and document the full procurement history. Procurement procedures should be designed, implemented, and written consistent with Uniform Guidance. Personnel responsible for procurement should be trained on Uniform Guidance requirements and Centro Hispano's written procurement procedures. Action Taken: Centro Hispano drafted and approved an Accounting Policies and Procedures manual in September 2024 which conforms with Uniform Guidance requirements.

View Audit 322967 Questioned Costs: $1

Finding 499999 (2023-001)

Material Weakness 2023

Northshore University Healthsystem

IL

Reporting § 200.303 § 200.502 § 200.510

Finding 2023-001 – Reporting Assistance Listing Multiple In the immediate term, management will work with the grant consultant to modify the existing report to capture all the costs in the general ledger related to grants. Management will start a quarterly review process of the report with reconcil...

Finding 2023-001 – Reporting Assistance Listing Multiple In the immediate term, management will work with the grant consultant to modify the existing report to capture all the costs in the general ledger related to grants. Management will start a quarterly review process of the report with reconciliation to the grant detail. In addition, prior to the UG audit, management will start a year-end review process to ensure accurate and timely reporting. Responsible Official: Annaliza Villamin, System Director of Accounting, Endeavor Health

View Audit 322924

Finding 499998 (2023-003)

Material Weakness 2023

Wayne Township

IN

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

FINDING 2023-003 (Medicaid Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number: 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The...

FINDING 2023-003 (Medicaid Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number: 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Federal Cost report beginning 2022 will be done by a new firm. The firm is Blue & Co. They are a wellestablished CPA. The information that is supplied to the CPA firm will be maintained by Wayne Township and will be put the finished cost report. This is for the financial and other metrics that are needed for the report. The cost report will be reviewed for accuracy by the Township Office. The Ambulance payment adjustment is received about two- and one-half years in arrears. This comment would be repeated until we receive the funds for ambulance activity completed in 2023, which will occur in 2026. The payments received by the Medicaid program will be reviewed by the Township Accounting Specialist. After the person agrees it is then inputted into the accounting software and coded to the proper account. Before the Cost report is signed and submitted it will be reviewed by the Township and will ask questions as needed. Anticipated Completion Date: 12/31/24

View Audit 322923

Finding 499960 (2023-009)

Significant Deficiency 2023

Kandiyohi County

MN

Student Financial Aid Allowable Costs / Cost Principles Significant Deficiency § 200.303

SSIS ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the County implement procedures to document review of disbursements when not able to show an electronic approval in the SSIS system. Explanation of disagreement with audit finding: There is no disagreement with the audit ...

SSIS ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the County implement procedures to document review of disbursements when not able to show an electronic approval in the SSIS system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to document review for all SSIS disbursements. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

View Audit 322900

Finding 499959 (2023-008)

Significant Deficiency 2023

Kandiyohi County

MN

Student Financial Aid Reporting Significant Deficiency § 200.303

FOSTER CARE REPORTING Recommendation: It is recommended that the County implement procedures to review the foster care report and retain evidence of the review on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to findin...

FOSTER CARE REPORTING Recommendation: It is recommended that the County implement procedures to review the foster care report and retain evidence of the review on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will start printing a coversheet for the Fiscal Supervisor to sign and retain physical evidence of the review being done. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

View Audit 322900

Finding 499955 (2023-005)

Significant Deficiency 2023

Kandiyohi County

MN

Student Financial Aid Eligibility Reporting § 200.303

CASEFILE REVIEW (2022-005) Recommendation: It is recommended the County review case files on a periodic basis throughout the year and document the reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Count...

CASEFILE REVIEW (2022-005) Recommendation: It is recommended the County review case files on a periodic basis throughout the year and document the reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

View Audit 322900

Finding 499954 (2023-011)

Significant Deficiency 2023

Kandiyohi County

MN

Procurement, Suspension & Debarment Significant Deficiency § 200.303

SLFRF SUSPENSION AND DEBAREMENT Recommendation: It is recommended that the County ensure properly language related to suspension and debarment is included in the contract, or other records are kept on file to support a verification was done. Explanation of disagreement with audit finding: There is n...

SLFRF SUSPENSION AND DEBAREMENT Recommendation: It is recommended that the County ensure properly language related to suspension and debarment is included in the contract, or other records are kept on file to support a verification was done. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

View Audit 322900

Finding 499953 (2023-007)

Significant Deficiency 2023

Kandiyohi County

MN

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

SLFRF REPORTING Recommendation: It is recommended that the County sign off to indicate review of SLFRF Report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work at this area and inter...

SLFRF REPORTING Recommendation: It is recommended that the County sign off to indicate review of SLFRF Report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

View Audit 322900

Finding 499952 (2023-004)

Significant Deficiency 2023

Kandiyohi County

MN

Reporting § 200.303

TIMELY REIMBURSEMENT REQUESTS (2022-004) Recommendation: It is recommended the County review internal controls currently in place and design and implement procedures to request reimbursements timelier and to submit requests for reimbursements on at least a quarterly basis. Explanation of disagreeme...

TIMELY REIMBURSEMENT REQUESTS (2022-004) Recommendation: It is recommended the County review internal controls currently in place and design and implement procedures to request reimbursements timelier and to submit requests for reimbursements on at least a quarterly basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

View Audit 322900

Finding 499948 (2023-003)

Material Weakness 2023

Town of Whitestown

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.1 § 200.303

FINDING 2023-003 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Town submitted one P&E report during the audit period timely; however, a single employee prepared and submitted the P&E report withou...

FINDING 2023-003 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Town submitted one P&E report during the audit period timely; however, a single employee prepared and submitted the P&E report without a review or oversight process in place to prevent or detect and correct errors. Only one annual report was required to be submitted by the Town. For the report tested, all activity for the reporting period was not included, information submitted was not supported by the Town's records, and the reports were not fairly presented. Contact Person Responsible for Corrective Action: Matt Sumner Contact Phone Number and Email Address: 317-732-4532, msumner@whitestown.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: For applicable reports that are to be submitted for federal grants, we will implement a control/review and ensure the information being reported is correct prior to submission. Anticipated Completion Date: November 1, 2024

View Audit 322895

Finding 499947 (2023-002)

Material Weakness 2023

Town of Whitestown

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.317 § 200.318 § 200.327

FINDING 2023-002 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: The Town's policies related to SLFRF suspension and debarment requirement did not include checking the EPL...

FINDING 2023-002 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: The Town's policies related to SLFRF suspension and debarment requirement did not include checking the EPLS for vendor suspension and debarment. All three covered transactions tested did not have documentation provided to show the vendor was checked for suspension and debarment. Additionally, the Town did not have a formalized procurement policy outlining its processes and procedures with regards to the procurement of goods and services using federal grant funds. Contact Person Responsible for Corrective Action: Matt Sumner Contact Phone Number and Email Address: 317-732-4532, msumner@whitestown.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will be more diligent in finding out if our grants are federal and what requirements they have for us to follow. We will check applicable vendors for suspension and debarment and implement a control/review over those searches. Anticipated Completion Date: November 1, 2024

View Audit 322895

Finding 499928 (2023-003)

Material Weakness 2023

Chris Properties Graham Circle, Inc.

GA

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

To address the deficiencies identified in the audit regarding allowable costs, the Organization has implemented the following procedures: 1. Procurement • A Procurement Manager was hired to lead the process for sourcing, negotiating terms and conditions, and purchasing items for the organization. • ...

To address the deficiencies identified in the audit regarding allowable costs, the Organization has implemented the following procedures: 1. Procurement • A Procurement Manager was hired to lead the process for sourcing, negotiating terms and conditions, and purchasing items for the organization. • The Procurement Manager is responsible for inspecting goods as necessary and keeping records of all steps in the process. 2. Accounts Payable • Manual check request forms have been implemented; however, the Finance Department is exploring an electronic approval process through a third-party system that interfaces with Sage Intacct. • Invoices are approved by the appropriate program or administrative leader prior to submitting to Accounts Payable. • The appropriate program or administrative leader is responsible for ensuring the correct department, project, and general ledger codes are included on the check request. • The Sr. Accounts Payable Analyst is responsible for ensuring the check requests are completed with the pertinent information, entering invoices that have been approved and uploading the invoices and any additional supporting documentation into the Sage Intacct accounting system as an attachment.

View Audit 322863 Questioned Costs: $1

Finding 499913 (2023-002)

Significant Deficiency 2023

Alabama Nursing Home Association Education Foundation

AL

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303 § 200.403 § 200.405

Planned Corrective Action: Management contact the facility receiving the overpayment to recoup the funds or ask the facility to provide proof the funds were used for qualifying purposes under the program. If funds are returned, they will be redistributed to other facilities or returned to the Granto...

Planned Corrective Action: Management contact the facility receiving the overpayment to recoup the funds or ask the facility to provide proof the funds were used for qualifying purposes under the program. If funds are returned, they will be redistributed to other facilities or returned to the Grantor no later than December 31, 2024. Person(s) Responsible: John Matson, Executive Director

View Audit 322841 Questioned Costs: $1

Finding 499912 (2023-001)

Significant Deficiency 2023

Alabama Nursing Home Association Education Foundation

AL

Period of Performance Significant Deficiency Matching / Level of Effort / Earmarking § 200.203 § 200.303

Planned Corrective Action: The Foundation followed the express instructions of the State of Alabama, Department of Finance (the “Grantor”) to The Alabama Nursing Home Association Education Foundation (the “Foundation”), which permitted the Foundation to rely upon the certifications of nursing home a...

Planned Corrective Action: The Foundation followed the express instructions of the State of Alabama, Department of Finance (the “Grantor”) to The Alabama Nursing Home Association Education Foundation (the “Foundation”), which permitted the Foundation to rely upon the certifications of nursing home applicants that the applicant had or will have sufficient unmet needs related to qualifying purposes due to the COVID‐19 pandemic to support the receipt of the various allocations of the herein described COVID‐19 Funds. Under the terms of the certification, each applying nursing home further certified that for ten (10) years it would maintain auditable records supporting the unmet need and use of the COVID‐19 Funds. This manner of requiring only a certification for the distribution to health care providers is consistent with the requirements the federal government used when distributing an array of emergency funding (e.g., provider relief funds, rural funds, and infection control funds) to health care providers to meet the unmet needs caused by the COVID‐19 pandemic. The term “COVID‐19 Funds” means those funds the Foundation received from the Grantor with respect to (i) The CARES Act Corona Virus Relief Funds for the period from January 31, 2020, through December 31, 2021, and (ii) America Rescue Plan Act (ARPA) funds for unmet needs for qualifying purposes incurred or to be incurred during the period March 11, 2021, through December 31, 2024. To provide further assurance that the COVID‐19 Funds were properly applied by the nursing home beneficiaries receiving COVID‐19 Funds through the Foundation, the Foundation is working with its outside accountants and legal counsel to develop a look‐back review plan. The framework of the lookback review plan will be for each nursing home beneficiary that received COVID‐19 Funds to submit during the calendar year 2024, a worksheet similar to the period reporting worksheets that are required by the federal Health Resources & Services Administration (HRSA) to justify the COVID‐19 provider relief funds, rural funds, and infection control funds received by health care providers. In addition to these HRSA type worksheets, a more in‐depth examination of a sample of nursing homes will be made by randomly selecting 10 nursing homes from a pool of the 30 nursing homes that received the most COVID‐19 Funds through the Foundation, plus another 10 nursing homes from the remainder of the pool of beneficiary nursing homes. These randomly selected nursing homes will be required to supply actual documentation supporting the COVID‐19 Funds received. This documentation will include invoices, payroll records, revenue journals, and cost reports. Among the provisions of the certifications submitted by each applying nursing home, is an acknowledgement that (i) the nursing home is subject to audit by the applicable State and federal agencies, and the Foundation, (ii) any COVID‐19 Funds received through the Foundation and not properly applied must be refunded, and the nursing home will comply with the requirement that it must maintain for ten (10) years auditable records supporting its use of the COVID‐19 Funds it received through the Foundation. In the event that it is determined that one or more nursing homes were unable to properly apply the COVID‐19 Funds to an unmet need for a qualifying purpose, those COVID‐19 Funds will be recouped and either redistributed to any nursing homes that are able show an unmet need continues to exist using a distribution formula consistent with past distributions of refunded COVID‐19 Funds, or returned to the Grantor. This redistribution or return to the Grantor will occur no later than December 31, 2024. Person(s) Responsible: John Matson, Executive Director

View Audit 322841

Finding 499893 (2023-003)

Significant Deficiency 2023

Lutheran Metropolitan Ministry

OH

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking § 200.303

LMM agrees that 4 out of 40 tested non-payroll costs did not have evidence of approval for payment. While the payments were for contracted services that were received by LMM the written approval for payment was not able to be located. LMM has recently adopted Concur for expense management. With this...

LMM agrees that 4 out of 40 tested non-payroll costs did not have evidence of approval for payment. While the payments were for contracted services that were received by LMM the written approval for payment was not able to be located. LMM has recently adopted Concur for expense management. With this platform all approvals are required electronically and evidence of approval will be able to be submitted.

View Audit 322823

Corrective Action Plans

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