Corrective Action Plans

Finding 499291 (2023-002)

Significant Deficiency 2023

NY

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

Corrective Action Plan: The Corporation will enhance internal control procedures to ensure that all cash disbursements are reviewed and approved by management before issuance. The procedure will involve: 1. Voucher Review Protocol: A checklist will be created to ensure that all disbursements are acc...

Corrective Action Plan: The Corporation will enhance internal control procedures to ensure that all cash disbursements are reviewed and approved by management before issuance. The procedure will involve: 1. Voucher Review Protocol: A checklist will be created to ensure that all disbursements are accompanied by documented approvals. This checklist will include verification of the approval by both management and legal counsel when necessary. 2. Management Approval: Disbursements, particularly those over $500,000, will require formal sign-off from the Chief Executive Officer and review by the Legal Department. 3. Training & Compliance: Staff will be trained on the updated process, and compliance will be regularly reviewed by the internal audit team. A report on adherence to these new procedures will be made available to the Board quarterly. 4. Verification of Prior Disbursement: Regarding the specific instance cited, management will review the process followed to verify that the review by Albanese and LDC counsel, as referenced in the email, was correctly documented. If this was indeed the case, a follow-up with the auditors will be initiated to clarify the discrepancy. Responsible Individual: Joseph Ninomiya - Chief Executive Officer Planned Date of Implementation: October 15, 2024

View Audit 322107

Finding 499241 (2023-001)

None 2023

The New York and Presbyterian Hospital

NY

Matching / Level of Effort / Earmarking Questioned Costs § 200.303 § 200.403

1)The duplicate invoice for $92,880.00 was removed from the Tracker worksheet which was submitted in 11/27/2023. 2)The duplicate invoice for $91,511.66 will be removed from the FEMA Project 140215 Tracker worksheet which will be submitted by the end of September 2024. 3)The discounts taken for early...

1)The duplicate invoice for $92,880.00 was removed from the Tracker worksheet which was submitted in 11/27/2023. 2)The duplicate invoice for $91,511.66 will be removed from the FEMA Project 140215 Tracker worksheet which will be submitted by the end of September 2024. 3)The discounts taken for early payment of contract labor invoices for a certain vendor will be corrected on the FEMA Project 140215 Tracker worksheet which will be submitted by the end of September 2024.

View Audit 322040 Questioned Costs: $1

Finding 499239 (2023-004)

Significant Deficiency 2023

Home Forward

OR

Questioned Costs Special Tests & Provisions Matching / Level of Effort / Earmarking § 200.303

Continuum of Care – Assistance Listing No. 14.267 Recommendation: We recommend Home Forward design controls to ensure formal documentation of approval of comparables is in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in r...

Continuum of Care – Assistance Listing No. 14.267 Recommendation: We recommend Home Forward design controls to ensure formal documentation of approval of comparables is in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Home Forward will add clarifying language in our Shelter Plus Care (Continuum of Care) Program operating manual indicating need for staff to document who completed rent reasonableness reviews including signatures from program supervisors or department staff responsible for approving comparables when necessary as part of the rent reasonableness review. Additional staff training will be conducted during Shelter Plus Care and department team meetings. Name(s) of the contact person(s) responsible for corrective action: Ian Slingerland, Director of Homeless Initiatives and Supportive Housing Planned completion date for corrective action plan: 10/1/2024

View Audit 322033

Finding 499238 (2023-003)

Significant Deficiency 2023

Home Forward

OR

Procurement, Suspension & Debarment Questioned Costs § 200.303

Continuum of Care – Assistance Listing No. 14.267 Recommendation: We recommend Home Forward implements a process to ensure exclusion checks are done prior to the execution of a contract. This process should include a system to ensure documentation is maintained in the files evidencing the date of t...

Continuum of Care – Assistance Listing No. 14.267 Recommendation: We recommend Home Forward implements a process to ensure exclusion checks are done prior to the execution of a contract. This process should include a system to ensure documentation is maintained in the files evidencing the date of the exclusion check as well as documented review and approval of the results of the exclusion check by program staff. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procurement has updated the Contract Request form to include a section for attesting yes or no for federal funds, also allowing for free form entry. After a discussion with DCR on situations where they are unsure if there will be HUD funding it was determined to treat all their Public Improvement projects as Davis Bacon projects and include all applicable steps throughout the solicitation process. We are doing a full background check on all contracts, which includes a sam.gov check. When the contracts come to the Contracts and Procurement Manager for final signature, a check will be made in the file to confirm the documents are present showing the sam.gov screen print was made and the Contracts and Procurement Manager will sign both the background check and the Contract at that time. Example attached. Name(s) of the contact person(s) responsible for corrective action: Celeste King Planned completion date for corrective action plan: June 1, 2024

View Audit 322033

Finding 499214 (2023-001)

Material Weakness 2023

Southwest Behavioral Health Services, Inc. and Subsidiaries

AZ

Subrecipient Monitoring Reporting Questioned Costs § 200.303

Finding Number: 2023-001- Schedule of Expenditures of Federal Awards (SEFA) Preparation – Material Weakness Criteria: Non-federal entities in receipt of federal funds must comply with the requirements of 2 CFR 200.303(a), which require an entity to establish and maintain effective internal control ...

Finding Number: 2023-001- Schedule of Expenditures of Federal Awards (SEFA) Preparation – Material Weakness Criteria: Non-federal entities in receipt of federal funds must comply with the requirements of 2 CFR 200.303(a), which require an entity to establish and maintain effective internal control over the federal award to ensure compliance with federal statutes, regulations, and the terms and conditions of the federal award. This includes properly identifying all federal awards subject to the Uniform Guidance and fairly presenting the required information in the schedule of expenditures of federal awards. Condition: Subsequent to the issuance of the Audit Report on the Consolidated Financial Statements and Supplementary Information for the year ended September 30, 2023, it was discovered that there was an omission of two federal grants with expenditures totaling $1,591,715 from the schedule of expenditures of federal awards. Cause: The Organization did not communicate with Care 1st Health Plan regarding the details of certain contracts to determine the amounts were subject to the Uniform Guidance and were to be included on the schedule of expenditures of federal awards. In addition, Care 1st Health Plan became the Regional Behavioral Health Authority for the Northern Arizona region effective October 1, 2022. Due to this transition, various changes occurred causing uncertainties with classifications of certain types of federal awards as subrecipient awards versus as contractor payments. Effect: The schedule of expenditures of federal awards was understated by $1,591,715, which resulted in the restatement of the previously issued schedule of expenditures of federal awards to correct the omission. Questioned Costs: Not applicable. Recommendation: We recommend that all funding contracts are carefully reviewed to determine whether amounts awarded should be classified as contractor payments or as subrecipient payments. If there is any uncertainty, we recommend that the Organization contact the funding source for clarification. Name of Contact Person: Mike Fett, CFO Phone Number: 602-265-8338 Anticipated Completion Date: September 30, 2024 Views of Responsible Officials and Corrective Actions: Southwest Behavioral Health Services, Inc. and Subsidiaries will establish procedures to review all contracts and to if necessary, to communicate with funding sources to ensure that receipts of federal funding are properly classified as being subrecipient versus contractor arrangements to ensure completeness of the Schedule of Expenditures of Federal Awards.

View Audit 322000

Finding 499167 (2023-003)

Significant Deficiency 2023

National Casa Association

WA

Subrecipient Monitoring Reporting § 200.303

Responsible: Denice Hairston, Chief Quality, Compliance and Accountability Officer Corrective Actions: Update FFATA reporting procedures to document and maintain documentation of Supervisory review and approval of FFATA data preparation. Completion Date: March 29, 2023 and July 10, 2024. Explana...

Responsible: Denice Hairston, Chief Quality, Compliance and Accountability Officer Corrective Actions: Update FFATA reporting procedures to document and maintain documentation of Supervisory review and approval of FFATA data preparation. Completion Date: March 29, 2023 and July 10, 2024. Explanation: National CASA/GAL has consistently maintained policies and procedures to ensure FFATA reports are filed timely. Documentation of review/approval from a person separate from the person filing the FFATA report was not readily available in some instances, so procedures were updated to include maintenance of such review/approval. FFATA reports are required to be filed “by the end of the month following the month after the subaward obligation date”. National CASA/GAL filed FFATA reports to adhere to this deadline in compliance with what it understood to be the obligation date, understanding an obligation date could not occur prior to the grant period. This finding was noted in the 2022 audit which was issued August 13, 2024. The 2023 audit, completed in September 2024, included in its scope, the same FFATA reports from the same federal grant that had been reviewed in the 2022 audit and OJJDP/OCFO monitoring visit. National CASA/GAL did not have an opportunity between the 2022 and 2023 audits to cure this finding in practice until the issuance of new subrecipient awards in 2024.

View Audit 321944

Finding 499148 (2023-004)

Significant Deficiency 2023

Children's Hospital Medical Center of Akron

OH

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303

Finding: Management did not have an internal control in place to review the allowability of the expenses to be allocated to the Congressional Directives grant. Corrective Action Plan: Akron Children's will implement a more detailed review and documentation process for allowable expenses prior to de...

Finding: Management did not have an internal control in place to review the allowability of the expenses to be allocated to the Congressional Directives grant. Corrective Action Plan: Akron Children's will implement a more detailed review and documentation process for allowable expenses prior to determining expenses that are eligible for federal grant reimbursement. Responsible Party: Vice President Finance Completion Date: November 30, 2024

View Audit 321917

Finding 499143 (2023-002)

Material Weakness 2023

Children's Hospital Medical Center of Akron

OH

Procurement, Suspension & Debarment § 200.213 § 200.303

Finding: Akron Children’s screening for suspension and debarment through the third-party vendor results does not include controls to ensure file completeness or accuracy. Corrective Action Plan: Akron Children’s implemented a periodic independent review of a sample of vendors sent to the third-p...

Finding: Akron Children’s screening for suspension and debarment through the third-party vendor results does not include controls to ensure file completeness or accuracy. Corrective Action Plan: Akron Children’s implemented a periodic independent review of a sample of vendors sent to the third-party vendor to ensure that the processes employed by third-party vendor are accurate. Completion Date: December 31, 2023 Corrective Action Plan: Akron Children’s developed a retention process for all vendor searches and file submissions to evidence compliance with the Federal regulations, including independent review of the accuracy of file submissions. Completion Date: October 31, 2024 Corrective Action Plan: Further, a contract management system was installed in 2023 that holds the validation of new vendors as acceptable for federal procurements. Completion Date: December 31, 2023 Resposible Party: Chief Legal Counsel

View Audit 321917

Finding 499139 (2023-001)

Significant Deficiency 2023

Fort Worth Housing Solutions

TX

Reporting § 200.302 § 200.303

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 2023-001 Coronavirus Local Fiscal Recovery– Assistance Listing No. 21.027 Recommendation: We recommend that the Authority implements a control to ensure that the preliminary SEFA is mostly accurate so that the correct programs are tested. Explanation ...

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 2023-001 Coronavirus Local Fiscal Recovery– Assistance Listing No. 21.027 Recommendation: We recommend that the Authority implements a control to ensure that the preliminary SEFA is mostly accurate so that the correct programs are tested. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Finance Department has implemented several processes and procedures to ensure pass-through funds or sub-awards are reported timely and accurately in the SEFA. The new processes include (1) review of grant award letters to determine reporting requirements, (2) comparing the award letter against the Minutes of the City Council or County Commissioners meetings to ensure grants accepted during the year are disclosed as such on both ends, (3) confirmed with source Agency Single Audit requirements, (4) and the implementation of revenue source checklist that will identify the source of the funds, type of grant, program name and cluster title, name of federal funding agency, federal assisting listing number (formerly known as CFDA number), etc. Name(s) of the contact person(s) responsible for corrective action: Hector Ordonez, Vice President of Finance and Administration Planned completion date for corrective action plan: December 31, 2024 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please contact Hector Ordonez, Vice President of Finance and Administration at (817) 333-3421 or hordonez@fwhs.org.

View Audit 321913

Finding 499130 (2023-009)

Significant Deficiency 2023

Nobles County

MN

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Questioned Costs § 200.303 § 200.403

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency ...

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Award Period: Year Ended December 31, 2023 Recommendation: We recommend that the County implement review procedures to ensure that the reports are submitted timely and accurately, and record of review is kept on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has implemented procedures and policies to have a secondary person review the reports and in a timely manner. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2024

View Audit 321906

Finding 499116 (2023-004)

Significant Deficiency 2023

Bronx Community Health Network, Inc.

NY

Allowable Costs / Cost Principles § 200.303

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2023 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2023-004 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles – Significant Deficiency Des...

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2023 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2023-004 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles – Significant Deficiency Description of Finding: There was no evidence, such as a signature, evidencing review and approval by a direct supervisor of the timesheets and time and effort reports. Statement of Concurrence: We concur with the finding above. Corrective Action: Effective immediately, a time and effort reporting policy was implemented and sent to all staff to ensure that staff follow the process. This policy will be reviewed with all new staff during new hire orientation and annually. Timesheets will be reviewed and approved by direct supervisors on a weekly basis. HR will send a reminder to all staff on a weekly basis to complete all missing time worked. Employees are responsible for updating the timesheet for each work week in Paylocity. HR will provide a monthly time and effort report to the finance team. This report will provide total number of hours worked by each employee for each assigned cost center. Completion Date: August 26, 2024. Name of Contact Person: James Paine, Ph.D. Chief Executive Officer Tel. No.: (646) 678-6711 E-mail: jpaine@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call James Paine at (646) 678-6711. Sincerely yours, _________________________ James Paine, Ph.D. Chief Executive Officer

View Audit 321903

Finding 499114 (2023-002)

Significant Deficiency 2023

Bronx Community Health Network, Inc.

NY

Subrecipient Monitoring Reporting Questioned Costs § 200.303

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2023 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2023-002 – Reporting: Federal Funding Accountability and Transparency Act (“FFATA”) – Significant Deficienc...

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2023 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2023-002 – Reporting: Federal Funding Accountability and Transparency Act (“FFATA”) – Significant Deficiency Description of Finding: There was no evidence of review and approval by someone other than the preparer of the FFATA subawards that were submitted to the FSRS. The FFATA subawards were not submitted timely to the Federal Funding Accountability and Transparency Act Subaward Reporting System (“FSRS”). Statement of Concurrence: We concur with the finding above. Corrective Action: As of September 1, 2023, BCHN implemented a workflow where FFATA information will be reported to the FSRS upon receipt of the Notices of Award. In addition, as of September 9, 2024, the FFATA report will be reviewed by someone other than the preparer prior to submission and evidence of the approval maintained. Completion Date: September 9, 2024. Name of Contact Person: James Paine, Ph.D. Chief Executive Officer Tel. No.: (718) 405-4993 E-mail: jpaine@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call James Paine at (718) 405-4993. Sincerely yours, _________________________ James Paine, Ph.D. Chief Executive Officer

View Audit 321903

Finding 499113 (2023-003)

Significant Deficiency 2023

Morrison County

MN

Procurement, Suspension & Debarment § 200.303

Finding Number: 2023-003 Finding Title: Suspension and Debarment Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Shannon Coyle, County Auditor-Treasurer Corrective Action Planned: Morrison County management is awa...

Finding Number: 2023-003 Finding Title: Suspension and Debarment Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Shannon Coyle, County Auditor-Treasurer Corrective Action Planned: Morrison County management is aware of the Federal requirements prohibiting non-federal entities from contracting with parties that are suspended or debarred. The County has reviewed the U.S. Department of the Treasury compliance and reporting guidance to ensure it checks SAM.gov exclusions, collects a certification, or adds a clause or condition to the covered transaction, prior to applying Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) funds. Anticipated Completion Date: SAM.gov searches are performed and documented prior to applying CSLFRF funds to all covered transactions, following August 2023.

View Audit 321900

Finding 499112 (2023-002)

Material Weakness 2023

Morrison County

MN

Reporting Questioned Costs Material Weakness § 200.303

Finding Number: 2023-002 Finding Title: Reporting Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Shannon Coyle, County Auditor-Treasurer Corrective Action Planned: Morrison County management is aware that the ann...

Finding Number: 2023-002 Finding Title: Reporting Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Shannon Coyle, County Auditor-Treasurer Corrective Action Planned: Morrison County management is aware that the annual Project and Expenditure Report submitted for Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) to the U.S. Treasury was done so incorrectly. The County has reviewed the U.S. Department of the Treasury guidance and form instructions to ensure it is correctly reporting its CSLFRF activity going forward. Anticipated Completion Date: The correction will be made on the Annual Project and Expenditure Report due in April 2024, for the reporting period ending March 31, 2024.

View Audit 321900 Questioned Costs: $1

Finding 499099 (2023-005)

Material Weakness 2023

Children's Health System of Texas

CA

Allowable Costs / Cost Principles § 200.303

97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Management did not adequately document the review and approval of expenditures associated with Federal Emergency Management Agency grant. While all expenditures were found to be allowable and within the period of perfor...

97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Management did not adequately document the review and approval of expenditures associated with Federal Emergency Management Agency grant. While all expenditures were found to be allowable and within the period of performance, documentation of management’s approval was not available. Management has implemented formal documentation processes to demonstrate review and approval has been performed. Contact Person: Jane Hardy, VP Corporate Accounting jane.hardy@childrens.com Expected Completion Date: October 1, 2024

View Audit 321892

Finding 499097 (2023-003)

Significant Deficiency 2023

Children's Health System of Texas

CA

Procurement, Suspension & Debarment § 200.214 § 200.303 § 200.318 § 200.320 § 200.327

93.493 Congressional Directives Complete documentation of vendor suspension and disbarment verification was not maintained. While outside vendor verification services were performed monthly, adequate documentation for all vendors is not provided, only vendors with suspension or disbarment issues ar...

93.493 Congressional Directives Complete documentation of vendor suspension and disbarment verification was not maintained. While outside vendor verification services were performed monthly, adequate documentation for all vendors is not provided, only vendors with suspension or disbarment issues are identified and communicated to management. Management will coordinate with appropriate departments to review federal provisions for grant procurement and adjust policies and procedures to comply. Management will work with appropriate departments and the outside vendor to identify all grant related vendors and request positive verification monthly. All grant project directors will be educated on the procurement requirements for all federal awards. Contact Person: Jane Hardy – VP Corporate Accounting jane.hardy@childrens.com Expected Completion Date: December 31, 2024

View Audit 321892

Finding 499096 (2023-002)

Significant Deficiency 2023

Children's Health System of Texas

CA

Matching / Level of Effort / Earmarking Questioned Costs Reporting § 200.303

93.493 Congressional Directives Management did not document the level of effort of key personnel identified as Project Directors which were providing in-kind support to the grant program. Management will implement bi-weekly tracking of effort via Excel spreadsheet by key personnel related to these...

93.493 Congressional Directives Management did not document the level of effort of key personnel identified as Project Directors which were providing in-kind support to the grant program. Management will implement bi-weekly tracking of effort via Excel spreadsheet by key personnel related to these grant projects. The tracking of hours of effort will be maintained along with other grant related documentation by the grant management team. Management will continue to seek clarification with awarding agency to clarify if such tracking can be eliminated. Contact Person: Danielle Wesley, VP Network Service Delivery danielle.wesley@childrens.com 214-456-8988 Expected Completion Date: October 31, 2024

View Audit 321892

Finding 499095 (2023-001)

Significant Deficiency 2023

Children's Health System of Texas

CA

Allowable Costs / Cost Principles § 200.303 § 200.430

93.493 Congressional Directives Of the forty (40) payroll expenditures selected for testing, the System’s management did not perform the internal controls over the required allowability criteria for four (4) samples. Management will implement additional review and approval processes by having grant...

93.493 Congressional Directives Of the forty (40) payroll expenditures selected for testing, the System’s management did not perform the internal controls over the required allowability criteria for four (4) samples. Management will implement additional review and approval processes by having grant supported employees provide bi-weekly screenshots of timecards to their direct manager for review and approval and forwarded to grant program leadership for approval and documentation. Contact Person: Danielle Wesley, VP Network Service Delivery danielle.wesley@childrens.com 214-456-8988 Expected Completion Date: October 31, 2024

View Audit 321892

Finding 499093 (2023-003)

Material Weakness 2023

Chisago County

MN

Procurement, Suspension & Debarment § 200.303

Finding Number: 2023-003 Finding Title: Suspension and Debarment Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Kristin Waddell Corrective Action Planned: Verifying that a new vendor has not been suspended or deb...

Finding Number: 2023-003 Finding Title: Suspension and Debarment Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Kristin Waddell Corrective Action Planned: Verifying that a new vendor has not been suspended or debarred is analyzed on a case-by-case basis depending on the Federal award. Doing this for each vendor for ARPA would significantly disrupt our A/P process with the limited number of staff we have. Analysis was done for each new ARPA Broadband grant awarded after the finding was issued in 2022, and for new vendors with significant project costs. Of the samples tested in 2023, some were paid prior to the completion of the 2022 audit, before the County was aware of the finding and corrective action could take place. Anticipated Completion Date: Immediately

View Audit 321886

Finding 499092 (2023-002)

Material Weakness 2023

Chisago County

MN

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.403

Finding Number: 2023-002 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Kristin Waddell Corrective Action Planned: Extensive rese...

Finding Number: 2023-002 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Kristin Waddell Corrective Action Planned: Extensive research was done on this topic and position of the County is that cities and townships are non-entitlement units (NEUs) who report to the Treasury directly. SLFRF Compliance and Reporting Guidance published by The Department of the Treasury states that NEUs are not subrecipients under the SLFRF program; they are SLFRF recipients that report directly to the Treasury. Recipients of the County’s ARPA Broadband grants: -provided the specific unserved or underserved areas located within the County where therequested ARPA funds would be used to deliver high-speed, reliable, and affordable internet(typically accompanied by the consultant report coordinating the construction) on their grantapplications to the County Board; and -have certified they are complying with “all federal, state, and local laws and all requirementsand published guidance set forth regarding the usage of any and all monies appropriated underthe ARPA” in their signed grant agreements with the County; However, beginning in 2024 the County will collect itemized support for the expenditures incurred related to the ARPA Broadband Grant Program. Anticipated Completion Date: Immediately

View Audit 321886 Questioned Costs: $1

Finding 499087 (2023-003)

Significant Deficiency 2023

Sound Generations

WA

Allowable Costs / Cost Principles § 200.303

Type of Finding: Significant Deficiency in Internal Control over Compliance – Activities Allowed or Unallowed, Allowable Costs / Cost Principles Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Aging Cluster Assistance Listing Number; 93.044 / 93.045 / 93.053 Feder...

Type of Finding: Significant Deficiency in Internal Control over Compliance – Activities Allowed or Unallowed, Allowable Costs / Cost Principles Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Aging Cluster Assistance Listing Number; 93.044 / 93.045 / 93.053 Federal Award Identification Number and Year: DA23-1109-2023, DA23-1176-2023 Pass-Through Agency: City of Seattle Pass-Through Number(s): DA23-1109, DA23-1176 Award Period: January 1, 2023 through December 31, 2023 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 the Organization of the Treadway Commission (COSO).” Condition: During testing of payroll, it was noted that three employee’s wages had been misallocated between contracts. These misallocations occurred due to clerical errors and inadequate monitoring and review of the allocation process. Questioned Costs: None Context: A sample of 60 payroll samples were made from a population of over 260 individual employee paychecks. Of the 60 sampled, three samples had wages misallocated. The first was misallocated between the Community Dining and Meals on Wheels contracts. The second had misallocations between two funding sources under the Meals on Wheels contract. The third had misallocations between the Meals on Wheels contract and another funder. Cause: In one instance, a manual intervening calculation needed to be made to a normally automated process due to an illness at the executive level during time study updates. As a result of a clerical error, the allocations between the contracts were accidentally switched and the misallocation was not caught during review. In the remaining two instances, a formula error resulted in a misallocation of wages between funding sources. Effect: The misallocation of expenses could impact on the accuracy of financial reporting for the major program and could result in noncompliance with federal regulations. Repeat Finding: No. Recommendation: CLA recommends that Sound Generations emphasize the importance of its procedures for monitoring and reviewing the allocation of wages between contracts and provide training to the individuals responsible for the allocation of expenses. Views of responsible officials and planned corrective actions: Sound Generations Agrees with the finding. Sound Generations has reviewed and revised its procedures to include reviews at intermediary steps as well as streamlined its automation to allow for less opportunity for manual inputs and clerical errors. Responsible Official: Carlos Rojas, Chief Financial Officer; Christina Hannan, Controller Anticipated Completion Date: June 30, 2024

View Audit 321877

Finding 499086 (2023-002)

Significant Deficiency 2023

Sound Generations

WA

Questioned Costs Cash Management Reporting § 200.303

Type of Finding: Significant Deficiency in Internal Control over Compliance - Reporting Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Aging Cluster Assistance Listing Number; 93.044 / 93.045 / 93.053 Federal Award Identification Number and Year: DA23-1109-2023 P...

Type of Finding: Significant Deficiency in Internal Control over Compliance - Reporting Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Aging Cluster Assistance Listing Number; 93.044 / 93.045 / 93.053 Federal Award Identification Number and Year: DA23-1109-2023 Pass-Through Agency: City of Seattle Pass-Through Number(s): DA23-1109 Award Period: January 1, 2023 through December 31, 2023 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 the Organization of the Treadway Commission (COSO).” Condition: During testing of reporting, it was noted that, for one sample, documentation was not retained of approval of financial reporting. Questioned Costs: None Context: A sample of 9 financial reports was made from a population of 54 total reports. Of the 9 sampled, 1 was missing evidence of authorized personnel review and approval. Cause: In this one instance, verbal approval was given rather than emailed approval. Effect: Without adequate documentation and controls in place to ensure costs are reasonable and intended for the program charged, Sound Generations could incorrectly charge expenditures to the federal program, report fraudulent expenditures, or not request appropriate reimbursement that Sound Generations is entitled to under the terms of the grant. Repeat Finding: No. Recommendation: CLA recommends that documentation is retained as proof of authorized personnel review. Views of responsible officials and planned corrective actions: Sound Generations agrees with the finding. Sound Generations has revised its approval process to include digital signatures with time stamps by authorized personnel on all documentation rather than emailed approvals. Responsible Official: Carlos Rojas, Chief Financial Officer; Christina Hannan, Controller Anticipated Completion Date: March 31, 2024

View Audit 321877

Finding 499076 (2023-001)

Material Weakness 2023

Gary Public Transportation Corporation

IN

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

CORRECTIVE ACTION PLAN Finding 2023-001 - Controls Over Payroll Expenditures (Material Weakness) Criteria: 2 CFR 200.403 establishes principles and standards for determining costs for federal awards carried out through grants, cost reimbursement contracts, and other agreements with state and loca...

CORRECTIVE ACTION PLAN Finding 2023-001 - Controls Over Payroll Expenditures (Material Weakness) Criteria: 2 CFR 200.403 establishes principles and standards for determining costs for federal awards carried out through grants, cost reimbursement contracts, and other agreements with state and local governments. To be allowable, under federal awards, cost must meet certain criteria: a) Be necessary and reasonable for the performance of the Federal award and be allocable thereto under these principles. b) Conform to any limitations or exclusions set forth in these principles or in the Federal award as to types or amount of cost items. c) Be consistent with policies and procedures that apply uniformly to both federally-financed and other activities of the non-Federal entity. d) Be accorded consistent treatment. A cost may not be assigned to a Federal award as a direct cost if any other cost incurred for the same purpose in like circumstances has been allocated to the Federal award as an indirect cost. e) Be determined in accordance with generally accepted accounting principles (GAAP), except, for state and local governments and Indian tribes only, as otherwise provided for in this part. f) Not be included as a cost or used to meet cost sharing or matching requirements of any other federally financed program in either the current or a prior period. g) Be adequately documented. h) Cost must be incurred during the approved budget period. Additionally, 2 CFR 200.303 indicates that non-Federal Entities receiving Federal awards 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 terms and conditions of the Federal award. The Corporation should have controls in place to document that salaries and overtime paid with federal funds were allowable. Timecards supporting hours worked should be approved and pay rates reviewed. Context: A summary of allowable charges for the grant was prepared for submission. Within a sample of 45, we noted that 25 timecards did not have a documented review. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. The Transportation Department provides a spreadsheet that details time operators work by route. This process is used to align FTA funding streams with routes driven. The spreadsheet is kept by the Transportation Manager and reviewed by the Director of Transportation. These two positions approve time prior to submitting it for processing. The Gary Public Transportation Corporation management had hoped to get its payroll provider to provide a solution to this particular timesheet approval matter. However, the complexity of these timesheets made a resolve too complicated for reasonable implementation. So, a simple solution has been devised. The Transportation Manager and Director shall sign off on a document to stating their review and approval of those timesheets.

View Audit 321864

Finding 499074 (2023-002)

Material Weakness 2023

City of West Lafayette

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Finding 2023-002 Finding Subject: • Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment. Summary of Finding: • Documentation was not created when vendor was verified that it was not suspended nor debarred. Contact Person: Peter Gray Contact Phone: 765-775-5150 Views of Respo...

Finding 2023-002 Finding Subject: • Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment. Summary of Finding: • Documentation was not created when vendor was verified that it was not suspended nor debarred. Contact Person: Peter Gray Contact Phone: 765-775-5150 Views of Responsible Official: • We concur with the finding. Explanation and Reasons for Disagreement: • N/A Description of Corrective Action: • The City did perform procedures to verify that the vendor was not suspended nor debarred. However, no documentation was created. The vendors in question were not, and are not currently, suspended nor debarred. • We will create an affidavit for vendors that receive Federal funds to sign that they are not suspended nor debarred from receiving Federal Funds. Any change in that status is to be reported to us. Anticipated Completion Date: 31 October 2024

View Audit 321859

Finding 499066 (2023-002)

Significant Deficiency 2023

Douglas County

MN

Questioned Costs Eligibility Reporting § 200.303

Recommendation: It is recommended County management add an additional control review over the eligibility of casefile 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 designate a...

Recommendation: It is recommended County management add an additional control review over the eligibility of casefile 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 designate an internal reviewer to continually review the casefile eligibility determinations throughout the year. Name of the contact person responsible for corrective action plan: Jill Frisell, Finance Director Planned completion date for corrective action plan: December 31, 2024

View Audit 321840

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