Corrective Action Plans

Finding 404749 (2023-003)

Significant Deficiency 2023

National Disability Rights Network, Inc.

DC

Reporting § 200.303 § 200.508 § 200.510

Views of Responsible Officials: NDRN’s finance staff turnover, coupled with the staff’s lack of formal training with NDRN’s accounting system, resulted in a lack of knowledge on how to prepare the actual schedule. However, it did not affect the staff’s ability to properly identify and categorize exp...

Views of Responsible Officials: NDRN’s finance staff turnover, coupled with the staff’s lack of formal training with NDRN’s accounting system, resulted in a lack of knowledge on how to prepare the actual schedule. However, it did not affect the staff’s ability to properly identify and categorize expenditures for invoicing purposes to the Federal government. Moving forward, NDRN finance fiscal staff will conduct regular internal SEFA reporting as part of the monthly reporting indicated in Finding 2023-002 above.

View Audit 311143

Finding 404698 (2023-002)

Significant Deficiency 2023

Ke Ola Mamo

HI

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

Ref No. 2023-002 SIGNIFICANT DEFICIENCYI It was noted one instance out of forty that the employee timesheet did not agree with the payroll register. The hours on the timesheet were 45, while the hours on the payroll register were 48 hours. This resulted in an overcharge of $159 to the program. I...

Ref No. 2023-002 SIGNIFICANT DEFICIENCYI It was noted one instance out of forty that the employee timesheet did not agree with the payroll register. The hours on the timesheet were 45, while the hours on the payroll register were 48 hours. This resulted in an overcharge of $159 to the program. It was also noted one out of seventy-one timesheets were not approved by the supervisor. Recommendation: Ke Ola Mamo should exercise greater care in reviewing timesheets and data entered into the payroll system to ensure that only allowable costs are charged to the program. Action Taken: Ke Ola Mamo was in the process of implementing an on-line payroll processing system during Fiscal Year 2023. The implementation was completed during Fiscal Year 2023. This process minimizes potential clerical errors as employees input the hours they work directly into the on-line payroll system, with employees’ supervisors and the Human Resources Specialist approving prior to the payroll being processed.

View Audit 311070

Finding 404424 (2023-001)

Significant Deficiency 2023

Primary Care Medical Services of Poinciana, Inc.

FL

Subrecipient Monitoring Special Tests & Provisions Allowable Costs / Cost Principles § 200.303

MANAGEMENT’S CORRECTIVE ACTION PLAN Finding Number: 2023-001 Planned Corrective Action: We concur with the finding. We will continue with retaining documentation of sliding scale determination electronically. The CFO will continue to monitor whether the record retention policy is being followed. In ...

MANAGEMENT’S CORRECTIVE ACTION PLAN Finding Number: 2023-001 Planned Corrective Action: We concur with the finding. We will continue with retaining documentation of sliding scale determination electronically. The CFO will continue to monitor whether the record retention policy is being followed. In regard to the finding, we had usual turnover in the department during the year which resulted in procedures not being followed precisely. We have since hired new employees and have provided additional training to prevent similar documentation errors from occurring. In additional, we have instituted a monitoring process to ensure that all policies and procedures are followed without exception. Anticipated Completion Date: On-going Responsible Contact Person: Cynthia Diaz, Chief Financial Officer

View Audit 311030

Finding 404251 (2023-001)

Significant Deficiency 2023

Central Texas Senior Ministry

TX

Cash Management Internal Control / Segregation of Duties § 200.303

Management has established and implemented written procedures to ensure future compliance. Management will increase the detail of the review process over the tracking of meals, including both the financial function and those with direct knowledge and supervision of the services being performed. Mana...

Management has established and implemented written procedures to ensure future compliance. Management will increase the detail of the review process over the tracking of meals, including both the financial function and those with direct knowledge and supervision of the services being performed. Management will also offer additional training for program staff.

View Audit 311007

Finding 404223 (2023-005)

Material Weakness 2023

Atrium Health, Inc.

NC

Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303

Corrective Action Plan: Atrium Health CMHA management will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT systems specific to the SFA program. Proposed Completion Date: ...

Corrective Action Plan: Atrium Health CMHA management will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT systems specific to the SFA program. Proposed Completion Date: Management will complete the corrective action plan by the end of 2024.

View Audit 310986

Finding 404222 (2023-004)

Material Weakness 2023

Atrium Health, Inc.

NC

Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303

Corrective Action Plan: Atrium Health CMHA management will address the current year finding either through system modifications to allow for electronic saving of the applicable notifications or by implementing a manual process to retain them. Proposed Completion Date: Management will complete...

Corrective Action Plan: Atrium Health CMHA management will address the current year finding either through system modifications to allow for electronic saving of the applicable notifications or by implementing a manual process to retain them. Proposed Completion Date: Management will complete the corrective action plan by October 2024.

View Audit 310986

Finding 404157 (2023-003)

Material Weakness 2023

City of Jacksonville

FL

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.212 § 200.303 § 200.318 § 200.332 § 200.514

Action Plan: Upon learning of this finding during the FY2022 audit, we worked with our external consultant, our Council auditors and our external auditor to reperform and review the base year and subsequent year calculations of revenue, using financial information in our final audit reports. These...

Action Plan: Upon learning of this finding during the FY2022 audit, we worked with our external consultant, our Council auditors and our external auditor to reperform and review the base year and subsequent year calculations of revenue, using financial information in our final audit reports. These corrected calculations of lost revenue have been clearly documented and will be reported going forward. We will continue to work to ensure that all controls for grants be documented with written procedures. The procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, reperformable manner including the name of each responsible individual, the specific control they performed over compliance for the grant and the date(s) the controls were performed. Contact Names responsible for the plan – Marcia Saulo Anticipated completion date of the plan – September 30, 2024

View Audit 310950

Finding 404156 (2023-002)

Material Weakness 2023

City of Jacksonville

FL

Allowable Costs / Cost Principles Special Tests & Provisions Subrecipient Monitoring § 200.303 § 200.330

Action Plan: Upon learning of this finding during the FY2022 audit, we worked with the Neighborhoods Department to ensure wage rate requirement compliance was prioritized going forward. Considering this finding was presented near the completion of the FY2023 year, we expect this finding to be resolv...

Action Plan: Upon learning of this finding during the FY2022 audit, we worked with the Neighborhoods Department to ensure wage rate requirement compliance was prioritized going forward. Considering this finding was presented near the completion of the FY2023 year, we expect this finding to be resolved in FY2024. We will continue to work with our departments to ensure that all controls for grants are documented with written procedures. The procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, reperformable manner including the name of each responsible individual, the specific control they performed over compliance for the grant and the date(s) the controls were performed. Contact Names responsible for the plan – Marcia Saulo Anticipated completion date of the plan – September 30, 2024

View Audit 310950

Finding 404102 (2023-001)

Material Weakness 2023

City of Groveland, Florida

FL

HUD Housing Programs Reporting Matching / Level of Effort / Earmarking § 200.303

The City agrees with the recommendation to strengthen internal controls over grant reporting processes. To enhance accountability and accuracy, grant reports authored by the designated grant recipient, who is the City employee tasked with managing the grant activity, will now undergo a review by som...

The City agrees with the recommendation to strengthen internal controls over grant reporting processes. To enhance accountability and accuracy, grant reports authored by the designated grant recipient, who is the City employee tasked with managing the grant activity, will now undergo a review by someone else in the City independent of the report preparation. This review will focus on ensuring the reports are complete, accurate, and fully compliant with all stipulated grant requirements.

View Audit 310883

Finding 404101 (2023-001)

Significant Deficiency 2023

City of Butler

PA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303

Federal Agency: Department of Housing and Urban Development Pass Through Agency: Pennsylvania Department of Community and Economic Development Program: Community Development Block Grants/ State's Program and Non-Entitlement Grants in Hawaii (CDBG), ALN 14.228 Criteria: In accordance with 2 CFR Pa...

Federal Agency: Department of Housing and Urban Development Pass Through Agency: Pennsylvania Department of Community and Economic Development Program: Community Development Block Grants/ State's Program and Non-Entitlement Grants in Hawaii (CDBG), ALN 14.228 Criteria: In accordance with 2 CFR Part 200.303, a non-Federal entity must establish and maintain effective internal control over Federal awards that provide 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: The City did not have a process in place to obtain invoices or other supporting documentation from the subrecipient to ensure that the CDBG funding was spent on activities allowed and allowable costs prior to reimbursing the subrecipient. Subsequent to making the 2023 payments to the subrecipient, the City obtained the invoices for review. Cause: The City did not have procedures in place to ensure that the CDBG invoices to support payments to the subrecipient were obtained and reviewed. Effect: The lack of internal control processes to review supporting documentation to ensure compliance with federal requirements prior to payments being made to subrecipients could result in unallowable costs to occur and not be detected prior to payment of funding to the subrecipient. Questioned costs: Unknown Recommendation: We recommend that the City obtains invoice support for all reimbursement requests from the subrecipient prior to payment. These requests should be reviewed for allowable activities and allowable costs by an individual knowledgeable of the program requirements prior to approving for payment. This review should be documented. View of Responsible Officials and Planned Corrective Action: Mayor and City Clerk will be responsible for corrective action. The City will obtain invoice support for all reimbursement requests from the subrecipient PRIOR to payment. These requests will be reviewed for allowable activities and allowable costs by the Mayor of the City of Butler prior to payment. This review (invoices) will be documented and saved in a file on the clerk's computer. Trigger for the mayor to review invoices will be the email from DCED requesting signatures from the Mayor and the City Clerk. The procedures for reviewing all payment requests shall begin July, 2024 and shall be ongoing.

View Audit 310881 Questioned Costs: $1

Finding 404039 (2023-002)

Material Weakness 2023

National Association of Chronic Disease Directors

GA

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

Finding 2023-002: Overdrawn Federal Funding Condition The auditors identified duplicated federal award expenditures amounting to $380,644, resulting in overdrawn federal funds by $380,644. The excess cash on hand was not returned to the funding source in a timely manner. Correction action: NACDD has...

Finding 2023-002: Overdrawn Federal Funding Condition The auditors identified duplicated federal award expenditures amounting to $380,644, resulting in overdrawn federal funds by $380,644. The excess cash on hand was not returned to the funding source in a timely manner. Correction action: NACDD has experienced drastic change in size over the past 3-4 years. Current policies and procedures have not been adequate for the size and volume of the transactions experienced in FY 23. In addition, there has been significant finance/accounting staff turnover including leadership of the Finance team. +The impact of this deficiency was isolated to one cooperative agreement which closed out as of 9.30.23. NACDD performed efficient and effective subsequent disbursement procedures after year end to ensure that expenses for this grant and others were recorded in the appropriate fiscal year. In the process of preparing the FFR and researching further additional expenditures related to this grant, expenses included in the initial subsequent disbursement adjustments, related to this grant were duplicated. +The Correction action plan includes previously implemented augmentation of the Finance staff. Since the end of the FY 23 fiscal year, the finance department has been fully staffed with knowledgeable accounting professionals, many who have financial federal grant experience. There is now a financial analyst on staff whose main responsibility is to reconcile and record federal grant expenditures and receivables. This process is done monthly. We believe that this additional procedure will eliminate the recurrence of this and any other like issues. Procedures related to the weekly PMS drawdown have been expanded to include reconciling the accounts receivable by grant with the PMS accounts to allow only amounts listed in PMS which are supported with appropriate expenditures to be drawn. +Implementation of corrective measures: The above expanded procedures and oversight have been in effect for most of the FY 24 fiscal year. PMS drawdowns are now done weekly with worksheets that tie in detail to the weekly expenditures. In addition, a control checklist will be created and utilized by the Finance staff leadership to monitor and document the successful implementation of corrective measures. + Additional over-arching controls – The Finance team will execute an interim audit process inhouse as of 6.30.24 and every year going forward to further identify errors and irregularities that may exist. If necessary, additional policies and procedures will be implemented to provide greater scope and assurance in preventing financial reporting errors. Responsible Person Trish H. Strong, CFO Anticipated completion date June 30, 2024

View Audit 310859 Questioned Costs: $1

Finding 404007 (2023-003)

Significant Deficiency 2023

Great Lakes Inter-Tribal Council Inc.

WI

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

Corrective Actions Taken or Planned: Create procedures by type of required reporting by grantor, as necessary. The procedure will include what and how the required report will be completed, who will and/or should review the required report, including signature for proof, and when the required report...

Corrective Actions Taken or Planned: Create procedures by type of required reporting by grantor, as necessary. The procedure will include what and how the required report will be completed, who will and/or should review the required report, including signature for proof, and when the required report should be completed. Procedures will be added to the accounting department procedures and shared with staff as necessary. Contact person(s) responsible for corrective action: Gina Brown, CFO Anticipated Completion Date: September 2024

View Audit 310846

Finding 403884 (2023-002)

Significant Deficiency 2023

Daleville City Board of Education

AL

Questioned Costs Equipment & Real Property Management Procurement, Suspension & Debarment § 200.303 § 200.313 § 200.439

Item 2023-002- Equipment and Real Property Management Recommendation: 2 CFR 200.303 requires the non-Federal entity to "(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non Federal entity is managing the Federal statutes, reg...

Item 2023-002- Equipment and Real Property Management Recommendation: 2 CFR 200.303 requires the non-Federal entity to "(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award." 2 CFR 200.313 and 2 CFR 200.439 requires that the following rules of allow ability must apply to equipment and other capital expenditures "Capital expenditures for special purpose equipment are allowable as direct costs, provided that items with a unit cost of $5,000 or more have the prior written approval of the Federal awarding agency or pass-through entity. The Chief School Financial Officer, Jessica Pettway, should review documentation for proper approval of equipment and real property prior to encumbrance. Action Taken: Management has reviewed the requirements of 2 CFR Section 200.13 and CFR 200.439 relating to capital expenditures and agrees with the recommendation. Effective July 1, 2024, the Chief School Financial Officer, Jessica Pettway, will review for proper approval of equipment and real property prior to encumbrance.

View Audit 310758 Questioned Costs: $1

Finding 403882 (2023-001)

Material Weakness 2023

Daleville City Board of Education

AL

Questioned Costs Allowable Costs / Cost Principles Special Tests & Provisions § 200.303 § 200.326

Item 2023-001- Special Tests and Provisions - Wage Rate Requirements Recommendation: 2 CFR 200.303 requires the non-Federal entity to "(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non- Federal entity is managing the Federa...

Item 2023-001- Special Tests and Provisions - Wage Rate Requirements Recommendation: 2 CFR 200.303 requires the non-Federal entity to "(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non- Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award." 2 CFR 200.326 and 29 CFR Part 5, Labor Standards Provisions Applicable to Contracts Governing Federally Financed and Assisted Construction (DOL Regulations) require the contractor or subcontractor to submit to the nonfederal entity weekly, for each week in which any contract work is performed, a copy of the payroll and a statement of compliance (certified payrolls). We recommend the strengthening of controls to ensure the prevailing wage rate clauses are included in the contracts and that certified payrolls are received for each week in which construction work is performed. The Chief School Financial Officer, Jessica Pettway, should review documentation for inclusion of the prevailing wage rate clauses in construction contracts as part of the bid process prior to expenditures being made. She should also review all invoices received from contractors and subcontractors to ensure that the certified payroll information is received for all weeks for which construction work is performed. Action Taken: Management has reviewed the requirements of 2 CFR Section 200.303 and 2 CFR 200.326 relating to wage rate requirements and agrees with the recommendation. Management has already communicated with all contractors and subcontractors regarding the wage rate requirements and has implemented additional procedures, effective July 1, 2023, stating that the Chief School Financial Officer, Jessica Pettway, will review documentation for inclusion of the prevailing wage rate clauses in construction contracts as part of the bid process prior to expenditures being made. She will also review all invoices received from contractors and subcontractors to ensure that the certified payroll information is received for all weeks for which construction work is performed.

View Audit 310758 Questioned Costs: $1

Finding 403861 (2023-001)

Material Weakness 2023

Washington County, Fl

FL

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Item 2023‐001 – Suspension & Debarment Contact person: Johnnie Pettis, Deputy Clerk Finding – Adequate controls were not in place to provide for proper review of covered transactions for suspension and debarment. Covered transactions, over $25,000 paid with grant funding were not reviewed for susp...

Item 2023‐001 – Suspension & Debarment Contact person: Johnnie Pettis, Deputy Clerk Finding – Adequate controls were not in place to provide for proper review of covered transactions for suspension and debarment. Covered transactions, over $25,000 paid with grant funding were not reviewed for suspension and debarment. Management Response – The County will implement additional controls to ensure there is evidence of review of covered transactions over $25,000 for suspension and debarment prior to payment. Johnnie Pettis, Deputy Clerk will be responsible for the corrective action and anticipates completion of corrective action will be taken before September 30, 2024. Effective date of completion: within the fiscal ending September 30, 2024

View Audit 310745

Finding 403813 (2023-004)

Significant Deficiency 2023

Institute for Sustainable Communities, Affiliate and Subsidiary

VT

Cash Management Period of Performance Significant Deficiency § 200.303

Management agrees with the recommendations. We are revising our Award Management policies to ensure the closeout procedures are clear and comply with this recommendation. We will ensure that all relevant teams are part of the closeout planning process to ensure expenses are planned for and allocated...

Management agrees with the recommendations. We are revising our Award Management policies to ensure the closeout procedures are clear and comply with this recommendation. We will ensure that all relevant teams are part of the closeout planning process to ensure expenses are planned for and allocated correctly within the period of performance. We also established a Grants Compliance Team that will be responsible for the compliance oversight of awards from inception to closeout.

View Audit 310730

Finding 403703 (2023-003)

Material Weakness 2023

City of Opp, Al

AL

Allowable Costs / Cost Principles § 200.303 § 200.328

Item 2023‐003 Performance Reporting – Annual Project and Expenditure Report Recommendation: We recommend the strengthening of controls to ensure annual reporting required under the compliance supplement is performed in a timely manner. Action Taken: Management, namely Jan Boutwell, City Clerk, agree...

Item 2023‐003 Performance Reporting – Annual Project and Expenditure Report Recommendation: We recommend the strengthening of controls to ensure annual reporting required under the compliance supplement is performed in a timely manner. Action Taken: Management, namely Jan Boutwell, City Clerk, agrees with the finding and will implement the necessary internal controls to ensure annual reporting is submitted timely. Management anticipates completion by September 30, 2024.

View Audit 310723

Finding 403702 (2023-002)

Material Weakness 2023

City of Opp, Al

AL

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.305 § 200.319 § 200.320

Item 2023‐002 Written policies, procedures, and standards of conduct Recommendation: Grantees should have written policies, procedures, and standards of conduct as required by 2 CFR 200, Subparts D & E of the Uniform Guidance. 2 CFR 200, Subparts D & E requires the non‐Federal entity to establish an...

Item 2023‐002 Written policies, procedures, and standards of conduct Recommendation: Grantees should have written policies, procedures, and standards of conduct as required by 2 CFR 200, Subparts D & E of the Uniform Guidance. 2 CFR 200, Subparts D & E requires the non‐Federal entity to establish and maintain written policies, procedures, and standards of conduct including internal controls over the Federal awards that provides reasonable assurance that the non‐Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award. Specific requirements relate to the following: § 200.302 Financial management  § 200.305 Payment  § 200.319 Competition  § 200.320 Methods of procurement to be followed  § 200.430 Compensation—personal services  § 200.431 Compensation—fringe benefits We recommend that the City implement the required written policies and procedures. Action Taken: Management, namely Jan Boutwell, City Clerk, agrees with the finding and will implement the necessary written policies to comply with the UG. Management anticipates completion by September 30, 2024.

View Audit 310723

Finding 403609 (2023-001)

Material Weakness 2023

Metropolitan Transit Authority of Harris County, Texas

TX

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.403

METRO's Grant Programs Administration Division will review and implement changes, as necessary, to established policies and procedures regarding expense transactions to be charged to a grant and reimbursed by the granting agency. Emphasis will be placed on reimbursements for prior year costs not typ...

METRO's Grant Programs Administration Division will review and implement changes, as necessary, to established policies and procedures regarding expense transactions to be charged to a grant and reimbursed by the granting agency. Emphasis will be placed on reimbursements for prior year costs not typically subject to detailed allowability assessments in accordance with federal requirements. Any change to processes and controls will be in accordance with cost principles criteria (i.e., allowable, allocable, reasonable, and necessary) as per Title 2 CFR 200.403 (a) and (b). This effort will be completed by Philip Brenner, Deputy CFO, before September 30, 2024.

View Audit 310653 Questioned Costs: $1

Finding 403580 (2023-002)

Significant Deficiency 2023

Family Health International

NC

Procurement, Suspension & Debarment § 200.303

Finding 2023-002 – Procurement and Suspension and Debarment Federal Program Information: Federal Agency: Department of Health and Human Services - Centers for Disease Control and Prevention United States Department of State Assistance Listing: 93.U02 – National Health Initiatives, Strategies and Act...

Finding 2023-002 – Procurement and Suspension and Debarment Federal Program Information: Federal Agency: Department of Health and Human Services - Centers for Disease Control and Prevention United States Department of State Assistance Listing: 93.U02 – National Health Initiatives, Strategies and Action Plans for Infectious Diseases 19.415 – Professional and Cultural Exchange Programs – Citizen Exchanges Federal Award Identification Number: 93.U02 – HHSD2002015M88157B – 75D30120F081052 19.415 – SECAGD22CA0060 Award Year: FY 2022 – 2023 Corrective Action Plan: FHI 360 will implement a corrective action plan comprised of the following actions: 1.) implement annual staff re-training and refresher on restricted party screening requirements; 2.) bi-annual validation that the vendor records enrolled in continuous monitoring are validated existing internal vendor records for consistency 3.) quarterly validation of a sample of suspension and debarment results from the third-party service provider to the publicly available service engines. Person(s) Responsible: Director and Associate Director(s) – Global Procurement Services in coordination with Information Solutions and Services and Contract Management Services Completion Date: September 30, 2024

View Audit 310612

Finding 403578 (2023-001)

Significant Deficiency 2023

Family Health International

NC

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

Finding 2023-001 – Reporting – Federal Funding Accountability and Transparency Act (FFATA) Federal Program Information: Federal Agency: United States Agency for International Development Assistance Listing: 98.001 - USAID Foreign Assistance for Programs Overseas 98.U04 – USAID Foreign Assistance for...

Finding 2023-001 – Reporting – Federal Funding Accountability and Transparency Act (FFATA) Federal Program Information: Federal Agency: United States Agency for International Development Assistance Listing: 98.001 - USAID Foreign Assistance for Programs Overseas 98.U04 – USAID Foreign Assistance for Economic Growth Federal Award Identification Number: 98.001 - 7200AA19CA00002; 72066418CA00001; 72044020CA00002; 72049218CA00008; 72066418CA00001; 7200AA18CA00011; 72066322CA00005. 98.U04 - 72026320C00005 Award Year: FY 2022 – 2023 Corrective Action Plan: FHI 360 will implement a corrective action plan comprised of the following actions: 1.) additional global communications and meetings with key management teams; 2.) targeted and detailed training on FFATA requirements and completion of the FSRS template via an e-module; and 3.) implement an additional review through a small, centralized team both to identify prospective transactions and perform a final review of data quality prior to data entry in FSRS. Person(s) Responsible: Director, Contract Management Services Chief Operating Officer Completion Date: July 31, 2024

View Audit 310612

Finding 403473 (2023-004)

Material Weakness 2023

Crow Wing County

MN

Subrecipient Monitoring § 200.303 § 200.331

SUBRECIPIENT MONITORING – COMMUNITY DEVELOPMENT BLOCK GRANTS Recommendation: It is recommended that the County reviews their policies to ensure they are monitoring subrecipients and retaining documentation as required by federal guidelines. Explanation of disagreement with audit finding: There is no...

SUBRECIPIENT MONITORING – COMMUNITY DEVELOPMENT BLOCK GRANTS Recommendation: It is recommended that the County reviews their policies to ensure they are monitoring subrecipients and retaining documentation as required by federal guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement policies to ensure all documentation is kept and subrecipient monitoring is in place. Name of the contact person responsible for corrective action plan: Nancy Malecha, Finance Director Planned completion date for corrective action plan: December 31, 2024

View Audit 310545

Finding 403472 (2023-003)

Material Weakness 2023

Crow Wing County

MN

Subrecipient Monitoring § 200.303 § 200.331

REPORTING – COMMUNITY DEVELOPMENT BLOCK GRANTS Recommendation: It is recommended that the County reviews their policies to ensure reporting requirements are met including a review of the subrecipient reports prior to submission. Explanation of disagreement with audit finding: There is no disagreeme...

REPORTING – COMMUNITY DEVELOPMENT BLOCK GRANTS Recommendation: It is recommended that the County reviews their policies to ensure reporting requirements are met including a review of the subrecipient reports prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement policies to ensure reporting processes include review by someone other than the preparer. Name of the contact person responsible for corrective action plan: Nancy Malecha, Finance Director Planned completion date for corrective action plan: December 31, 2024

View Audit 310545

Finding 403357 (2023-005)

Material Weakness 2023

Mile Bluff Medical Center, Inc.

WI

Allowable Costs / Cost Principles Eligibility Material Weakness § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP identified the lack of documentation of review processes surrounding the expenditures ...

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP identified the lack of documentation of review processes surrounding the expenditures of the federal award. Responsible Individuals: Dara Bartels, CEO Corrective Action Plan: We have a process that requires the Grant “owners” to review and sign off on the expenditures related to any Federal Awards and other expenditure in the organization. We will add a quarterly review in the Grants office to verify the expected purpose, compliance with federal statutes, regulations and conditions of the federal award. This will also be reviewed by the CFO to create checks and balances. Anticipated Completion Date: Ongoing

View Audit 310474

Finding 403356 (2023-004)

Material Weakness 2023

Mile Bluff Medical Center, Inc.

WI

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP assisted in the Preparation of Schedule of Expenditures of Federal Awards Responsible ...

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP assisted in the Preparation of Schedule of Expenditures of Federal Awards Responsible Individuals: Dara Bartels, CEO Corrective Action Plan: Mile Bluff Medical Center has not had a lot of experience with a single audit prior to COVID grant funds. This year we experienced turnover in our CFO role, leaving the process to be re-created. We pulled together most of the information that was required but needed assistance/guidance from our auditors on how to pull the information together and report them on the required forms. We will continue to learn the layout and review the Schedule of Expenditures of Federal Awards prior to sending or addressing this with the Auditors. Anticipated Completion Date: Ongoing

View Audit 310474

Corrective Action Plans

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