Corrective Action Plans

Finding 41766 (2022-002)

Material Weakness 2022

City of Kokomo

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2022-002 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Weston Reed Contact Phone Number: 765-456-7455 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Going forward, city of Kokomo will include the sente...

FINDING 2022-002 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Weston Reed Contact Phone Number: 765-456-7455 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Going forward, city of Kokomo will include the sentence below to all ARPA contract that are above $25,000.00 The Contractor certifies, warrants, and represents that it has no current, pending, or outstanding criminal, civil, or enforcement actions initiated by the City and that neither it nor its principal(s) is/are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from entering into this Contract by any federal agency or by any department, agency, or political subdivision of the State of Indiana, or the City. The Contractor agrees that it will immediately notify the City and the Department of any such actions and during the term of such actions, the City or the Department may delay, withhold, or deny work under any supplement, amendment, change order, or other contractual device issued pursuant to this Contract. Anticipated Completion Date: July 31, 2023

View Audit 38488

Finding 41765 (2022-001)

Significant Deficiency 2022

City of Kokomo

IN

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

FINDING 2022-001 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Weston Reed Contact Phone Number: 765-456-7455 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: 1. Starting with the 2023 June quarter-end P&E repor...

FINDING 2022-001 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Weston Reed Contact Phone Number: 765-456-7455 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: 1. Starting with the 2023 June quarter-end P&E report which is due in July 31, 2023 City will have another employee review and sign off on the report prior to final submission on line. Anticipated Completion Date: July 31, 2023

View Audit 38488

Finding 41757 (2022-001)

Significant Deficiency 2022

Calvert County Public Schools

MD

Subrecipient Monitoring Procurement, Suspension & Debarment § 200.303

2022-001 Suspension and Debarment SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL, OTHER MATTERS Coronavirus State and Local Fiscal Recovery Funds (CSLFRF), ALN 21.027 Child Nutrition Cluster (CNC), ALN 10.553, 10.555, 10.559 Auditor?s Recommendation: We recommend that the schools develop internal contro...

2022-001 Suspension and Debarment SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL, OTHER MATTERS Coronavirus State and Local Fiscal Recovery Funds (CSLFRF), ALN 21.027 Child Nutrition Cluster (CNC), ALN 10.553, 10.555, 10.559 Auditor?s Recommendation: We recommend that the schools develop internal controls and procedures to ensure that documentation of vendor?s suspension and debarment status is maintained in accordance with the required retention policy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: When issuing contracts in excess of $25,000 for goods or services, a school district employee will do one or both of the following: A. Add suspension and debarment language to the applicable vendor contract. B. (1) Check the federal government?s suspension and debarment website to determine if the vendor has been suspended or debarred, (2) take a screen shot that shows ?not found? or similar language to support that the vendor is not suspended or debarred, (3) save a copy of a screen shot to document completion of this check, and (4) retain the screen shots for the school district auditors. When using this option (instead of Option A above), staff will ensure that the date of the screen shot will be before or on the date on which the vendor contract is fully executed. Name(s) of the contact person(s) responsible for corrective action: Sheldon Taylor Planned completion date for corrective action plan: June 30, 2023 If the Maryland State Department of Education has any questions regarding this plan, please call Scott Johnson at 443-550-8200.

View Audit 38696

Finding 41733 (2022-007)

Significant Deficiency 2022

Urshan College

MO

Special Tests & Provisions Subrecipient Monitoring Reporting § 200.303

2022-007 Special Tests and Provisions ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. After year end, the College engaged CLA to assist with the GLBA pr...

2022-007 Special Tests and Provisions ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. After year end, the College engaged CLA to assist with the GLBA process for the next fiscal year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: College IT department is currently working with outside consultants to perform a risk assessment. Name(s) of the contact person(s) responsible for corrective action: Ashley Chancellor, CFO Planned completion date for corrective action plan: 11/1/2022

View Audit 38581

Finding 41731 (2022-005)

Significant Deficiency 2022

Urshan College

MO

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

2022-005 Special Tests and Provisions ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagr...

2022-005 Special Tests and Provisions ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The director of financial aid works with the third-party servicer to ensure accurate and timely enrollment updates to NSLDS. Name(s) of the contact person(s) responsible for corrective action: Grant Pollard, Director of Financial Aid Planned completion date for corrective action plan: 11/1/2022

View Audit 38581

Finding 41728 (2022-004)

Material Weakness 2022

University of Sioux Falls

SD

Procurement, Suspension & Debarment § 200.303 § 200.317 § 200.327

Finding 2022-004 Department of Education Education Stabilization Fund - Higher Education Emergency Relief Fund - Student Portion Federal Financial Assistance Listing #84.425F P425F200756-20A and P425F200756-20B Procurement, Suspension and Debarment Finding Summary: Eide Bailly LLP found that the U...

Finding 2022-004 Department of Education Education Stabilization Fund - Higher Education Emergency Relief Fund - Student Portion Federal Financial Assistance Listing #84.425F P425F200756-20A and P425F200756-20B Procurement, Suspension and Debarment Finding Summary: Eide Bailly LLP found that the University's procurement policy did not include all of the required elements as outlined in Uniform Guidance. Additionally, the University did not retain documentation to support the procedures it performed to ensure compliance with procurement, suspension, and debarment. Responsible Individuals: Michael Van Surksum, Vice President for Business and Finance; Elizabeth Porteous, Accountant Corrective Action Plan: Management is reviewing the Uniform Guidance set out in 2 CFR 200.317 through 200.327. 2 CFR 200 Appendix II and 2 CFR 180 and will update their policies for detailed use going forward. Anticipated Completion Date: Management hopes to have the new policy in place by December 31, 2022.

View Audit 38495

Finding 41727 (2022-003)

Material Weakness 2022

University of Sioux Falls

SD

Allowable Costs / Cost Principles § 200.303 § 200.430

Finding 2022-003 Department of Education Education Stabilization Fund - Higher Education Emergency Relief Fund - Student Portion Federal Financial Assistance Listing #84.425E P425E200919- 20B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: Eide Bailly LLP found...

Finding 2022-003 Department of Education Education Stabilization Fund - Higher Education Emergency Relief Fund - Student Portion Federal Financial Assistance Listing #84.425E P425E200919- 20B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: Eide Bailly LLP found that the University over-awarded Higher Education Emergency Relief Fund (HEERF) funding to one student based on its determination over eligibility of the student portion of HEERF funding, which is awarded based on (1) expected family contribution and (2) enrollment status. The student was awarded based on fulltime enrollment; however, the student's enrollment status was part-time. Responsible Individuals: Michael Van Surksum, Vice President for Business and Finance; Elizabeth Porteous, Accountant; Karrie Morgan, Director of Financial Aid; Anna Heckenliable, Registrar Corrective Action Plan: Responsible Individuals above will review credit hour reports pulled from the system for accuracy to ensure no hours are duplicated. Anticipated Completion Date: Management expects this finding to be resolved by January 31, 2023.

View Audit 38495

Finding 41655 (2022-002)

Material Weakness 2022

Whatley Health Services, Inc.

AL

Reporting § 200.303

2022-002 Reporting The Corporation is increasing its efforts to ensure that its policies and procedures are in place to ensure the timely submission of reports. Completion Date: Estimated December 2023 Contact Person: Rajuan Sherman Chief Financial Officer 2731 M.L. King, Jr. Blvd Tusca...

2022-002 Reporting The Corporation is increasing its efforts to ensure that its policies and procedures are in place to ensure the timely submission of reports. Completion Date: Estimated December 2023 Contact Person: Rajuan Sherman Chief Financial Officer 2731 M.L. King, Jr. Blvd Tuscaloosa, AL 35403 (205) 614-6070 rsherman@whatleyhealth.org

View Audit 38162

Finding 41653 (2022-002)

Significant Deficiency 2022

City of Mishawaka

IN

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Subject: 2022-002 Coronavirus State and Local Fiscal Recovery Funds ? Reporting Federal Agency: Department of the Treasury Federal Program: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Compliance Requirement: Reporting Audit Finding: Significant Deficiency Rec...

Subject: 2022-002 Coronavirus State and Local Fiscal Recovery Funds ? Reporting Federal Agency: Department of the Treasury Federal Program: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Compliance Requirement: Reporting Audit Finding: Significant Deficiency Recommendation: The Auditor recommends the City implement procedures to ensure reports are being reviewed by an individual or third-party familiar with the grant prior to their submission, including reconciliation of the report to the general ledger system. Planned Corrective Actions: The City agrees with the recommendation and plans to implement the recommendation during 2023.

View Audit 38159

Finding 41652 (2022-002)

Significant Deficiency 2022

Adult Care Management, Inc.

CO

Allowable Costs / Cost Principles Reporting § 200.303 § 200.430

2022-002 Activities Allowed or Unallowed, Allowable Costs/Cost Principles Medical Assistance Program ? CFDA No. 93.778 ? Award Period: July 1, 2021 through June 30, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance Response: Adult Care Management, Inc. (ACMI) agrees w...

2022-002 Activities Allowed or Unallowed, Allowable Costs/Cost Principles Medical Assistance Program ? CFDA No. 93.778 ? Award Period: July 1, 2021 through June 30, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance Response: Adult Care Management, Inc. (ACMI) agrees with the finding of Taylor Roth & Company, PLLC, in the fiscal year 2022 Single Audit (SEFA) that the established internal controls over payroll cost allocation did not operate as intended to ensure appropriate allocation of payroll costs across all programs in the five (5) of the twenty-four sampled payroll periods for one (1) individual. Action: Effective March 10, 2023, the internal control practices of ACMI will be strengthened to support a review system able to prevent and/or detect and correct errors in a timely manner to ensure payroll costs are accurate, allowable, and properly allocated. Specifically, management?s monthly review of all cost allocations will include a review of the data entry hours from payroll timesheets into the payroll allocation spreadsheet of no less than 10% of total reporting employees, with a priority focus on employees reporting time to more than one program / cost center.

View Audit 38172

Finding 41583 (2022-001)

Significant Deficiency 2022

Lawrence Union Free School District

NY

School Nutrition Programs Procurement, Suspension & Debarment Cash Management § 200.303

2022-001. Procurement United States Department of Education, passed through New York State Department of Education Title I Grants to Local Educational Agencies ALN: 84.010 Special Education Cluster Special Education Grants to States ALN: 84.027A Special Education Preschool Grants ALN: 84.173A Educat...

2022-001. Procurement United States Department of Education, passed through New York State Department of Education Title I Grants to Local Educational Agencies ALN: 84.010 Special Education Cluster Special Education Grants to States ALN: 84.027A Special Education Preschool Grants ALN: 84.173A Education Stabilization Fund COVID-19: Governor?s Emergency Education relief (GEER) Fund ALN: 84.425C COVID-19: Elementary and Secondary School Emergency Relief (ESSER) Fund ALN: 84.425D COVID-19: American Rescue Plan ? Elementary and Secondary School Emergency Relief (ARP ESSER) Fund ALN: 84.425U COVID-19: American Rescue Plan ? Elementary and Secondary School Emergency Relief - Homeless Children and Youth ALN: 84.425W United States Department of Agriculture, passed through New York State Department of Education Child Nutrition Cluster COVID-19: School Breakfast Program (SSO) ALN: 10.553 National School Lunch Program ALN: 10.555 COVID-19: National School Lunch Program ALN: 10.555 COVID-19: Summer Food Service Program for Children ALN: 10.559 Condition: The District has not updated its existing policies and written procedures to conform to Uniform Guidance requirements. Planned Corrective Action: The District?s Assistant Superintendent for Business and Operations will work on updating all policies and procedures relating to U.S. Office of Management and Budget Uniform Guidance to ensure that District policies are in compliance with these guidelines. Responsible Contact Person: Jeremy Feder Assistant Superintendent for Business and Operations Lawrence Union Free School District 2 Reilly Road Cedarhurst, NY 11516 Anticipated completion date: June 30, 2023.

View Audit 38733

Finding 41564 (2022-101)

Significant Deficiency 2022

Bay Haven Charter Academy, INC

FL

Procurement, Suspension & Debarment § 200.303 § 200.320

Finding Number: 2022-01 Planned Correction Action: Management will implement additional procedures to make sure suspension and debarment requirements are considered as well as additional oversight procedures to verify quotes are being obtained when required. Management reprimanded the staff who was...

Finding Number: 2022-01 Planned Correction Action: Management will implement additional procedures to make sure suspension and debarment requirements are considered as well as additional oversight procedures to verify quotes are being obtained when required. Management reprimanded the staff who was told to obtain quotes and procurement procedures were taken away from the staff in the future. Anticipated Completion Date: 11/16/2022 Responsible Contact Person(s): Kelly Phelan, Larry Bolinger, Laura Adams

View Audit 41129

Finding 41498 (2022-002)

Material Weakness 2022

Lighthouse Social Service Centers

CA

Subrecipient Monitoring Cash Management Material Weakness § 200.1 § 200.303

Finding 2022-002 The Corrective Action Plan (CAP) is designed to address audit recommendations related to revenue recognition, timely grant claims submission, and monthly expenditure reconciliation. To enhance revenue recognition, the Finance Department will review and update existing accounting pro...

Finding 2022-002 The Corrective Action Plan (CAP) is designed to address audit recommendations related to revenue recognition, timely grant claims submission, and monthly expenditure reconciliation. To enhance revenue recognition, the Finance Department will review and update existing accounting procedures, provide clearer guidelines, and conduct staff training. The timely submission of grant claims will be ensured through a monitoring mechanism, reporting structure, and an escalation process. Monthly reconciliation of revenue to expenditures will be established, with management reviewing and taking corrective actions as needed. Progress will be closely monitored and reported, with the goal of implementing these improvements immediately, involving the Finance Department, Grants Management Team, and relevant management personnel.

View Audit 38289

Finding 41478 (2022-004)

Significant Deficiency 2022

Safe and Sound

CA

Subrecipient Monitoring Equipment & Real Property Management Matching / Level of Effort / Earmarking § 200.1 § 200.303 § 200.403 § 200.414

2022-004 ? Allowable Costs/Activities Allowed or Unallowed: Indirect Cost Name of Responsible Individual(s): Pamela Aguilera, Chief Financial Officer. Corrective Action: Safe & Sound?s Finance team implemented policies and procedures to ensure the indirect cost rate is calculated based on modified t...

2022-004 ? Allowable Costs/Activities Allowed or Unallowed: Indirect Cost Name of Responsible Individual(s): Pamela Aguilera, Chief Financial Officer. Corrective Action: Safe & Sound?s Finance team implemented policies and procedures to ensure the indirect cost rate is calculated based on modified total direct costs, which excludes amounts over $25,000 for subawards. We updated our formulas to ensure that we properly calculated indirect costs on a monthly basis, ensuring the exclusion of subawards over $25,000. Date Completed: 7/31/2023

View Audit 37696

Finding 41477 (2022-003)

Material Weakness 2022

Safe and Sound

CA

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.403 § 200.430 § 200.431 § 200.447

2022-003 ? Allowable Costs/Activities Allowed or Unallowed: Fringe Benefits and Shared Costs Name of Responsible Individual(s): Pamela Aguilera, Chief Financial Officer Corrective Action: During the initial year of receiving our first direct federal grant, Safe & Sound calculated fringe benefits bas...

2022-003 ? Allowable Costs/Activities Allowed or Unallowed: Fringe Benefits and Shared Costs Name of Responsible Individual(s): Pamela Aguilera, Chief Financial Officer Corrective Action: During the initial year of receiving our first direct federal grant, Safe & Sound calculated fringe benefits based on a percentage of the salaries allocated to the grant. Salaries were calculated based on time and effort. Safe & Sound has reviewed the current practices related to allocating fringe benefits and shared costs. Safe & Sound?s Finance team reviewed and verified that we have the adequate fringe benefit and shared costs to meet the costs allocated to this grant. To ensure we have the proper supporting documentation to meet the Uniform Guidance requirements in 2 CFR Sections 200.303 and 200.403, we will implement time and effort documentation for benefit and shared cost allocations on a monthly basis and will review for any necessary budget to actual adjustments. Date Completed: 8/31/2023

View Audit 37696 Questioned Costs: $1

Finding 41467 (2022-003)

Material Weakness 2022

Tri-Creek School Corporation

IN

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.208 § 200.303 § 200.403

Information on the federal program: Subject: Special Education Cluster - Earmarking Federal Agency: Department of Education Federal Program: Special Education Grants to States, Special Education Preschool Grants ALN: 84.027, 84.173 Federal Award Numbers and Years: 19611-045-PN01 Pass-Through Entity:...

Information on the federal program: Subject: Special Education Cluster - Earmarking Federal Agency: Department of Education Federal Program: Special Education Grants to States, Special Education Preschool Grants ALN: 84.027, 84.173 Federal Award Numbers and Years: 19611-045-PN01 Pass-Through Entity: Indiana Department of Education Compliance Requirements: Matching, Level of Effort, Earmarking Audit Findings: Material Weakness Context: The School Corporation is a member of the Northwest Indiana Special Education Cooperative (Cooperative). During fiscal years 2020-2021 and 2021-2022, the Cooperative operated the special education programs and spent the federal money on behalf of all its members. As the grant agreements were between the Indiana Department of Education (IDOE) and each member school, the School Corporation was responsible for ensuring and providing oversight of the Cooperative. However, there was inadequate oversight performed by the School Corporation in order to ensure compliance with the Matching, Level of Effort, and Earmarking compliance requirements. The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the earmarking requirements. The Cooperative did not have adequate procedures in place to ensure that the required level of expenditures for non-public school students with disabilities was met for each member school. The Cooperative did not have effective internal controls to ensure non-public school expenditures were appropriately identified and reported. The lack of internal controls and noncompliance was isolated to the 19611-045-PN01 and 20611-045-PNO1 grant awards. The Non-Public Proportionate Share expenditures for the 19611-045-PN01 grant award could not be verified for the individual member schools. The non-public school share funds for all member schools were comingled and the aggregate amount of expenditures was then allocated to the member schools ona percentage basis. These allocations were the amounts reported to IDOE. As such, we were unable to identify which expenditures were for each school in order to verify the minimum amount per the grant award was expended and properly reported to IDOE as required. The School Corporation?s minimum earmarking requirement for the 19611-045-PNO1 grant award was $6,228. The Non-Public Proportionate Share expenditures for the 20611-045-PN01 and 21611-045-PNO1 grant awards could not be verified for the individual member schools. The non-public school share funds for all member schools were comingled and the aggregate amount of expenditures was then allocated to the member schools on a percentage basis. These allocations were the amounts reported to IDOE. As such, we were unable to identify which expenditures were for each school in order to verify the minimum amount per the grant award was expended and properly reported to IDOE as required.Views of Responsible Officials and Planned Corrective Actions: The district agrees with the finding and notes as a member of the Northwest Indiana Special Education Cooperative (NISEC), Tri-Creek School Corporation reported their proportionate share based on a percentage of expenditures and had successful audits in doing so. When the Tri-Creek School Corporation was notified that this process was no longer acceptable, we immediately implemented an internal control process with NISEC which included a detailed reporting of staff work hours for nonpublic schools related to only our school corporation. The report is then reviewed and signed by the NISEC staff working for the nonpublic school and their supervisor. The employee's detailed time and effort report is then provided to the NISEC finance department for a second review and signature before being provided to payroll. NISEC payroll then charges the proportionate share to the IDEA Part B grant in the payroll system bi-weekly based on the time and effort report pertinent to just Tri-Creek Non-Public schools. The time and effort reports are then used to submit the reimbursement request to the Department of Education for Tri Creek?s proportionate share. Additionally, any IDEA Part B nonpublic material expense is broken out in detail with Tri-Creek?s proportionate share for approval by the NISEC finance office prior to vendor payment and the reimbursement request is submitted to the Department of Education. Responsible party and timeline for completion: Responsible parties: Lisa Rosinko, Northwest Indiana Special Education Cooperative Chief Financial Officer Anticipated Completion Date: The Northwest Indiana Special Education Cooperative discontinued reporting nonpublic proportionate share expenditures by percentage as of the 2022-2023 school year. An internal control procedure to report nonpublic proportionate share expenditures by detailed time and effort work and expenditures was implemented as of the 2022-2023 school year.

View Audit 37708

Finding 41442 (2022-005)

Material Weakness 2022

Freeman Regional Health Services

SD

Questioned Costs Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.327

Finding 2022-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Testing and Mitigation for Rural Health Clinics FFAL #93.697 Compliance Requirements: Procurement, Suspension, and Debarment Finding Summary: The Facility did not obtain quotes from multiple vendor...

Finding 2022-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Testing and Mitigation for Rural Health Clinics FFAL #93.697 Compliance Requirements: Procurement, Suspension, and Debarment Finding Summary: The Facility did not obtain quotes from multiple vendors as it relates to the procurement and purchasing of flooring which was over the micro-purchase threshold. In addition, the vendor was not verified against the central contractor registry prior to transaction inception or on a periodic basis to ensure the vendor was not suspended or debarred. Responsible Individuals: Phillip Husher, CFO, Freeman Regional Health Services Corrective Action Plan: Going forward Freeman Regional Health Services will obtain and retain quotes from multiple vendors based on our procurement policies. Documentation will be retained to support the decision of the vendor selected. Also, we will review the Central Contractor Registry to ensure vendors are not suspended or debarred before entering into covered transactions. Anticipated Completion Date: September 30th, 2023

View Audit 37685 Questioned Costs: $1

Finding 41441 (2022-004)

Significant Deficiency 2022

Freeman Regional Health Services

SD

Equipment & Real Property Management Significant Deficiency Matching / Level of Effort / Earmarking § 200.303 § 200.313

Finding 2022-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Testing and Mitigation for Rural Health Clinics FFAL #93.697 Compliance Requirements: Equipment and Real Property Management Finding Summary: Federal-funded equipment and real property is not disti...

Finding 2022-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Testing and Mitigation for Rural Health Clinics FFAL #93.697 Compliance Requirements: Equipment and Real Property Management Finding Summary: Federal-funded equipment and real property is not distinguished separately from non-federal-funded equipment and real property within the Facility's fixed asset listing. Responsible Individuals: Phillip Husher, CFO, Freeman Regional Health Services Corrective Action Plan: Freeman Regional Health Services will review our fixed asset policies and procedures in order to identify expenditures for Federal-Funded equipment. We will update our current fixed asset listing to identify federally funded equipment. Anticipated Completion Date: December 31st, 2023.

View Audit 37685

Finding 41440 (2022-003)

Material Weakness 2022

Freeman Regional Health Services

SD

Allowable Costs / Cost Principles Material Weakness Period of Performance § 200.303

Finding 2022-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Testing and Mitigation for Rural Health Clinics FFAL #93.697 Compliance Requirements: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Period of Performance Finding Summary: ...

Finding 2022-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Testing and Mitigation for Rural Health Clinics FFAL #93.697 Compliance Requirements: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Period of Performance Finding Summary: The Facility's expense tracking spreadsheet which identified the expenses claimed under the federal program as allowable costs included three expenses which related to a future period. The Facility also claimed the cost of eleven chairs which had been returned to the third-party vendor during November 2022. A formula error was also identified within the calculation of clinic salaries and fringe benefits claimed under the federal program which was based upon a prorated basis of COVID related clinic visits as a percentage of total clinic visits. The Facility had multiple individuals identifying and compiling eligible expenses; however, the Facility's review and approval process over the Facility's expense tracking spreadsheet was not formally documented. Responsible Individuals: Phillip Husher, CFO, Freeman Regional Health Services Corrective Action Plan: We understand that future expenses and expenses for the chairs returned cannot be claimed under FFAL#93.697. We feel this will not require us to return funds to the Department of Health and Human Services as other eligible expenses qualifying under the COVID-19 Testing and Mitigation for Rural Health Clinics Program FFAL #93.697 were available. We know and understand the importance of reporting accurate information. We will have a formal review and approval process documented for future submissions. We agree with findings reported above. Anticipated Completion Date: December 31, 2023

View Audit 37685

Finding 40125 (2022-001)

Material Weakness 2022

Spencer-Owen Community Schools

IN

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

FINDING 2022-001 Contact Person Responsible for Corrective Action: Annette Brown, Treasurer Contact Phone Number: (812)829-2233 Views of Responsible Official: We concur with Audit Finding Description of Corrective Action Plan: The School Corporation will implement procedures and processes to ensure ...

FINDING 2022-001 Contact Person Responsible for Corrective Action: Annette Brown, Treasurer Contact Phone Number: (812)829-2233 Views of Responsible Official: We concur with Audit Finding Description of Corrective Action Plan: The School Corporation will implement procedures and processes to ensure that the School Corporation and 3rd Party Inventory Vendor includes all required information on all property purchased with federal funds that is outlined in 2 CFR 200.313(d)(1). The Treasurer will list items that are purchased with federal funds and forward that information to the 3rd Party Vendor. Once the report from the 3rd Party Vendor is received either the Treasurer/Deputy Treasurer/Grant Administrator will review the report to ensure all required information has been included on all items purchased with federal funds. Anticipated Completion Date: Will begin this process moving forward with any property purchased after February 2023.

View Audit 53434

Finding 40121 (2022-002)

Material Weakness 2022

Spencer-Owen Community Schools

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.303

FINDING 2022-002 Contact Person Responsible for Corrective Action: Annette Brown, Treasurer Contact Phone Number: (812) 829-2233 Views of Responsible Official: We concur with the Audit Finding Description of Corrective Action Plan: The School Corporation will implement procedures and processes to en...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Annette Brown, Treasurer Contact Phone Number: (812) 829-2233 Views of Responsible Official: We concur with the Audit Finding Description of Corrective Action Plan: The School Corporation will implement procedures and processes to ensure that the reporting compliance requirement is met for the Education Stabilization Fund. All reporting information will be gathered either by the Treasurer, Payroll Clerk or Accounts Payable depending on the information being requested. The information will then be reviewed for accuracy by the Grant Administrator or Superintendent before being submitted. All documentation will be signed and dated by the appropriate individuals and be filed with the appropriate ESF. Anticipated Completion Date: Will begin this process moving forward with future reporting after February 2023.

View Audit 53434

Finding 40099 (2022-001)

Significant Deficiency 2022

Providence St. Joseph Health

WA

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

Providence Corrective Action Plan Year ended December 31, 2022 Contact: Nate Johnson, Senior Manager Finance nathaniel.johnson@providence.org Finding 2022-001 Statement of Condition: During testwork over allowability, a sample of 60 payments was selected for testing. Within the sample, 1 selection...

Providence Corrective Action Plan Year ended December 31, 2022 Contact: Nate Johnson, Senior Manager Finance nathaniel.johnson@providence.org Finding 2022-001 Statement of Condition: During testwork over allowability, a sample of 60 payments was selected for testing. Within the sample, 1 selection was identified where the charges submitted for reimbursement to HRSA were unallowable. Further, as the charges submitted were not properly reviewed this is an instance of the Health System?s internal control not operating as designed. Corrective Action Plan: Management will prioritize strengthening our processes and controls before proceeding. Management will add a layer of review for all potential new claims. All accounts will be audited by management prior to submission to ensure compliance. Management will do a post submission audit to confirm billing compliance on paid claims. This will be implemented by December 31, 2023.

View Audit 41243 Questioned Costs: $1

Finding 40098 (2022-001)

Significant Deficiency 2022

Aids Foundation Houston, Inc.

TX

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

September 26, 2023 AIDS Foundation Houston, Inc. dba Allies in Hope respectfully submits the following corrective action plan in response to our single audit results for the year ended December 31, 2022. Carr, Riggs & Ingram, LLC Two Riverway, 15th Floor Houston, Texas 77056 Audit Period: Fiscal Yea...

September 26, 2023 AIDS Foundation Houston, Inc. dba Allies in Hope respectfully submits the following corrective action plan in response to our single audit results for the year ended December 31, 2022. Carr, Riggs & Ingram, LLC Two Riverway, 15th Floor Houston, Texas 77056 Audit Period: Fiscal Year January 1, 2022 ? December 31, 2022 The finding from the schedule of findings and questioned costs dated September 26, 2023, is discussed below. The finding is numbered consistently with the number assigned in the schedule. 2022-001 Internal Controls over Reporting (Significant Deficiency) Recommendation: The Foundation review its controls and ensure that the copies of the submission emails be part of the Foundation?s grant records. Corrective Action: Effective 10/1/23 we are using a shared system to house and track our reporting to our funders and will save emails sent to funders in this shared system in order to document the submission of the reports. Responsible Parties: Chief Financial Officer, Chief Program Officer, and Director of Compliance Date Expected to be Corrected: 10/1/23 If the U.S. Department of Housing and Urban Development has any questions regarding this plan, please contact Nicholas Williams, CFO at 713-623-6796 x285. Sincerely yours, Nicholas Williams Nicholas Williams Chief Financial Officer

View Audit 48673

Finding 40066 (2022-005)

Significant Deficiency 2022

Legal Services Alabama, INC

AL

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding 2022-005 ? Internal Control over Reporting (Significant Deficiency) Corrective Action: LSA will resume a review and approval of every grant report and document the review as of the date of this audit report. Contact Person: David Roberson, Director of Finance; (334) 223-0251; droberson@al...

Finding 2022-005 ? Internal Control over Reporting (Significant Deficiency) Corrective Action: LSA will resume a review and approval of every grant report and document the review as of the date of this audit report. Contact Person: David Roberson, Director of Finance; (334) 223-0251; droberson@alsp.org

View Audit 45011

Finding 39994 (2022-005)

Significant Deficiency 2022

One Vision

IA

Allowable Costs / Cost Principles Eligibility Reporting § 200.303

Finding 2022-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Applicable Federal Award Number and Year ? Period 2 TIN #420953968 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowe...

Finding 2022-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Applicable Federal Award Number and Year ? Period 2 TIN #420953968 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: The Organization?s Period 2 report to HHS included expenditures that were not properly supported. Responsible Individuals: Mario Van Dijk, CFO Corrective Action Plan: Management is aware of the expenditures, even though small in amount, that were not properly supported, and lost revenue calculation and some of the expenditure listings not being reviewed separate from the preparer. The organization has created processes around preparing and reviewing for items such as this. The finance team is committed to these changes to improve accuracy of our work. Anticipated Completion Date: September 28, 2023

View Audit 45801

Corrective Action Plans

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