Corrective Action Plans

Finding 59406 (2022-006)

Material Weakness 2022

NH

Cash Management Subrecipient Monitoring § 200.303 § 200.305

View of Responsible Officials The State concurs in part with the premise of the findings identified, but it does not concur with the characterization of the Governor?s Office for Emergency Relief and Recovery (GOFERR), the process for authorizing the relevant subaward and relevant amendments, the na...

View of Responsible Officials The State concurs in part with the premise of the findings identified, but it does not concur with the characterization of the Governor?s Office for Emergency Relief and Recovery (GOFERR), the process for authorizing the relevant subaward and relevant amendments, the nature of the subaward and amendments, or the recommended corrective action. Moreover, the full $49,250,000 identified in the finding was not provided to the subrecipient in one lump sum. The State was allocated $50,000,000 from U.S. Treasury for the purposes of designing and facilitating the State?s HAF program. The State received $5,000,000 from U.S. Treasury up front and received the remainder after approval of the State?s planned program. As a result, the State?s subrecipient received an initial subaward for administrative and planning purposes from within the initial $5,000,000 delivered to the State. The subrecipient was advanced only a portion of those initial funds and then was provided the remainder upon request and justification. A subsequent amendment to that subaward provided additional funds to the subrecipient as needed for the same purpose and as part of the U.S. Treasury required process of designing and then attaining approval for the State?s HAF program. The State ultimately received approval from U.S. Treasury for the State?s HAF program plan, which is a complex multi-faceted program that provides various forms of assistance to homeowners, and then received approval from State officials to launch the program. The State?s program is run entirely through a single subrecipient, New Hampshire Housing Finance Authority, which is the only entity of its kind as a statewide housing authority. This subrecipient facilitates a variety of larger-scale, federally funded housing programs. While developing the State?s HAF program and as it neared the launch date, the State began receiving preapplications through its subrecipient. Additionally, during this time, the State was facilitating its Emergency Rental Assistance (ERA) program, which has provided assistance to renters as opposed to homeowners and is facilitated by the same subrecipient of the State. Within the context of having received nearly 200 preapplications for the HAF program and witnessing a heavy and increasing demand in the rental assistance program, the decision was made to advance the remainder of the State?s HAF allocation ($45,000,000) to its subrecipient in order to provide prompt and adequate assistance, believing the program would experience high demand at the outset and funding shortfalls would be problematic for its success. Moreover, the amount of funds provided to the subrecipient was consistent with past advances to the same subrecipient under the ERA program, and as with prior delivery of funds, the subrecipient placed the funds in an appropriate account. However, demand for assistance did not unfold as anticipated due to the features of the program and the areas of need ultimately demonstrated by applicants after review and processing of initial applications. As part of the State?s monitoring protocols, and in part because of a lower initial expenditure rate than expected, the subrecipient began providing biweekly reports on the usage of funds, which the State has used as a measure of cash on hand. Moreover, the State also engages in standing, calendared, weekly calls with the subrecipient to discuss these reports. The State has provided documentation to support the process outlined above as well. Finally, as a result of the State?s remaining HAF allocation having already been provided to the subrecipient, the recommended corrective action is not feasible. However, the State acknowledges the need to more formally memorialize its review of the subrecipient?s cash on hand. As a result, the biweekly reports received and reviewed by the State will now include a specific section providing such information; review and discussion of that data will be incorporated into the weekly calls with the subrecipient, and the process and protocols will be documented in the State?s transaction processing memo for the program. Corrective Action Incorporation of cash on hand related data in biweekly reports received and reviewed by the State, documentation of that review as part of the weekly calls with subrecipient, and memorialization of the process and protocols in the State?s transaction processing memo for its HAF program. Anticipated Completion Date: Cash on hand data into biweekly reports and documentation of review said data as part of weekly calls with the subrecipient is being is actively being incorporated as of this response. The State will ensure that the transaction processing memo is updated with the requisite processes and protocols during the next update before the end of Q1 2023. Contact Persons: Chase Hagman, Lisa Cota-Robles, and Michele Zangri-Crean

View Audit 49723

Finding 59405 (2022-005)

Material Weakness 2022

State of New Hampshire

NH

Subrecipient Monitoring Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

Quarterly Reporting The State concurs in part with the condition and recommendation. A unique challenge with ERA reporting has been changes in the U.S. Treasury portal for that program, which have impacted the State?s ability to download and provide copies of past reports that have been submitted. I...

Quarterly Reporting The State concurs in part with the condition and recommendation. A unique challenge with ERA reporting has been changes in the U.S. Treasury portal for that program, which have impacted the State?s ability to download and provide copies of past reports that have been submitted. In addition, this issue in the reporting portal has been inconsistent, as some previously submitted reports were made accessible by Treasury, while others were not, which resulted in the State being able to access some requisite materials but not others. The State did not have documented procedures to ?pull down? copies of reports it had submitted to Treasury because the State has otherwise been able to rely on access to its previously submitted reports within reporting portals in order to enable the testing required during audit for the relevant periods. Meaning, in the State?s experience with COVID-19 related federal funds reporting, it has been able to access and download past reports for purposes of audit. However, also noted above is that the Treasury portal was recently revised and updated to allow for accessing previously submitted ERA reports that were not otherwise available (the communication from Treasury acknowledging this change was provided by the State). However, the reporting portal change did not take place in time for the State?s auditors to reasonably conduct the necessary testing. The State did provide the data and materials it reported to Treasury for the relevant periods, but auditors were unable to test and validate that data because the State could not access and provide a copy of what was actually uploaded into the portal. Nevertheless, to avoid any such potential issues in the future, the State has already implemented a procedure that involves downloading copies of reports as soon as they are submitted and taking screenshots of portions of the portal where perceived necessary to support what the State has submitted to Treasury. This updated procedure will be memorialized in the program?s transaction processing memo during its next update. Monthly Reporting The State concurs in part but has already implemented related corrective action in line with the recommendation above. The State would also like to note that as part of the ERA reallocation process U.S. Treasury has relied on both quarterly and monthly reporting, and that the State has continued to engage in thorough monitoring of its subrecipient and receives regular reports from that subrecipient, including weekly, biweekly, and quarterly data, which also includes quality control reports. This is inclusive of the monthly reports that were required by U.S. Treasury at one time but no longer are. The State reviews and then discusses reports received at standing, calendared, weekly meetings with the subrecipient and often engages in e-mail correspondence concerning those reports, especially if any questions concerning the data provided arise. However, the State has acknowledged that its documentation of those weekly conversations needed to be more formally memorialized. During the current fiscal year, the State began providing agendas and summaries of topics discussed during the weekly check-ins and will ensure that the program?s transaction processing memo adequately documents this requirement and procedure. The very nature of this program and U.S. Treasury?s facilitation of it has required the State and its subrecipient to stay in close contact, make regular decisions on strategies and policies within the program, and closely consider data relative to it. Anticipated Completion Date Quarterly reporting - Corrective action relative to acquisition of submitted federal reports has already been implemented and this revised procedure will be memorialized in the transaction processing memo for the program during its next update in Q1 2023. Monthly Repotting - Corrective action relative to documentation of weekly meetings was already complete as of the State?s response to this finding, and the State will ensure that the transaction processing memo for the program reflects these measures during its next update in Q1 2023. Contact Person Chase Hagaman, Lisa Cota-Robles, and Emily Larson

View Audit 49723

Finding 59404 (2022-004)

Significant Deficiency 2022

State of New Hampshire

NH

Subrecipient Monitoring § 200.251 § 200.303 § 200.331 § 200.332 § 200.521

View of Responsible Officials The State concurs in part with the findings and concurs in part with the recommendations. Given that CARES Act CRF is a funding source that is no longer eligible for use because program obligations were required to be entered into by December 31, 2021, and program expe...

View of Responsible Officials The State concurs in part with the findings and concurs in part with the recommendations. Given that CARES Act CRF is a funding source that is no longer eligible for use because program obligations were required to be entered into by December 31, 2021, and program expenditures complete by September 30, 2022, there are no ongoing CRF funded projects or programs. As a result, any corrective actions would relate to ensuring any other federal funding sources are achieving compliance requirements. With regard to condition A, the State partially concurs. Federal guidance concerning CARES Act CRF did not allow for charging indirect costs. That guidance indicated ?Payments from the Fund are not administered as part of a traditional grant program and the provisions of the Uniform Guidance, 2 CFR part 200, that are applicable to indirect costs do not apply. Recipients may not apply their indirect costs rates to payments received from the Fund.? Thus, awardees and recipients of funds were not permitted to charge indirect costs against CARES Act CRF. However, the state acknowledges inclusion of language specifically acknowledging the disallowance of indirect costs could have been included in the agreements. With regard to condition B, the State concurs. The four identified subrecipients were awardees of a program that was facilitated at the very end of CARES Act CRF eligibility for the period of performance. This program was run due to updated guidance by U.S. Treasury on December 14, 2021, that extended the deadline for expenditure of funds so long as obligations were entered into by December 31, 2021. That program largely resulted in direct beneficiary awards, but due to the nature of some expenditures awarded some entities received a subaward. Those subawards identified a brief timeline for project completion, between December 2021 and September 2022. Most projects were completed in February and March, with two of the subrecipients finalizing projects in September. Given the nature and timing of the program, those subawardees were closely monitored and regularly interacted with the State in order to receive reimbursement for eligible expenses and complete projects. The State can provide documentation of that monitoring and expense review. However, formal risk assessments were not initially done for those entities. Since then, the State has implemented policies and procedures that help ensure risk assessments are completed for all subrecipients, regardless of the nature of the program. With regard to condition C, the State concurs and has already implemented corrective actions to ensure procedures and policies are in place concerning Uniform Guidance Report review and the issuance of any necessary management decision letters to the extent required and where this deficiency could impact any other sources of federal funding. It is worth noting that the State in most cases has timely conducted risk assessments of subrecipients and reviewed relevant Uniform Guidance Reports, but its corrective action will result in better documentation of that process and protocol. Anticipated Completion Date: The corrective actions indicated above have already been implemented as of the date of this response. Contact Person: Steve Giovinelli and Chase Hagaman

View Audit 49723

Finding 59399 (2022-002)

Significant Deficiency 2022

State of New Hampshire

NH

Subrecipient Monitoring Reporting Allowable Costs / Cost Principles § 200.303 § 200.502 § 200.510

Views of Responsible Officials The Department of Administrative Services (DAS) concurs. Financial management of individual federal awards is decentralized throughout state agencies which centralizes annually in the culmination of the State?s SEFA. During this process, each agency is required to com...

Views of Responsible Officials The Department of Administrative Services (DAS) concurs. Financial management of individual federal awards is decentralized throughout state agencies which centralizes annually in the culmination of the State?s SEFA. During this process, each agency is required to complete a standardized SEFA analysis and reconciliation tool for review by the DAS prior to the incorporation of the data into the State?s SEFA. This process also includes an annual Single Audit training and update session organized by the DAS. Additionally, the DAS notes all contracts, including subawards, entered by state agencies over a designated threshold are required to be authorized by the State?s Legislative Fiscal Committee and the Governor and Executive Council. The DAS will examine each of these processes to identify additional control activities to improve the accuracy and completeness of the pass through element of the SEFA. Anticipated Completion Date: April 30, 2024 Contact: Steven Giovinelli, Federal Grants and Cost Allocation Administrator, Department of Administrative Services

View Audit 49723

Finding 59395 (2022-003)

Significant Deficiency 2022

State of New Hampshire

NH

Special Tests & Provisions Significant Deficiency Equipment & Real Property Management § 200.303

View of Responsible Officials We concur. The Department has been saving and scanning the inventory sheets that are accompanied with the daily EBT card delivery since May 2022. We believe this current control in place allows us to remain in compliance with all requirements. We currently save the ...

View of Responsible Officials We concur. The Department has been saving and scanning the inventory sheets that are accompanied with the daily EBT card delivery since May 2022. We believe this current control in place allows us to remain in compliance with all requirements. We currently save the inventory sheets in a folder with the daily date as the title and save them in the correct monthly folder. Those monthly folders will then be kept in a yearly folder. Anticipated Completion Date 02/23/2023 Contact Person Frank Beck, EBT Administrator

View Audit 49723

Finding 59394 (2022-003)

Material Weakness 2022

School City of Hobart

IN

Equipment & Real Property Management Procurement, Suspension & Debarment Material Weakness § 200.303 § 200.313

FINDING 2022-003 Contact Person Responsible for Corrective Action: Robert Glover Jr. Contact Phone Number: (219) 945-0250 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: COVID-19 ? Education Stabilization Fund ? Equipment and Real Property Accounts P...

FINDING 2022-003 Contact Person Responsible for Corrective Action: Robert Glover Jr. Contact Phone Number: (219) 945-0250 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: COVID-19 ? Education Stabilization Fund ? Equipment and Real Property Accounts Payable will track purchases of equipment over the capitalization threshold and notify the Business Manager of qualifying expenditures. The Business Manager will confirm that the items have been barcoded with the appropriate fund administrator.

View Audit 56049

Finding 59390 (2022-002)

Significant Deficiency 2022

Seward County

NE

Procurement, Suspension & Debarment § 200.303

Finding 2022-002: Department of the Treasury Equitable Sharing Program ? Suspension & Debarment Corrective Action Planned: The County Sheriff has implemented a procedure to verify an entity is not excluded or disqualified prior to paying said entity, and such verification will be adequately documen...

Finding 2022-002: Department of the Treasury Equitable Sharing Program ? Suspension & Debarment Corrective Action Planned: The County Sheriff has implemented a procedure to verify an entity is not excluded or disqualified prior to paying said entity, and such verification will be adequately documented in the entity?s file. Anticipated Completion Date: The change in procedures is effective immediately. Responsible Party: Michael Vance, County Sheriff

View Audit 56119

Finding 59384 (2022-007)

Material Weakness 2022

School Town of Munster

IN

Equipment & Real Property Management § 200.303 § 200.313

Contact Person Responsible for Corrective Action: Sean Begley Contact Phone Number: (219) 836-9111 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: There are currently controls in place for the recording of capital assets. Inventory that meets the $5,...

Contact Person Responsible for Corrective Action: Sean Begley Contact Phone Number: (219) 836-9111 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: There are currently controls in place for the recording of capital assets. Inventory that meets the $5,000 capitalization threshold is added to the spreadsheet periodically. We had turnover in staff and did not begin to do this until 2021. We do not identify assets that have been paid for using federal funds. The Director of Operations is going to add a column to our inventory spreadsheet that will identify any items or projects over the capitalization threshold paid for out of federal funds. The project for $20,650 has been added and corrected. Anticipated Completion Date: August 2023

View Audit 55071

Finding 59381 (2022-006)

Material Weakness 2022

School Town of Munster

IN

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

Contact Person Responsible for Corrective Action: Jessica Espinoza Contact Phone Number: (219) 836-9111 Views of Responsible Official: We concur with the finding partially. No federal funds were used to pay for labor. Description of Corrective Action Plan: We have shared the wage rate requirements w...

Contact Person Responsible for Corrective Action: Jessica Espinoza Contact Phone Number: (219) 836-9111 Views of Responsible Official: We concur with the finding partially. No federal funds were used to pay for labor. Description of Corrective Action Plan: We have shared the wage rate requirements with the Director of Operations. Moving forward, weekly certified payrolls will be collected for projects paid for out of federal funds. We will also ensure that contracts include the required clause in the contract. Anticipated Completion Date: March 2023

View Audit 55071

Finding 59365 (2022-005)

Material Weakness 2022

School Town of Munster

IN

Procurement, Suspension & Debarment § 200.303 § 200.319 § 200.320

Contact Person Responsible for Corrective Action: Sean Begley Contact Phone Number: (219) 836-9111 Views of Responsible Official: We concur with the finding partially. All purchases from C&T Design were for different types of kitchen equipment located in different schools throughout the school distr...

Contact Person Responsible for Corrective Action: Sean Begley Contact Phone Number: (219) 836-9111 Views of Responsible Official: We concur with the finding partially. All purchases from C&T Design were for different types of kitchen equipment located in different schools throughout the school district. For the time period audited, there were eight purchase orders. Of these purchase orders, three were created prior to the hiring of the new Director of Operations in July 2021. For the five purchase orders created by the Director of Operations, the five POs are for different types of equipment in two different schools and should be considered different projects. For each purchase a minimum of three different qualified vendors were provided the same scope, the same time, and deadline for providing a quote. In each case, C&T Design was the lowest. At the same time, the IDOE Division of School and Community Nutrition Program is expecting the School Town of Munster to follow a spend down plan in order to comply with maintaining an appropriate cash balance in the food service account. As specified in Finding 2022-005, barring a vendor from bidding due to the aggregate amount of goods and/or services provided to multiple School Town of Munster schools in one year would disqualify a company that consistently provided the lowest bid. Description of Corrective Action Plan: The School Town of Munster will have the school attorney conduct a legal review for all projects with an estimated cost over $50,000 to ensure compliance under Indiana Code 4-13.6-5 Chapter 5 ? Bidding Requirements. We will use SAM.GOV to verify that vendors we use are neither suspended nor debarred. Anticipated Completion Date: August 2023

View Audit 55071

Finding 59364 (2022-004)

Material Weakness 2022

School Town of Munster

IN

School Nutrition Programs Subrecipient Monitoring Cash Management § 200.302 § 200.303 § 200.327 § 200.328 § 200.329

Contact Person Responsible for Corrective Action: Jessica Espinoza Contact Phone Number: (219) 836-9111 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: There has been turnover in the finance department and the past employees who would have been respo...

Contact Person Responsible for Corrective Action: Jessica Espinoza Contact Phone Number: (219) 836-9111 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: There has been turnover in the finance department and the past employees who would have been responsible for this are no longer here. There are already internal controls in place to ensure that the monthly sponsor claims submitted match the school?s meal count reports. The Treasurer will continue to ensure that everything is correctly entered before submission. Anticipated Completion Date: March 2023

View Audit 55071

Finding 59363 (2022-003)

Material Weakness 2022

School Town of Munster

IN

Questioned Costs Allowable Costs / Cost Principles School Nutrition Programs § 200.303 § 200.403

Contact Person Responsible for Corrective Action: Jessica Espinoza Contact Phone Number: (219) 836-9111 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We currently only have one employee who is partially paid through the federal lunch program. Movin...

Contact Person Responsible for Corrective Action: Jessica Espinoza Contact Phone Number: (219) 836-9111 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We currently only have one employee who is partially paid through the federal lunch program. Moving forward, the employee will be keeping a log of the daily start and end time working on food service. These times will be entered into her timecard as a foodservice event. The supervisor will review the time card. This will ensure that she is only being paid with federal lunch funds while she is working on food service. Also, a grant distribution payroll report for all foodservice employees is signed off on by the Director of Operations after each payroll, verifying the amounts expended from the foodservice fund. Anticipated Completion Date: To be completed by the next payroll dated March 3, 2023.

View Audit 55071 Questioned Costs: $1

Finding 59307 (2022-002)

Significant Deficiency 2022

Memorial Hospital of Laramie County D/b/a Cheyenne Regional Medical Ce

WY

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges Federal Financial Assistance Listing/CFDA #93.332 Finding Summary: There was no evidence retained that the Medical Center?s com...

Finding 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges Federal Financial Assistance Listing/CFDA #93.332 Finding Summary: There was no evidence retained that the Medical Center?s compliance and financial reports submitted to the Department of Health and Human Services were reviewed and approved prior to submission. Responsible Individuals: Lead Navigator ? Dasa Robertson Program Director ? Jason Mincer Corrective Action Plan: One step will be added to the current plan: Existing steps: 1. Weekly, individual Enroll Wyoming Navigators input required information (meetings with consumers, partners, tabling events, presentations, and marketing numbers) into the reporting spreadsheet. 2. Lead Navigator, Dasa Robertson, verifies the information input by Navigators is accurate, follows the reporting guidelines from the Department of Health and Human Services and works with the Navigators to change any info that needs adjusted. Once this is completed, she performs a final review and approves the information. 3. Lead Navigator, Dasa Robertson, uploads the information from the reporting spreadsheet into the online forms in the federal HIOS system, so that the Department of Health and Human Services can access this information. New Step: ? Prior Step 3, Program Director, Jason Mincer will review and approve the data input into the reporting spreadsheet by Navigators and the Lead Navigator. If red flags (high or low values) are identified, he will reach out to the Navigator for clarification and needed adjustments will be made. As a portion of his weekly meeting with each staff person the Program Director will familiarize himself with the projects each person is working on to assure prepare for review and approval. Once deemed satisfactory, the Program Director will electronically initial in the reporting spreadsheet to denote review and approval for submission. ? Once approved by the Program Director, the Lead Navigator will submit the information to the Department of Health and Human Services through HIOS. ? The same process will be used to review monthly, quarterly, and annual reports aggregated and submitted to HIOS. Anticipated Completion Date: The new process will begin with the filling of the weekly reports on 3/31/23.

View Audit 54541

Finding 59304 (2022-002)

Significant Deficiency 2022

Tri-County Senior Citizens and Housing, Inc.

CO

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Finding 2022-002:Section 8 Project-Based Cluster Federal Assistance Number: 14.182 and 14.195 U.S. Department of Housing and Urban Development Compliance Requirements: Cash Management, Eligibility, Reporting Type of finding: Internal Control Over Compliance (significant deficiency) Reco...

Finding 2022-002:Section 8 Project-Based Cluster Federal Assistance Number: 14.182 and 14.195 U.S. Department of Housing and Urban Development Compliance Requirements: Cash Management, Eligibility, Reporting Type of finding: Internal Control Over Compliance (significant deficiency) Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to ensure a review process is established through adequate segregation of duties. The Organization should consider assessing and realigning the duties and responsibilities of administrative staff allowing the administrator to act in a more supervisory position. Action Taken: This is not a "non-compliance" finding, however, management and the Board understand that internal controls and best management practices need to be strengthened. Management will review job descriptions and evaluate the number of staff needed to strengthen internal controls. Policies and procedures will be reviewed and adopted to segregate duties for best management practices in internal controls given the size of the organization we are. If the U.S. Department of Housing and Urban Development have questions regarding this plan, please call the responsible party at (719) 852-5778. Sincerely yours, Karla Shriver Managing Board Member Tri-County Senior Citizens and Housing, Inc.

View Audit 51940

Finding 59221 (2022-002)

Significant Deficiency 2022

Kipp North Philadelphia Charter School

PA

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

U.S. Department of Education KIPP North Philadelphia Charter School respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The find...

U.S. Department of Education KIPP North Philadelphia Charter School respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Education 2022-002 Education Stabilization Fund: 84.425D Elementary and Secondary School Emergency Relief (ESSER) Fund Recommendation: To ensure timeliness and accountability with the required reporting to the Pennsylvania Department of Education, we recommend management review and update procedures to establish consistent preparation, review, and submission of all program reports by the required deadline. Such controls would ensure timely and accurate reporting being produced and optimum cash flow management. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: The team began expanding to close the capacity gaps. A public grants manager was added in April 2022. Additionally, the team began recruiting for a Controller. This role will be onboarding in spring 2023. In addition to the new roles, the Controller will be tasked with reviewing policies and procedures and identifying opportunities to improve efficiencies. Name of the contact person responsible for corrective action: Natalie Wiltshire, Chief Operating Officer ? Phone: 215-294-8596 Email: nwiltshire@kippphiladelphia.org Planned completion date for corrective action plan: 09/30/2023 If the U.S. Department of Education has questions regarding this plan, please contact Natalie Wiltshire at 215-294-8596.

View Audit 56146

Finding 59138 (2022-002)

Material Weakness 2022

Habitat for Humanity Intl Yuba Sutter

CA

Material Weakness Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.514

Finding 2022-002: Internal Controls (Material Weakness) The Chief Executive Officer will ensure that the Accounting Officer makes adjustments to record all grants ahead of time in Quickbooks and deduct funding as we spend from these areas to directly show grant balances and that the restricted fundi...

Finding 2022-002: Internal Controls (Material Weakness) The Chief Executive Officer will ensure that the Accounting Officer makes adjustments to record all grants ahead of time in Quickbooks and deduct funding as we spend from these areas to directly show grant balances and that the restricted funding is spent in compliance with the funding received. We will also provide these findings to a certified public accountant to make sure they are adhered to correctly and meet the requirements of both state and federal funding. To address these findings and ensure compliance with Title 2 requirements, Habitat for Humanity Yuba/Sutter will implement the following corrective action plan: 1. Operationalize the Grants Management Standards ? Habitat for Humanity Yuba/Sutter will conduct a comprehensive review of its current grants management policies and procedures to identify any gaps or deficiencies in compliance with Title 2 requirements. ? The organization will update its grants management policies and procedures to align with Title 2 regulations, including documentation requirements, financial management, reporting, and record keeping. ? Habitat for Humanity Yuba/Sutter will provide training and resources to its staff involved in grants management to ensure they are knowledgeable about the updated policies and procedures. ? The organization will establish a system for ongoing monitoring and internal audits to ensure compliance with grants management standards, and make necessary adjustments as needed. 2. Establish a Robust Marketplace of Modern Solutions ? Habitat for Humanity Yuba/Sutter will conduct a thorough review of its current marketplace of solutions, including vendors, software, and technologies used in its operations. ? The organization will identify opportunities to modernize its systems and processes to enhance efficiency, streamline operations, and ensure compliance with Title 2 requirements. ? Habitat for Humanity Yuba/Sutter will develop a plan to implement modern solutions, including budgeting, procurement, and implementation timelines. ? The organization will establish a process for ongoing evaluation and monitoring of the effectiveness of the modern solutions implemented, and make necessary adjustments as needed. 3. Manage Risk ? Habitat for Humanity Yuba/Sutter will conduct a comprehensive risk assessment to identify potential risks associated with grants management and compliance with Title 2 requirements. ? The organization will develop and implement risk mitigation strategies, including internal controls, monitoring mechanisms, and contingency plans. ? Habitat for Humanity Yuba/Sutter will establish a system for ongoing risk management, including regular risk assessments and reviews, and updates to risk mitigation strategies as needed. ? The organization will ensure that all staff involved in grants management are aware of the risk mitigation strategies and trained on how to implement them effectively. 4. Achieve Program Goals and Objectives ? Habitat for Humanity Yuba/Sutter will review and align its program goals and objectives with the requirements of Title 2. ? The organization will develop a comprehensive plan to ensure that its programs are designed, implemented, and evaluated in accordance with Title 2 guidelines, including outcome measurement, data collection, and reporting. ? Habitat for Humanity Yuba/Sutter will establish regular monitoring and reporting mechanisms to track progress towards program goals and ensure compliance with Title 2 requirements. ? The organization will provide training and resources to its staff involved in program management to ensure they are knowledgeable about the updated program goals and objectives and the requirements of Title 2.

View Audit 55974

Finding 58986 (2022-001)

Material Weakness 2022

The Nemours Foundation

FL

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.430

Nemours will create a standard operating procedure (SOP) that outlines a centralized process for effort allocation review and editing. The SOP will incorporate procedures to ensure accuracy and validation of all correcting entries. Meetings with each Nemours principal investigator (PI) will occur ...

Nemours will create a standard operating procedure (SOP) that outlines a centralized process for effort allocation review and editing. The SOP will incorporate procedures to ensure accuracy and validation of all correcting entries. Meetings with each Nemours principal investigator (PI) will occur at least quarterly to review study financial information. An effort certification report will be reviewed by the PI for accuracy and sign off. Nemours policy 11.1.4, Cost Transfers for Funded Activities, will be reviewed and updated. Corrective action will be complete by October 31, 2023.

View Audit 49560 Questioned Costs: $1

Finding 58984 (2022-003)

Material Weakness 2022

Jasper County

IN

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

FINDING 2022-003 Contact Person Responsible for Corrective Action: Donya Jordan Contact Phone Number: 219-866-4654 Views of Responsible Officer: We concur with the finding Description of Corrective Action Plan: We will have the Interim Report and Project and Expenditure Reports be reviewed by one of...

FINDING 2022-003 Contact Person Responsible for Corrective Action: Donya Jordan Contact Phone Number: 219-866-4654 Views of Responsible Officer: We concur with the finding Description of Corrective Action Plan: We will have the Interim Report and Project and Expenditure Reports be reviewed by one of the deputies in the office which would ensure accurate and timely reporting. Anticipated Completion Date: 07-01-23

View Audit 55082

Finding 58896 (2022-004)

Material Weakness 2022

Pr Health Corporation D/b/a First Care Health Center

ND

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

Finding 2022-004 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the reserve...

Finding 2022-004 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the reserve funds for the federal program. Responsible Individuals: Nina Hollingsworth, CFO and Marcus Lewis, CEO Corrective Action Plan: Management will ensure a review separate from the preparer of the reconciliation for the Health Center?s reserve fund is completed with formal documentation noting the review. Anticipated Completion Date: 10/31/2023

View Audit 55393

Finding 58865 (2022-005)

Material Weakness 2022

Delta County Memorial Hospital

CO

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

2022-005 Department of Agriculture Federal Assistance Listing #10.766 Community Facilities Loans and Grants Cluster Activities Allowed or Unallowed and Allowable Costs/Costs Principles Material Weakness in Internal Control Over Compliance Finding Summary: There was no review and approval...

2022-005 Department of Agriculture Federal Assistance Listing #10.766 Community Facilities Loans and Grants Cluster Activities Allowed or Unallowed and Allowable Costs/Costs Principles Material Weakness in Internal Control Over Compliance Finding Summary: There was no review and approval by a separate individual outside of the preparer over the lost revenue calculation utilized to claim expenditures under the federal program. Responsible Individuals: Kelly Johnston, Interim CFO; Larin Jones, Controller Corrective Action Plan: There will be a secondary review and approval by a separate individual outside of the preparer over future lost revenue calculations, if applicable. The secondary review and approval will be documented and recorded. Anticipated Completion Date: December 31, 2023

View Audit 55028

Finding 58864 (2022-004)

Material Weakness 2022

Delta County Memorial Hospital

CO

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

2022-004 Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #840428757 Activities Allowed or Unallowed, Allowable Costs/Costs Principles,...

2022-004 Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #840428757 Activities Allowed or Unallowed, Allowable Costs/Costs Principles, and Reporting Material Weakness in Internal Control Over Compliance Finding Summary: There was no review and approval by a separate individual outside of the preparer over the lost revenue calculation and the special report submitted to the Department of Health and Human Services Responsible Individuals: Kelly Johnston, Interim CFO; Larin Jones, Controller Corrective Action Plan: There will be a secondary review and approval by a separate individual outside of the preparer over future lost revenue calculations and expense listings, if applicable, and the special report submitted to the Department of Health and Human Services. The secondary review and approval prior to submission will be documented and recorded. Anticipated Completion Date: December 31, 2023

View Audit 55028

Finding 58830 (2022-006)

Significant Deficiency 2022

White Mountain Communities Hospital, Inc. Dba White Mountain Regional

AZ

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

Finding 2022-006 Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster CFDA # 10.766 Finding Summary: Included in the population of the Hospital?s program expenditures included amounts prior to the period of performance. There is a potential ...

Finding 2022-006 Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster CFDA # 10.766 Finding Summary: Included in the population of the Hospital?s program expenditures included amounts prior to the period of performance. There is a potential that expenses claimed under the major federal program are not during the period of performance. Responsible Individuals: Ashley Jaramillo, Chief Financial Officer Corrective Action Plan: Amounts prior to funding were paid for by the hospital. Anticipated Completion Date: Completed

View Audit 54485

Finding 58829 (2022-004)

Material Weakness 2022

White Mountain Communities Hospital, Inc. Dba White Mountain Regional

AZ

Reporting Material Weakness Matching / Level of Effort / Earmarking § 200.303

Finding 2022-004 Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster CFDA # 10.766 Finding Summary: The Hospital?s Federal Financial Report for grant number 02-001-916646223 through the period ending June 7, 2022, was marked as final and in...

Finding 2022-004 Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster CFDA # 10.766 Finding Summary: The Hospital?s Federal Financial Report for grant number 02-001-916646223 through the period ending June 7, 2022, was marked as final and indicated the Hospital expended the full $435,625 federal award, which was not accurate. Responsible Individuals: Ashley Jaramillo, Chief Financial Officer Corrective Action Plan: Informed USDA of actual expended. Anticipated Completion Date: September 29, 2023

View Audit 54485

Finding 58827 (2022-005)

Significant Deficiency 2022

White Mountain Communities Hospital, Inc. Dba White Mountain Regional

AZ

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding 2022-005 Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster CFDA # 10.766 Finding Summary: The Hospital was required to establish a Reserve Account with monthly deposits of $620 until a total balance of $74,342 was obtained. The Ho...

Finding 2022-005 Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster CFDA # 10.766 Finding Summary: The Hospital was required to establish a Reserve Account with monthly deposits of $620 until a total balance of $74,342 was obtained. The Hospital did not establish this account or make any required deposits during 2022. This caused the Hospital to not be in compliance with the terms of the loan agreement related to the Reserve Fund. Responsible Individuals: Ashley Jaramillo, Chief Financial Officer Corrective Action Plan: Loan was subsequent paid in full and requirements of a Reserve Account are no longer needed. Anticipated Completion Date: September 29, 2023

View Audit 54485

Finding 58754 (2022-001)

Significant Deficiency 2022

Appling County Board of Education

GA

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.403

FA 2022-001 Improve/Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding ...

FA 2022-001 Improve/Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund Federal Award Number: S425D200012 (Year: 2020), S425D210012 (Year: 2021) S425U2120012 (Year: 2021) Questioned Costs: $104,640.00 Prior Year Finding: None Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over expenditures as it relates to the Elementary and Secondary School Emergency Relief Fund program. Corrective Action Plans: We concur with this finding. The process used to pay retention pay to staff has been reviewed and will only be a paid to staff employed by the Appling County Board of Education. Estimated Completion Date: 5/5/2023 Contact Person: Adrienne Taylor, CFO Telephone: (912)367-8600 Email: Adrienne.taylor@appling.k12.ga.us

View Audit 54825 Questioned Costs: $1

Corrective Action Plans

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