Corrective Action Plans

Finding 399178 (2022-005)

Material Weakness 2022

Elkhart County

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.303

FINDING 2022-005 Finding Subject: Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (SED) – Suspension and Debarment Summary of Finding: The County stated procedures were not in place to ensure vendors were not suspended or debarred prior to entering int...

FINDING 2022-005 Finding Subject: Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (SED) – Suspension and Debarment Summary of Finding: The County stated procedures were not in place to ensure vendors were not suspended or debarred prior to entering into covered transactions. One covered transaction for funds passed through to a subrecipient was identified during the audit period. The amount passed through to the subrecipient was $914,863. The identified transaction was examined to determine if the County verified the suspension and debarment status of the subrecipient prior to payment. Upon review we determined that the County entered into a Memorandum of Understanding (MOU) with the subrecipient on June 22, 2020. However, the County had not performed procedures to ensure the subrecipient was not suspended or debarred, or otherwise excluded or disqualified from participation in federal assistance programs or activities at the time of the initial MOU or at any time during the audit period. Recommendation We recommended that management of the County establish a proper system of internal controls and develop policies and procedures to ensure contractors and subrecipients, as appropriate, are not suspended, debarred, or otherwise excluded prior to entering into any contracts or subawards. We also recommended that supporting documentation be retained in order to be presented for audit. Contact Person Responsible for Corrective Action: Concetta Sanfilippo Contact Phone Number and Email Address: 574.523.2101 csanfilippo@elkhartcounty.com Views of Responsible Officials: We concur that suspension and debarment was not run within the audit period. However, it was not done under the direction of CLA Auditing team 2021 who instructed it was not necessary, rather the most current audit report should be run which Elkhart County did do and had on file for their subrecipient Oaklawn Psychiatric. Description of Corrective Action Plan: The Elkhart County Health Department and Auditor’s Office Grants Administrator are working collaboratively to administer this grant award with strong internal controls. The Grant’s Administrator has taken the role to routinely run Suspension and Debarment verification on this subrecipient. The date it is run is recorded and a pdf is retained for records. Anticipated Completion Date: This procedure is in place as of 2023 and correction is completed.

View Audit 307736

Finding 399177 (2022-004)

Material Weakness 2022

Elkhart County

IN

Internal Control / Segregation of Duties Cash Management Material Weakness § 200.303

FINDING 2022-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: The County Health Department was required to submit data through the online portal, National Electronic Disease Surveillance System Base System, monthly beginning in October...

FINDING 2022-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: The County Health Department was required to submit data through the online portal, National Electronic Disease Surveillance System Base System, monthly beginning in October 2022. The submitted data included program specific metrics related to patient case management of certified Elevated Blood Lead Levels. A Case Manager managed all aspects of an individual patient’s care. Once a patient’s care was complete, the case was closed by the Case Manager in the online portal. Completed cases were compiled by the Clinical Manager into a data sheet, which was then submitted to the Manager of Administration. The Manager of Administration based on the compiled data sheet prepared and submitted a reimbursement request to the State without an oversight, review, or approval process to ensure the reimbursement request was complete and accurate. Recommendation: We recommended that management of the County design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place to ensure reports are complete and accurate.” Contact Person Responsible for Corrective Action: Concetta Sanfilippo Contact Phone Number and Email Address: 574.523.2101 csanfilippo@elkhartcounty.com Views of Responsible Officials: Option 2: “We disagree with part of the finding.” Explanation and Reason for Disagreement: The County already has an established process of review and evaluation. The Case Manager’s reports on work are reported to their superior, the Clinical Manager. The Clinical Manager reviews data, enters report data into the program portal as required. A spreadsheet with case start date, patient ID number, home address and payment is submitted to the Manager of Administration who acts as secondary review and completes the invoice and submits it to the State where an additional process of review is then executed before approval and federal funds are drawn. Once the invoice is submitted, the Manager of Administration makes two copies of the invoice and the spreadsheet, one copy is sent to the Clinical Manager and the other to the Auditors office. This is an excellent procedure for checking and balance. Description of Corrective Action Plan: The Elkhart County Health Department receives elevated blood lead levels from the State. The Lead Case Manager determines if criteria are met to initiate a case. They conduct a home visit and make appropriate referrals. The lead case manager enters case information into NBS. INDIANA STATE BOARD OF ACCOUNTS 38 Ongoing case management for children with elevated blood leads levels includes coordination of blood lead tests, education, and appropriate referrals. The Lead Case Manager submits a list of cases each month to the Clinical Manager that meet the criteria for submission for reimbursement. The criteria are a completed home visit, a completed nutrition assessment, a referral for developmental assessment and documentation in NBS. The Clinical Manager reviews the cases in NBS and compiles a list and submits the data sheet to the Fiscal Manager. The Fiscal Manager prepares the invoice and submits it along with documentation to the State and Timothy Conley for review and approval. The Elkhart County Health Department will continue to have collaborative compilation of data which will be reviewed by field specialists before being submitted to the Manager of Administration for invoice reimbursement. The data and records are reviewed by the Manager of Administration and the invoice total will be confirmed and documented with the Clinical Manager prior to being submitted to the State for review and approval. Confirmation emails of secondary review will be retained as documentation. The State must approve invoices with supporting documentation and is the external party requesting reimbursement with Federal funds once approved. A copy of supporting documentation is supplied to the Elkhart County Auditor’s Office to be retained on file and to be used for receipting records once reimbursement is received and deposited into its unique 8000 series fund. Anticipated Completion Date: August of 2023 (Note: Provide the projected date of completion of major tasks for the planned corrective actions.)

View Audit 307736

Finding 399176 (2022-003)

Material Weakness 2022

Elkhart County

IN

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.1 § 200.303

FINDING 2022-003􀯗 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting􀯗 Summary of Finding:􀯗􀯗 Recipients are required to submit quarterly or annually Project and Expenditure (P&E) reports to the Department of the Treasury (Treasury). The reporting periods, as wel...

FINDING 2022-003􀯗 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting􀯗 Summary of Finding:􀯗􀯗 Recipients are required to submit quarterly or annually Project and Expenditure (P&E) reports to the Department of the Treasury (Treasury). The reporting periods, as well as the respective due dates, are based upon type of recipient and its population, as well as the recipient's allocation amount. Information to be reported includes projects funded, expenditures, and contracts for the appropriate reporting period. The County was classified as a metropolitan county with a population below 250,000 residents that received an allocation of more than $10 million in Coronavirus State and Local Fiscal Recovery Funds (CSLFRF). Therefore, quarterly P&E Reports were due by January 31, 2022, and the last day of the month after the end of each quarter thereafter. The County submitted four quarterly P&E Reports during the audit period. The County’s process for the completion and submission of the P&E Reports was the Grant Administrator prepared the P&E Reports and the County Auditor reviewed them prior to submission; however, the control was not effective in detecting and preventing noncompliance. Two of the four quarterly reports submitted during the audit period were selected for testing. The County utilized the current period obligations field to document total obligations less current period expenditures. For the reports tested, the current period obligations, per the County’s interpretation of the field, were not supported by the County’s records. The following errors were noted: Quarter 2 P&E Report (April 1, 2022 - June 30, 2022) 􀄁 The Current Period Obligations for the Revenue Replacement project were overstated by $399,097. Quarter 3 P&E Report (July 1, 2022 - September 30, 2022) 􀄁 The Current Period Obligations for the Prairie Creek Water Run Water Line project were overstated by $67,773. 􀄁 The Current Period Obligations for the Parks Department - Latrine project were overstated by $25,758. 􀄁 The Current Period Obligations for the Foraker/Southwest project were overstated by $230,338. The lack of effective internal controls and noncompliance was a systemic issue during the audit period. Contact Person Responsible for Corrective Action: Patricia Pickens Contact Phone Number and Email Address: 574.535.6719 ppickens@elkhartcounty.com􀯗 􀯗 􀯗 INDIANA STATE BOARD OF ACCOUNTS 36 117 N. 2ND St Rm 203 Goshen, IN 46526 - 574-535-6719 􀀃 Views of Responsible Officials:􀯗􀯗 We disagree with the finding.􀯗􀯗 􀯗 Explanation and Reasons for Disagreement:􀯗􀯗 The finding does not accurately reflect the administration of the SLFRF program and fails to correctly identify key challenges that impacted the difference in data. There is a rigorous system of diligent records keeping, auditing expenditures, and internal controls including multiple points of review and approval for reporting ARPA funds. All expenditures are accounted for and maintained with supporting documentation. The auditing team can clearly demonstrate attention to detail in the tracking and reporting of all expenditures. They also have extensive record of on-going issues with the reporting portal including tickets and communications with Treasury support. They have identified issues with the portal that prevented the submission of reports or caused erroneous calculations/data.

View Audit 307736

Finding 398980 (2022-004)

Material Weakness 2022

Coastal Harvest

WA

Special Tests & Provisions Subrecipient Monitoring Cash Management § 200.303

Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024

View Audit 307582

Finding 398468 (2022-005)

Significant Deficiency 2022

Yuma District Hospital

CO

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

Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Cluster Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliations for the federal program. In ...

Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Cluster Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliations for the federal program. In addition, there was lack of review of the quarterly internal monitoring of the Hospital’s debt covenants. Responsible Individuals: Rick Korf, CFO Corrective Action Plan: For the reserve fund reconciliations, a secondary review will be completed and documented. The Hospital will also ensure that the quarterly covenant calculations are completed and presented to the board for review with the financials. Anticipated Completion Date: 05/31/2024

View Audit 307192

Finding 398465 (2022-004)

Material Weakness 2022

Yuma District Hospital

CO

Reporting Allowable Costs / Cost Principles Material Weakness § 200.303

Federal Agency Name: Department of Health and Human Services; Department of Agriculture Assistance Listing Number: #93.498; #10.766 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution; Community Facilities Loans and Grants Cluster Finding Summary: The Hospi...

Federal Agency Name: Department of Health and Human Services; Department of Agriculture Assistance Listing Number: #93.498; #10.766 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution; Community Facilities Loans and Grants Cluster Finding Summary: The Hospital does not have an internal control system designed to allow for a complete and accurate Schedule being audited. We were requested to draft the Schedule. Responsible Individuals: Rick Korf, CFO Corrective Action Plan: We will continue to have our auditors assist with preparing the schedule of expenditures of federal awards (SEFA). Anticipated Completion Date: Ongoing

View Audit 307192

Finding 398353 (2022-002)

Significant Deficiency 2022

Eastern Plains Community Action Agency, Inc.

NM

Equipment & Real Property Management Internal Control / Segregation of Duties Reporting § 200.303

Auditor's Recommendation: We recommend the Entity implement adequate controls to ensure the accuracy of the information reported to the Grantor Agency in a timely manner. Action Taken: The Organization will create an electronic calendar with reminders for all reporting requirements and respective du...

Auditor's Recommendation: We recommend the Entity implement adequate controls to ensure the accuracy of the information reported to the Grantor Agency in a timely manner. Action Taken: The Organization will create an electronic calendar with reminders for all reporting requirements and respective due dates. Responsible Official: John Clemons, Chief Financial Officer Timeline for Implementation: July 31, 2023

View Audit 307024

Finding 398352 (2022-001)

Material Weakness 2022

Eastern Plains Community Action Agency, Inc.

NM

Equipment & Real Property Management § 200.303 § 200.313

Auditor's Recommendation: We recommend the Entity enhance the design of its control activities and policies and procedures should be developed to ensure physical inventories are taken at least once every two years. Action Taken: The Organization understands the importance of regular physical invento...

Auditor's Recommendation: We recommend the Entity enhance the design of its control activities and policies and procedures should be developed to ensure physical inventories are taken at least once every two years. Action Taken: The Organization understands the importance of regular physical inventories and will implement this control activity for the June 30, 2023 fiscal year end. Responsible Person: John Clemons, Chief Financial Officer Timeline for Implementation: July 31, 2023

View Audit 307024

Finding 398190 (2022-006)

Material Weakness 2022

St. Vincent General Hospital District

CO

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303

Finding 2022‐006 – Special Tests and Provisions Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Finding Summary: The Hospital did not have adequate internal control policies in place to ensure...

Finding 2022‐006 – Special Tests and Provisions Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Finding Summary: The Hospital did not have adequate internal control policies in place to ensure review and approval over the reserve funds, monitoring of all required debt covenants, proper funding of the reserve accounts, or to ensure that proper procedures are followed for obtaining USDA approval for any withdrawals from the debt service reserve funds. Responsible Individuals: Kelly Johnston, CFO Status: The Hospital enhance internal control policies to ensure formal documentation of reviews for the reserve fund reconciliations is retained, monitoring that the required debt covenants are monitored and reviewed, reserve funds are properly funded, and that there are proper procedures in place for obtaining USDA approval for any future withdrawals from the debt service reserve funds. Anticipated Completion Date: 6/30/2024

View Audit 306892

Finding 398088 (2022-002)

Material Weakness 2022

Dixon County

NE

Reporting § 200.303 § 200.502 § 200.508 § 200.509 § 200.510

Finding 2022-002: Emergency Watershed Protection Program - Reporting Program: AL 10.923 - Emergency Watershed Protection Program - Reporting Corrective Action Planned: The County will ensure County personnel obtain training to ensure there is a proper understanding of the Federal reporting requi...

Finding 2022-002: Emergency Watershed Protection Program - Reporting Program: AL 10.923 - Emergency Watershed Protection Program - Reporting Corrective Action Planned: The County will ensure County personnel obtain training to ensure there is a proper understanding of the Federal reporting requirements and preparation of the Schedule of Federal Awards. Anticipated Completion Date: Ongoing Responsible Party: Dixon County Board of Supervisors: Don Andersen, Deric Anderson, Roger Peterson, Neil Blohm, Lisa Lunz, Terry Nicholson, and Steve Hassler

View Audit 306806

Finding 396711 (2022-004)

Material Weakness 2022

Point of Freedom

OH

Matching / Level of Effort / Earmarking Subrecipient Monitoring Reporting § 200.1 § 200.303

POF’s initial exposure to Single Audit compliance requirements has sharpened its focus on the need to purposefully identify and maintain corroborating evidence regarding its timely submission and acceptance by each of the respective funding sources. While POF believes that all these reporting requir...

POF’s initial exposure to Single Audit compliance requirements has sharpened its focus on the need to purposefully identify and maintain corroborating evidence regarding its timely submission and acceptance by each of the respective funding sources. While POF believes that all these reporting requirements were timely met and accepted by all funding sources, it did not consistently maintain either the report itself, or the related documentation such as copies of the emails sent or the associated read-receipts as evidence of these reports. Effective July 1, POF will routinely and consistently accumulate and organize these documents as well as ancillary evidence of their transmission to, receipt by, and acknowledgement of acceptance by the federal agency. As it deems necessary, POF will seek professional education and advice in implementing policies, practices, and procedures in addition to those already described herein.

View Audit 306345

Finding 396710 (2022-003)

Material Weakness 2022

Point of Freedom

OH

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.516

As more fully described above, additional internal control procedures and practices will be implemented effective July 1, 2024, to ensure that underlying cost documentation is adequate, reasonable, and complete in accordance with 2 CFR and other regulatory requirements. More specifically, vendor inv...

As more fully described above, additional internal control procedures and practices will be implemented effective July 1, 2024, to ensure that underlying cost documentation is adequate, reasonable, and complete in accordance with 2 CFR and other regulatory requirements. More specifically, vendor invoices and the like will be scanned and electronically saved on QBO, as incurred. On the other hand, contractors were engaged to perform certain tasks and were not constrained by hours. If the subject service required on-site intervention by the contractor with a POF client at 3 AM, then the contractor was expected to and had agreed to deliver. The contractor would report any such encounters at the subsequent weekly meetings with certain contractors present. Consistent with IRS employer guidelines, POF did not supervise contractors or dictate work habits or work schedules. Instead, POF defined what each contractor was expected to do or deliver. It was incumbent upon the contractor to determine how best to accomplish the assigned and agreed upon duties defined in their jointly signed agreement. POF’s contractors were and are professionals with state credentials, degrees, or certifications which permit them to serve other NPOs or customers as independent contractors. In many cases, their work products were summarized during the previously mentioned POF weekly meetings and transmitted to Wright State University (now the Ohio State University) where the data were aggregated independently by these contracted third parties and made available to POF’s funders. Effective July 1, 2024, copies pf these weekly report summaries will be routinely saved to provide further evidence of POF’s monitoring of contractors’ activities and adherence to contract terms.

View Audit 306345 Questioned Costs: $1

Finding 396647 (2022-007)

Material Weakness 2022

The Astraea Foundation, Inc.

NY

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

Views of Responsible Officials and Planned Corrective Actions: This unallowable expense was charged inadvertently, and corrections have been made. Astraea is in discussion with the Federal agency about appropriate adjustments to account for this and will take subsequent action per Federal agency ins...

Views of Responsible Officials and Planned Corrective Actions: This unallowable expense was charged inadvertently, and corrections have been made. Astraea is in discussion with the Federal agency about appropriate adjustments to account for this and will take subsequent action per Federal agency instructions. In addition, Astraea is in current discussions with USAID to update the current agreement so that a 10% de minimis overhead cost allocation will be explicitly allowed. Further, Astraea is seeking a NICRA in FY2025. Anticipated Completion Date: June 30, 2024 Responsible Officials: Associate Director, Grants Management and Compliance; Associate Director, Partnerships

View Audit 306244

Finding 396419 (2022-004)

None 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Special Tests & Provisions Allowable Costs / Cost Principles Eligibility § 200.303

The Authority expects to issue its 2023 financial statements prior to June 2024

View Audit 305996

Finding 396418 (2022-003)

None 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

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

The Authority expects to issue its 2023 financial statements prior to June 2024

View Audit 305996

Finding 396390 (2022-007)

Material Weakness 2022

Mille Lacs County

MN

Questioned Costs Reporting Material Weakness § 200.303

Finding Number: 2022-007 Finding Title: Reporting Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Dillon Hayes, County Administrator Corrective Action Planned: Guidance and timelines for reporting on the CSLFRF ...

Finding Number: 2022-007 Finding Title: Reporting Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Dillon Hayes, County Administrator Corrective Action Planned: Guidance and timelines for reporting on the CSLFRF award have been changing constantly. Staff will take better care to follow future guidance. Additionally, all funds have been expended. Anticipated Completion Date: Completed

View Audit 305961 Questioned Costs: $1

Finding 396236 (2022-003)

Significant Deficiency 2022

Houston Regional Hiv/aids Resource Group, Inc.

TX

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

2022-003 Compliance and Internal Controls over Allowable and Allocable Costs (Significant Deficiency) U.S. Department of Health and Human Services 93.918- Ryan White Title C Contract No. H7CHA36798-01-03, H76HA00684-22-00, and H76HA00684-23-00 Texas Department of State Health Services State HIV Serv...

2022-003 Compliance and Internal Controls over Allowable and Allocable Costs (Significant Deficiency) U.S. Department of Health and Human Services 93.918- Ryan White Title C Contract No. H7CHA36798-01-03, H76HA00684-22-00, and H76HA00684-23-00 Texas Department of State Health Services State HIV Service Grants Contract No. 537-18-0097-00001 and HHS001022300002 Recommendation: The Resource Group should follow its policies regarding expense reimbursement grants and ensure support for costs submitted for reimbursement comply with 2 CFR Subpart E. Corrective Action: To ensure expense reimbursement and support of cost submitted by subrecipients comply with 2 CFR Subpart E, The Resource Group will annually verify the subrecipient’s cost allocation plan. To verify costs are allowable and allocable to the grant, The Finance Director will conduct fiscal monitoring of subrecipients. The fiscal monitoring will be conducted at least annually in accordance with all state and federal statues, regulations and terms and conditions. As a component of the monitoring, The Resource Group will verify costs submitted for reimbursement are allowable, reasonable, approved and accurately submitted. This includes verification of the cost allocation plan and underlying documentation of associated expenses. The Finance Director is responsible for oversight and administration of fiscal monitoring. The process will include desktop/remote verification of applicable financial policy and procedures and an onsite review. A standardized monitoring tool will be used to evaluate financial compliance. The fiscal monitoring observations will result in a monitoring report, disseminated to the subrecipient within 60 days of the onsite review. In the event the Finance Director position is vacant more than 90 days, The Resource Group will contract with an appropriate financial contractor to conduct annual monitoring as needed. In the event of extenuating circumstances and the subrecipient is not reviewed annually, The Resource Group will determine the appropriateness of all costs under the cost allocation plan through the submission of alternate supporting documentation. This will be verified prior to the close of the grant period. Progress to date 1. The Finance Director was hired in August 2023. To support the financial monitoring efforts, technical assistance was received on February 5-7, 2024, from the DSHS Fiscal Support and Oversight department. The primary objective of the visit was to discuss financial monitoring requirements as it allies to state and federal regulations, statues and terms and conditions. The standardized monitoring tool was also evaluated for compliance. 2. The Finance Director has developed a fiscal monitoring schedule for 2024. Onsite reviews started in February 2024. The testing period for subrecipient monitoring has been expanded to include a testing period from Fiscal Year 2022 and Fiscal Year 2023. Responsible Party: Finance Director, Garland Thompson; Executive Director, Tiffany Shepherd, MPH Date to be Corrected: August 2024

View Audit 305880 Questioned Costs: $1

Finding 396235 (2022-002)

Significant Deficiency 2022

Houston Regional Hiv/aids Resource Group, Inc.

TX

Subrecipient Monitoring § 200.303 § 200.332

2022-002 Compliance and Internal Controls over Subrecipient Fiscal Monitoring (Significant Deficiency) U.S. Department of Housing and Urban Development 14.241- Housing Opportunities for Persons with AIDS Contract No. 537-17-0195-00001 and HHS001022300003 Texas Department of State Health Services Sta...

2022-002 Compliance and Internal Controls over Subrecipient Fiscal Monitoring (Significant Deficiency) U.S. Department of Housing and Urban Development 14.241- Housing Opportunities for Persons with AIDS Contract No. 537-17-0195-00001 and HHS001022300003 Texas Department of State Health Services State HIV Service Grants Contracts No. 537-18-0097-00001 and HHS001022300002 Recommendation: The Resource Group should follow its policies to perform fiscal monitoring of its subrecipients in accordance with 2 CFR Section 200.332. Corrective Action: In accordance with 2 CFR Section 200.332, The Resource Group as the pass-through entity will ensure subrecipient fiscal monitoring is completed in 2024 to ensure compliance with federal and state requirements. The Finance Director is responsible for oversight and administration of fiscal monitoring. Fiscal monitoring will be conducted at least annually in accordance with HRSA Monitoring Standards 45 CFR 74.51 and 45 CFR 75.352. As a pass-through entity, the fiscal monitoring will include at minimum reviews of financial performance and compliance with federal and state statues, regulations and terms and conditions. The process will include desktop/remote verification of applicable financial policy and procedures and an onsite review. A standardized monitoring tool will be used to evaluate financial compliance. The fiscal monitoring observations will result in a monitoring report, disseminated to the subrecipient within 60 days of the onsite review. Progress to date: 1. The Finance Director was hired in August 2023. To support the financial monitoring efforts, technical assistance was received on February 5-7, 2024, from the DSHS Fiscal Support and Oversight department. The primary objective of the visit was to discuss financial monitoring requirements as it allies to state and federal regulations, statues and terms and conditions. The standardized monitoring tool was also evaluated for compliance. 2. The Finance Director has developed a fiscal monitoring schedule for 2024. Onsite reviews started in February 2024. The testing period for subrecipient monitoring has been expanded to include a testing period from Fiscal Year 2022 and Fiscal Year 2023. Responsible Party: Finance Director, Garland Thompson Date to be Corrected: February-August 2024

View Audit 305880

Finding 395860 (2022-005)

Material Weakness 2022

Boulder City Hospital, Inc.

NV

Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking § 200.303

Finding 2022-005 Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Cluster Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not sufficiently fund their reserve account. As o...

Finding 2022-005 Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Cluster Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not sufficiently fund their reserve account. As of December 31, 2022, the Hospital should have USDA debt reserves at least equal to $320,669. Responsible Individuals: Douglas B. Lewis, CFO Corrective Action Plan: Management will review the reserve account requirements and ensure appropriate contributions are made during the fiscal year.

View Audit 305482

Finding 395811 (2022-002)

Material Weakness 2022

City of Anaheim

CA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Finding 2022-002, ALN 21.027 Coronavirus State and Local Fiscal Recovery Funds Following the comprehensive audit conducted on the CWWAPP 1.0 disbursement Year Ended June 30, 2022, the following exceptions have been identified that require immediate attention. Below is a summary of the exceptions obs...

Finding 2022-002, ALN 21.027 Coronavirus State and Local Fiscal Recovery Funds Following the comprehensive audit conducted on the CWWAPP 1.0 disbursement Year Ended June 30, 2022, the following exceptions have been identified that require immediate attention. Below is a summary of the exceptions observed: Summary of Exceptions: 1.Credits applied for electric and secondary water disbursements exceeded the prescribed 60-day timeframe. 2.Recalculation of eligible credits for three out of sixty samples resulted in awarded amounts surpassing the calculated eligibility, leading to questioned costs (i.e., over award). Corrective Action Plan: 1.In order to ensure adherence to the stipulated 60-day window for credit applications, for the upcoming CWWAPP arrearage funding we have initiated immediate testing of bill notices upon receipt of the CWWAPP 2.0 disbursement check. Simultaneously, a secondary query has been implemented to validate consistency between the initial query and the present data. Should any discrepancies or technical issues arise, we will promptly seek extension from the State Water Resources Control Board (SWRCB) to facilitate timely funding. 2.To mitigate the risk of over awarding eligible customers, a final query will be conducted prior to disbursement to confirm the accuracy of awarded amounts for each eligible account. We are committed to implementing these corrective measures swiftly and effectively to uphold compliance standards and improve efficiency within the framework of the SWRCB and CWWAPP. Responsible Official: Jeff Sparks Assistant Customer Service Manager Corrective Action Plan Implementation Date: May 17th, 2024

View Audit 305456 Questioned Costs: $1

Finding 395661 (2022-003)

Material Weakness 2022

Next Move Homeless Services

CA

Procurement, Suspension & Debarment § 200.303 § 200.317 § 200.327

Program: Continuum of Care, Emergency Solutions Grant Program Federal Financial Assistance Listing No.:14.267, 14.231 Federal Agency: U.S. Department of Housing and Urban Development Pass-through: Sacramento Steps Forward, Sacramento County Department of Human Assistance Award Year: 2022 Compliance ...

Program: Continuum of Care, Emergency Solutions Grant Program Federal Financial Assistance Listing No.:14.267, 14.231 Federal Agency: U.S. Department of Housing and Urban Development Pass-through: Sacramento Steps Forward, Sacramento County Department of Human Assistance Award Year: 2022 Compliance Requirement: Procurement, Suspension and Debarment Grant Award Number: CA0955L9T032007, CA0955L9T032108, CA0143L9T032013, CA0143L9T032114, CA1303L9T032006, CA1303L9T032107, DHA-PRTS-NM-06-22, DHA-NM-03-22, DHA-NM-03-23, DHA-NM-08-23, DHA-NM-10-23 Finding Summary: The Organization’s procurement policy did not include all the required elements as outlined in the Uniform Guidance. Additionally, the Organization did not retain documentation to support the procedures performed to ensure compliance with suspension and debarment requirements. Management’s Response: We concur. Views of Responsible Officials and Corrective Action: • Management will update policies and procedures to ensure they confirm to the Uniform Guidance regarding procurement, suspension and debarment (2 CFR 200.317 through 200.327, 2 CFR 180). • Train grant staff on new policies and procedures. Name of Responsible Person: Bryan Wagner, CFO Projected Implementation Date: December 31, 2024

View Audit 305283

Finding 394926 (2022-004)

Significant Deficiency 2022

St. Francis Center

CO

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

Finding 2022-004 Federal Agency Name: Department of Housing and Urban Development Program Name: Block Grants for Community mental Health Services Federal Financial Assistance Listing: #93.958 Finding Summary: The Organization did not have adequate internal controls to ensure costs requested for reim...

Finding 2022-004 Federal Agency Name: Department of Housing and Urban Development Program Name: Block Grants for Community mental Health Services Federal Financial Assistance Listing: #93.958 Finding Summary: The Organization did not have adequate internal controls to ensure costs requested for reimbursement were eligible under program requirements. Time incurred on a different program was included in error when summarizing payroll costs. Responsible Individuals: Nancy Burke, CEO Corrective Action Plan: We will implement controls and processes to review reimbursement requests to ensure allowable costs are being reimbursed through the grant. Anticipated Completion Date: December 31, 2023

View Audit 304772

Finding 394924 (2022-003)

Material Weakness 2022

St. Francis Center

CO

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.303

Finding 2022-003 Federal Agency Name: Department of Housing and Urban Development Program Name: Block Grants for Community mental Health Services Federal Financial Assistance Listing: #93.958 Finding Summary: The Organization did not have adequate internal controls to ensure matching expenses were a...

Finding 2022-003 Federal Agency Name: Department of Housing and Urban Development Program Name: Block Grants for Community mental Health Services Federal Financial Assistance Listing: #93.958 Finding Summary: The Organization did not have adequate internal controls to ensure matching expenses were appropriately tracked to meet award requirements. In addition, it was identified that all expenses did not have adequate documentation supporting the review and approval of the amounts meeting the matching requirements. Additionally, select payroll allocations did not have supporting documentation for the amounts allocated to the program. Responsible Individuals: Nancy Burke, CEO Corrective Action Plan: We will implement controls and processes to appropriately track and monitor matching requirements in each period for all awards. In addition, we will implement approval processes to ensure proper qualification for the match requirements and allocations. Anticipated Completion Date: December 31, 2023

View Audit 304772

Finding 394879 (2022-008)

Significant Deficiency 2022

Carlton County, Minnesota

MN

Student Financial Aid Cash Management Reporting § 200.303

Finding Number: 2022-008 Finding Title: LCTS Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Ann Ozan – Fiscal Supervisor II. Corrective Action Planned: Document the review of the public health, corrections, and school district quarterly...

Finding Number: 2022-008 Finding Title: LCTS Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Ann Ozan – Fiscal Supervisor II. Corrective Action Planned: Document the review of the public health, corrections, and school district quarterly reports. Review is being done when the state report is prepared, but not currently documented. Anticipated Completion Date: December 31, 2023.

View Audit 304767

Finding 394336 (2022-007)

Significant Deficiency 2022

Williston Basin Public School District #7

ND

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.303 § 200.403

2022-007 – TITLE I – INADEQUATE SUPPORTING DOCUMENTATION– ALN 84.010 – SIGNIFICANT DEFICIENCY & OTHER NONCOMPLIANCE FINDING TYPE: SIGNIFICANT DEFICIENCY & OTHER NONCOMPLIANCE Finding 2022-007 Federal Program: Title I ALN: 84.010 Federal Award Number(s) and Year(s): S010A200034, 2022 Federal Agency:...

2022-007 – TITLE I – INADEQUATE SUPPORTING DOCUMENTATION– ALN 84.010 – SIGNIFICANT DEFICIENCY & OTHER NONCOMPLIANCE FINDING TYPE: SIGNIFICANT DEFICIENCY & OTHER NONCOMPLIANCE Finding 2022-007 Federal Program: Title I ALN: 84.010 Federal Award Number(s) and Year(s): S010A200034, 2022 Federal Agency: U.S. Department of Education Questioned Cost: $7,591 Condition: We were unable to verify whether 6 of 60 expenditures totaling $7,591 were for costs allowed under the Title I grant. When projected against the total population of $1,628,283, the total projected error is $15,939. Corrective Action Plan: Agreed. WBSD#7 created a new Grants Coordinator position in July 2023 with one of the specific responsibilities for that position being oversight of all Federal Title programs. This oversight responsibility includes monitoring expenditures to ensure all expenditures are allowable within the parameters of each program and also that proper documentation for those expenditures has been maintained. Anticipated Completion Date: • Fiscal Year 2024

View Audit 304345 Questioned Costs: $1

Corrective Action Plans

Filters