Corrective Action Plans

Finding 497454 (2022-005)

Material Weakness 2022

Lead Academy

AL

Questioned Costs Internal Control / Segregation of Duties Cash Management § 200.303

here was inadequate oversight of activities and information provided by the contractor resulting in a material overstatement of meals claimed for the current year. Sufficient controls were not in place for the current fiscal year to ensure that an accurate meal count was claimed for USDA reimburseme...

here was inadequate oversight of activities and information provided by the contractor resulting in a material overstatement of meals claimed for the current year. Sufficient controls were not in place for the current fiscal year to ensure that an accurate meal count was claimed for USDA reimbursement. We recommend that a knowledgeable person be assigned responsibility for oversight of the child nutrition program. We further recommend procedures be implemented to provide oversight of contractor services and information provided including a review process for the USDA claims requests. Views of Responsible Officials and Planned Corrective Actions: The Academy has employed a supervisor responsible for overseeing the child nutrition program and the contract with the previous provider has terminated. Further, the Academy currently provides onsite meal service beginning with the 2022-23 school year provided by a new contractor.

View Audit 320243 Questioned Costs: $1

Finding 497056 (2022-007)

Material Weakness 2022

Disability Empowerment Center

WA

Allowable Costs / Cost Principles § 200.303

ACL Centers for Independent Living – Assistance Listing No. 93.435 Type of Finding: Allowable Activities and Allowable Costs – Payroll Disbursements • Material Weakness in Internal Control over Compliance Criteria or specific requirement: Per 2 CFR 200.303, non-Federal entities must “establish and m...

ACL Centers for Independent Living – Assistance Listing No. 93.435 Type of Finding: Allowable Activities and Allowable Costs – Payroll Disbursements • Material Weakness in Internal Control over Compliance Criteria or specific requirement: Per 2 CFR 200.303, non-Federal entities must “establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statues regulations, and the terms and conditions of the Federal award.” Condition: Payroll allocation review is performed annually by ED, which is not timely enough to accurately reflect employee's time worked. Additionally, the allocation performed had logical errors, including one employee’s time missing from the allocation calculation, and using an inappropriate allocation basis. Questioned costs: None Context: All employees included in selection deemed to work positions that are allowable to the program, however the client allocation process unreliable for all sections tested (25). Cause: Allocations to program based on one employee's memory (ED) for full-year organizational operations. Allocations not reviewed for accuracy by other individual. Effect: Currently, all assigned work activities employees engage in are theoretically allowable under the program, however if an employee were to work projects that are not allowable under the Federal award, reimbursement requests could be made for unallowable costs. Repeat Finding: No Recommendation: 1) Have employees enter time by period and ensure time codes reflect type of activities worked that tie to Federal program allocations. 2) Have ED review employee timesheets each pay period. 3) Review allocations by program each pay period. 4) Have a second individual (contract accountant) review allocations to ensure accuracy and completeness. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: DEC employees enter their time by period and code activities to the corresponding programs. Program Directors, then the ED reviews all employees time sheets and allocations each pay period. DEC’s contract accountant reviews monthly. Name(s) of the contact person(s) responsible for corrective action: Kimberly Meck, Executive Director Planned completion date for corrective action plan: Already implemented.

View Audit 319773

Finding 497055 (2022-006)

Significant Deficiency 2022

Disability Empowerment Center

WA

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Cash Management § 200.303

ACL Centers for Independent Living – Assistance Listing No. 93.435 Type of Finding: Allowable Activities and Allowable Costs – General Disbursements • Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: Per 2 CFR 200.303, non-Federal entities must establish a...

ACL Centers for Independent Living – Assistance Listing No. 93.435 Type of Finding: Allowable Activities and Allowable Costs – General Disbursements • Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: Per 2 CFR 200.303, non-Federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statues regulations, and the terms and conditions of the Federal award. Condition: Documentation not maintained to support one cash disbursement. Questioned costs: None Context: 1/40 of the general disbursements tested lacked indication of approval. Deemed to be an isolated incident as the vendor in question provides physical receipts to DEC, which is an unusual and infrequent method. Limited transactions with said vendor. Cause: Vendor purchases are in-person and physical receipt is obtained. This is unusual for common vendors used and leads to more opportunity for documentation loss. Effect: Reimbursement requests could be made for unallowed expenditures. Repeat Finding: No Recommendation: Review document retention process to ensure all costs that are charged to a federal program are adequately reviewed and documentation of that process is maintained. If documentation is not available, costs should not be charged to the Federal program. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: This was an isolated incident and DEC now takes steps to digitally record physical receipts with a photograph as soon as possible. Name(s) of the contact person(s) responsible for corrective action: Kimberly Meck, Executive Director Planned completion date for corrective action plan: Already implemented.

View Audit 319773

Finding 496178 (2022-001)

Significant Deficiency 2022

City of Beverly Hills

CA

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.300 § 200.303 § 200.306 § 200.308 § 200.309

CORRECTIVE ACTION PLAN Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing No.: 21.027 Federal Agency: Department of the Treasury ? Pass-through from the State of California Award No.: WWID 4SSO10370 & CA 1910156 Award Year: Fiscal year 2021-2022 Category o...

CORRECTIVE ACTION PLAN Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing No.: 21.027 Federal Agency: Department of the Treasury ? Pass-through from the State of California Award No.: WWID 4SSO10370 & CA 1910156 Award Year: Fiscal year 2021-2022 Category of Finding: Activities Allowed or Unallowed, Allowable Costs Name responsible for correction action plan: Emily Armstrong, Revenue Services Manager The corrective action planned: Payments applied to the 93 water bills and 81 wastewater bills will be reversed on the customer?s accounts. A notice will be issued to customers via mail and email (where possible) of the discrepancy. The funds will be returned to the State pursuant to their outlined procedures. Moving forward, the City will ensure that there is a multi-layered approval process to review the eligibility period of any State funding to identify the correct eligible applicants prior to disbursement. For future funding related to water and/or waster bills, the list of eligible applicants will be compiled by an analyst within the department and will be reviewed by the Revenue Services Manager and Assistant Finance Director prior to disbursement. Anticipated completion date: March 24, 2023

View Audit 319093 Questioned Costs: $1

Finding 496175 (2022-001)

Material Weakness 2022

Metcalfe County Fiscal Court

KY

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.303

The Metcalfe County Fiscal Court contracted with an outside entity to manage the CSLFRF disbursements and reporting requirements. We entrusted that we were in compliance for all federal program expenditures where these funds were concerned. Prepared by: County Treasurer Page Edwards Date Prepared:...

The Metcalfe County Fiscal Court contracted with an outside entity to manage the CSLFRF disbursements and reporting requirements. We entrusted that we were in compliance for all federal program expenditures where these funds were concerned. Prepared by: County Treasurer Page Edwards Date Prepared: March 6, 2023 Person Responsible for Corrective Action Plan: Judge/Executive Larry Wilson Anticipated Completion Date: July 1, 2023

View Audit 319058 Questioned Costs: $1

Finding 485707 (2022-002)

Material Weakness 2022

The Queen's Health Systems and Subsidiaries

HI

Reporting § 200.303 § 200.502 § 200.510

Views of Responsible Officials QHS agrees with the finding and accepts the recommendation.

View Audit 318521

Finding 485461 (2022-004)

Material Weakness 2022

Community Development Partnership

MA

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

A consistent and substantiated methodology for accounting for indirect costs to be allocated was implemented in FY 23 and remains in place. Anticipated Completion Date-Completed.Responsible Contact Person-Kathleen Boyce, CFAO

View Audit 318188

Finding 485451 (2022-005)

Significant Deficiency 2022

County of Imperial

CA

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

2022-005 Temporary Aid for Needy Families (TANF) Federal Financial Assistance Listing Number: 93.558 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Social Services Award No. and Year: 1946001347-A7 2022 Compliance Requirements: Eligibility ...

2022-005 Temporary Aid for Needy Families (TANF) Federal Financial Assistance Listing Number: 93.558 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Social Services Award No. and Year: 1946001347-A7 2022 Compliance Requirements: Eligibility Type of Finding: Significant Deficiency Management’s or Department’s Response: Imperial County Department of Social Services agrees with the finding. Views of Responsible Officials and Corrective Action Plan: The Count of Imperial, Department of Social Services, is committed to maintaining robust monitoring and oversight controls in place to ensure that applicant eligibility is thoroughly reviewed and approved. The Department will continue to monitor compliance with policies to ascertain that eligibility technicians follow guidelines for redetermination of recipients of need and amount of assistance, including to retain acceptable documentation to support the determinations. The Department will implement enhances training and guidance to include refresher training that will be developed based on needs identified during this review. The training will address any changes in regulations and/or internal processes. Name of Responsible Person: Paula S. Llanas, County of Imperial – Department of Social Services Director Implementation Date: September 1, 2024

View Audit 318179

Finding 485448 (2022-007)

Significant Deficiency 2022

County of Imperial

CA

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

2022-007 Program: WIOA Cluster Federal Financial Assistance Listing Number: 17.258, 17.259, 17.277, 17.278 Federal Grantor: U.S. Department of Labor Pass-Through: California Department of Employment Development Award No. and Year: AA111008 and 2021 Compliance Requirements: Reporting Type of Finding...

2022-007 Program: WIOA Cluster Federal Financial Assistance Listing Number: 17.258, 17.259, 17.277, 17.278 Federal Grantor: U.S. Department of Labor Pass-Through: California Department of Employment Development Award No. and Year: AA111008 and 2021 Compliance Requirements: Reporting Type of Finding: Significant Deficiency Management’s or Department’s Response: Imperial County Workforce Development Office (ICWDO) agrees with the finding. Views of Responsible Officials and Corrective Action Plan: ICWDO acknowledges the recommendation and is actively working on a remedy and on the development of formal policies as recommended, which will assist ICWDO’s fiscal team in ensuring that all reports are appropriately reconciled. ICWDO acknowledges the recommendations from finding 2021-010 related to a formalization of the Administrative/fiscal processes and protocols to ensure that procedures are consistently followed to guarantee that reports agree to the amounts recorded in the general ledger and SEFA. Additionally, the recommendation specifics that protocols to ensure the separation of duties are featured in the policy. ICWDO operates under WIOA guidelines and follows County fiscal/administrative policies. Internal policies that include formal controls and procedures to ensure that monthly reports and general ledgers are consistent, with clear segregation of duties will be formally adopted. Aspects of these policies will include: • Protocol for preparation of monthly reports by the fiscal manager, and approval and signature by ICWDO Director • Protocol for preparation of closeouts that will provide the hierarchy of development, review, and approval for future reference. • Schedule monthly closeout meetings with the fiscal department and administration to ensure that documents are reviewed separately, and issues are addressed promptly. • Protocol for Policy Committee review, comment and direction, and approval for implementation by vote of the full workforce development board. ICWDO anticipates to implement the corrective action by December 31, 2023. Name of Responsible Person: Priscilla A Lopez, ICWDB Director Implementation Date: December 31, 2023

View Audit 318179

Finding 485445 (2022-006)

Material Weakness 2022

County of Imperial

CA

Subrecipient Monitoring § 200.1 § 200.303 § 200.331 § 200.332 § 200.414

2022-006 Program: WIOA Cluster Federal Financial Assistance Listing Number: 17.258, 17.259, 17.277, 17.278 Federal Grantor: U.S. Department of Labor Pass-Through: California Department of Employment Development Award No. and Year: AA011008 and 2019 Compliance Requirements: Subrecipient Monitoring T...

2022-006 Program: WIOA Cluster Federal Financial Assistance Listing Number: 17.258, 17.259, 17.277, 17.278 Federal Grantor: U.S. Department of Labor Pass-Through: California Department of Employment Development Award No. and Year: AA011008 and 2019 Compliance Requirements: Subrecipient Monitoring Type of Finding: Material Weakness Management’s or Department’s Response: Imperial County Workforce Development Office (ICWDO) agrees with the finding. Views of Responsible Officials and Corrective Action Plan: The questions from finding 2021-008 relate to a formalization of the fiscal processes and protocols. ICWDO operates under WIOA guidelines and follows Imperial County’s fiscal policies. Internal policy will be formally updated to reflect compliance with WIOA regulations, as well as Imperial County policies. These policies will include formal controls and procedures to evaluate each subrecipient’s risk of noncompliance. Once the formal procedure is drafted, it will go through the ICWDO Policy Committee for comment and direction, and then finally reviewed and approved for implementation by the full Workforce Development Board. Additionally, for any future Memorandums of Understanding (MOUs) between this Imperial County department and any outside agency, there will be an additional step to include review by Imperial County Counsel to reflect that recital around the funding source will specify the following required information: • Federal Award Identification Number • Federal award date of award to recipient by the Federal agency • Name of Federal awarding agency • CFDA Number • Specific identification of whether the award is research and development ICWDO will develop internal policies for formalizing all subrecipient monitoring process. ICWDO operates under WIOA guidelines for monitoring; therefore a formal internal policy for future contracts will be developed and implemented using the usual review and approval procedures followed by the department. ICWDO will develop a formal internal documentation system, with appropriate checks and signatures, for the evaluation and assessment of each subrecipient’s risk of noncompliance. ICWDO will utilize this formal process to properly document the risk assessment of all subrecipients. ICWDO anticipates to implement the corrective action by December 31, 2023. Name of Responsible Person: Priscilla A Lopez, ICWDB Director Implementation Date: December 31, 2023

View Audit 318179

Finding 485287 (2022-004)

Significant Deficiency 2022

American Association of Physics Teachers, Inc.

MD

Matching / Level of Effort / Earmarking Significant Deficiency § 200.303

Finding 2022-004: Payroll Federal Programs: Research and Development Cluster: 47.0746 Condition: Payroll approvals for individuals are not always made by individuals who are the employee's supervisors or are otherwise knowledgeable about their level of effort during the payroll periods paid for. Vie...

Finding 2022-004: Payroll Federal Programs: Research and Development Cluster: 47.0746 Condition: Payroll approvals for individuals are not always made by individuals who are the employee's supervisors or are otherwise knowledgeable about their level of effort during the payroll periods paid for. Views of Responsible Officials and Planned Corrective Actions: AAPT has made changes to correctly reflect the employee’s assigned supervisor based on the position and job duties of the employees. Anticipated Completion Date: 04/01/2024 Responsible Official: Michael Brosnan, CFO

View Audit 318055

Finding 485094 (2022-002)

Significant Deficiency 2022

El Programa Hispano Catolico

OR

Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties § 200.303

The Director of Finance and Accounting Manager will work with the Grants and Contract Accountant to coordinate grant kickoff meetings with Program Directors and Managers to ensure they have procedures in place to meet the requirements for the agreement. These meetings will be held in August and Sept...

The Director of Finance and Accounting Manager will work with the Grants and Contract Accountant to coordinate grant kickoff meetings with Program Directors and Managers to ensure they have procedures in place to meet the requirements for the agreement. These meetings will be held in August and September.

View Audit 317889

Finding 484690 (2022-001)

Material Weakness 2022

Save the Children Federation, INC and Related Entities

CT

Reporting § 200.303 § 200.510

Finding: 2022-001 Material Weakness over SEFA Preparation Federal Agency: U.S. Department of State Federal Program: Overseas Refugee Assistance Program for Near East (ALN 19.519) Contact Person: Corey Dillow, Senior Managing Director, Financial Controller Criteria 2 CFR 200.510 (b)(3) requires ...

Finding: 2022-001 Material Weakness over SEFA Preparation Federal Agency: U.S. Department of State Federal Program: Overseas Refugee Assistance Program for Near East (ALN 19.519) Contact Person: Corey Dillow, Senior Managing Director, Financial Controller Criteria 2 CFR 200.510 (b)(3) requires non-Federal entities receiving Federal award to (at minimum) provide total Federal awards expended for each individual Federal program and the Assistance Listings Number. Internal controls around the identification of ALNs and reporting of the SEFA should ensure proper presentation for each ALN number. Condition and Context During our planning meetings with management, we were notified that an award was recorded to an incorrect ALN in the 2022 Schedule of Expenditures of Federal Awards. The 2022 Schedule of Expenditures of Federal Awards was corrected and an additional major program, Overseas Refugee Assistance Program for Near East (ALN 19.519), was identified. Corrective Action: As result of the finding, management will be implementing the below steps to further refine internal controls in the identification and reporting of ALNs in the SEFA by: 1. Reinforcing the importance of ALN assignment and tracking through training. 2. Including the ALN attribute as a required element for award setup reviews. 3. Conducting periodic checks of ALNs to source agreements. 4. Documenting and performing additional SEFA data quality checks. Anticipated Completion Date: July 2024

View Audit 317575

Finding 484629 (2022-002)

Significant Deficiency 2022

Corporacion Del Centro De Bellas Artes De Puerto Rico

PR

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.302 § 200.303

Action Item Title 2022-002 – Financial Management and Internal Controls Compliance Requirement Allowable Costs/Cost Principles Status (Open: In-process) Condition Written Policies The Corporation has no written policies for determining the activities allowed or unallowed and the allowability of...

Action Item Title 2022-002 – Financial Management and Internal Controls Compliance Requirement Allowable Costs/Cost Principles Status (Open: In-process) Condition Written Policies The Corporation has no written policies for determining the activities allowed or unallowed and the allowability of costs as described in subpart E, Cost Principles of 2 CFR Part 200. Identified root cause It is the first year for the Corporation to be subjected to a single audit compliance requirement. However, since the Commonwealth of Puerto Rico (the Commonwealth) filed for Title III under the PROMESA, all the instrumentalities of the Commonwealth had to reduce their staff as part of the Fiscal Plan to reduce expenditures. This has disrupted the segregation of duties, which is a key control. Grantee resolution plan Written Policies The Corporation received federal funds for the first time in 2022. For the purposes of purchases or acquisitions, the Corporation is governed by Law of the General Service Administration for the Centralization of Government Purchases in Puerto Rico, Law No. 73 of 2019, which establishes the uniform purchasing process for acquisitions by the Commonwealth. The Corporation will adopt regulations for the use and disbursement of federal funds and comply with the federal regulations. Completion Date Written Policies By June 30, 2025 Name and Title of contact: Linnette Dávila Alemán- Financial and Budget Assistant Manager Phone: 787-724-4747 ext. 2105 Email: ldavila@cba.pr.gov Jetppeht Pérez de Corcho Morgado – General Manager Phone: 787-724-4747 ext. 2102 Email: jperez@cba.pr.gov

View Audit 317516

Finding 481368 (2022-001)

Material Weakness 2022

Monongalia Health System, Inc. and Subsidiaries

WV

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

Corrective Action Planned: Subsequent to the filing of the Period 1 reports Monongalia Health System, Inc. and Subsidiaries instituted new policies and procedures surrounding the use, tracking and reporting on federal funds, including the Provider Relief Fund and American Rescue Plan Act (ARP) Rural...

Corrective Action Planned: Subsequent to the filing of the Period 1 reports Monongalia Health System, Inc. and Subsidiaries instituted new policies and procedures surrounding the use, tracking and reporting on federal funds, including the Provider Relief Fund and American Rescue Plan Act (ARP) Rural Distribution. Under the new policies and procedures the usage of all funds is accumulated and reviewed on a monthly basis, and all reporting is subjected to reviews by the VP’s of Finance prior to reporting. Name(s) of Contact Person(s) Responsible for Corrective Action: Kevin Gessler, VP of Finance and Rick Scherich, VP of Finance are responsible for effectuating updated procedures Anticipated Completion Date: Updated Policies and procedures were implemented on September 30, 2023

View Audit 317404

Finding 481175 (2022-002)

Significant Deficiency 2022

Regional Office of Education #47

IL

Subrecipient Monitoring § 200.303 § 200.332

FINDING NO: 2022-002 - Subrecipient Monitoring (Repeated from Prior Year Findings 21-003, 20-004, 19-005, 18-004, and 17-003) CONDITION: Audit procedures revealed that ROE #47 was not properly monitoring subrecipients in accordance with the Uniform Guidance standards as follows: McKinney Educa...

FINDING NO: 2022-002 - Subrecipient Monitoring (Repeated from Prior Year Findings 21-003, 20-004, 19-005, 18-004, and 17-003) CONDITION: Audit procedures revealed that ROE #47 was not properly monitoring subrecipients in accordance with the Uniform Guidance standards as follows: McKinney Education for Homeless Children – for three (3) of three (3) subrecipients tested, ROE #47: • Did not evaluate the risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward. • Did not determine whether the subrecipient met the 2 CFR 200 Subpart F Audit requirements criteria for a single audit. COVID-19 ARP - McKinney Education for Homeless Children – for two (2) of two (2) subrecipients tested, ROE #47: • Did not identify the subaward and applicable requirements in the agreements. • Did not evaluate the risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward. • Did not conduct subrecipient monitoring procedures. • Did not determine whether the subrecipient met the 2 CFR 200 Subpart F Audit requirements criteria for a single audit. PLAN: Moving forward, The Regional Office will formally identify the subaward and applicable requirements in our agreements. We will conduct subrecipient monitoring procedures. We will determine if the subrecipient met the requirement criteria of 2 CFR 200 Subpart F Audit requirements for a single audit. ANTICIPATED DATE OF COMPLETION: Fiscal Year 2025 CONTACT PERSON: Mr. Chris Tennyson, Regional Superintendent for Lee, Ogle, and Whiteside Counties.

View Audit 317273

Finding 481134 (2022-017)

Significant Deficiency 2022

Unity Health Care, Inc.

MD

Matching / Level of Effort / Earmarking § 200.303 § 200.306

Management Response #2022-017: Due to the staff shortages and turnover in FY2020-2022 the company did not have adequate personnel in place to monitor or document grant activity. Formal documentation of policies and procedures were also deficient. Additionally, documents were not stored centrally, wh...

Management Response #2022-017: Due to the staff shortages and turnover in FY2020-2022 the company did not have adequate personnel in place to monitor or document grant activity. Formal documentation of policies and procedures were also deficient. Additionally, documents were not stored centrally, which made it extremely difficult to find supporting documentation. Corrective Action Plan: The procedures adopted in 2024 will be formally documented and published that will ensure proper cost sharing or matching are clearly understood and defined. The requirements for matching as well as consistent monitoring metrics will be outlined in the procedures document as well. Greater and enhanced documentation will be properly maintained and available for review as required. Responsible Party: Tamara Barnes, CFO

View Audit 317252

Finding 481133 (2022-016)

Significant Deficiency 2022

Unity Health Care, Inc.

MD

Allowable Costs / Cost Principles § 200.303

Management Response #2022-016: Due to the staff shortages and turnover in FY2020-2022 the company did not have adequate personnel in place to monitor or document grant activity. Formal documentation of policies and procedures were also deficient. Additionally, documents were not stored centrally, wh...

Management Response #2022-016: Due to the staff shortages and turnover in FY2020-2022 the company did not have adequate personnel in place to monitor or document grant activity. Formal documentation of policies and procedures were also deficient. Additionally, documents were not stored centrally, which made it extremely difficult to find supporting documentation. Corrective Action Plan: The Grants program management team will expand upon their current process that was instituted in 2024 to ensure the calculation for indirect costs and documentation supporting the indirect cost pools is properly maintained and that costs conform to the current regulations as required. Responsible Party: Tamara Barnes, CFO

View Audit 317252

Finding 481132 (2022-013)

Significant Deficiency 2022

Unity Health Care, Inc.

MD

Subrecipient Monitoring § 200.303 § 200.322

Management Response #2022-013: Due to staff turnover in prior years and inadequate handover procedures, the Subrecipient Monitoring was not done as required. Corrective Action Plan: The Grants program management team has developed a Title X Program Manual to include a clearer Subrecipient Monitorin...

Management Response #2022-013: Due to staff turnover in prior years and inadequate handover procedures, the Subrecipient Monitoring was not done as required. Corrective Action Plan: The Grants program management team has developed a Title X Program Manual to include a clearer Subrecipient Monitoring process that includes regular site visits and requiring supporting documentation of expenses. Furthermore, the Grants program management team will report out to the applicable internal parties on status of visits and findings on a quarterly basis. Responsible Party: Erin Flior, CDSO

View Audit 317252

Finding 481107 (2022-009)

Significant Deficiency 2022

National Casa Association

WA

Subrecipient Monitoring Reporting § 200.303

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

Responsible: Denice Hairston, Chief Quality, Compliance and Accountability Officer Corrective Actions: Update FFATA reporting procedures to document and maintain documentation of Supervisory review and approval of FFATA data preparation. Completion Date: March 29, 2023 Explanation: Management concurs that although it already enhanced policies to comply with an OJJDP/OCFO recommendation resolved in 2023, which included a two-step review and approval process for subrecipient awards involving the Executive Team, grantor procedures will be updated as recommended to include a third step to specify review and approval of subrecipient FFATA data prior to submission. The Supervisor or member of the Executive Team will capture review and approval of FFATA data with an email including the approved list attached. When FFATA reporting is submitted by staff, the list will be updated with the date submitted and returned to the Supervisor to confirm timeliness. Regarding the 12 subrecipient awards for Court Appointed Special Advocates selected for testing FFATA submission requirements, 9 out of 12 reports were submitted by the last day of the month following the start of the grant period.

View Audit 317239

Finding 480051 (2022-004)

Significant Deficiency 2022

Cornerstones Inc, Cornerstones Housing Corporation & Rihc Partners, Lp

VA

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303 § 200.334

Management agrees with the recommendation and will implement stronger processes to ensure that all records are organized and maintained for ease of timely and complete review and consultation when needed. The processes to organize and secure files will be executed by program staff, with oversight by...

Management agrees with the recommendation and will implement stronger processes to ensure that all records are organized and maintained for ease of timely and complete review and consultation when needed. The processes to organize and secure files will be executed by program staff, with oversight by the Vice President of Community Building and Neighborhood Resources, Executive Vice President of Housing and Community Programs, Vice President of Family Empowerment and Self Sufficiency, Chief Financial & Operating Officer, and Sr. Director of Finance. Due to timing of receiving this finding, remediation processes began in fiscal year 2024 and will be applied fully to the fiscal year 2025, beginning 7/1/2024, files.

View Audit 316339

Finding 480050 (2022-003)

Significant Deficiency 2022

Cornerstones Inc, Cornerstones Housing Corporation & Rihc Partners, Lp

VA

Significant Deficiency Internal Control / Segregation of Duties § 200.303 § 200.334

Management agrees with and will implement the recommendation that processes be in place to review and confirm the completeness and accuracy of intake forms within the regulations while also considering the needs and choices of the program participants. These file completeness processes will be execu...

Management agrees with and will implement the recommendation that processes be in place to review and confirm the completeness and accuracy of intake forms within the regulations while also considering the needs and choices of the program participants. These file completeness processes will be executed by program staff, with oversight by the Vice President of Community Building and Neighborhood Resources, Executive Vice President of Housing and Community Programs, Vice President of Family Empowerment and Self Sufficiency, Chief Financial & Operating Officer, and Sr. Director of Finance. Due to timing of receiving this finding, remediation processes began in fiscal year 2024 and will be applied fully to the fiscal year 2025, beginning 7/1/2024, files.

View Audit 316339

Finding 479520 (2022-001)

Material Weakness 2022

Wyoming Coalition Against Domestic Violence and Sexual Assault

WY

Matching / Level of Effort / Earmarking Reporting § 200.303

Finding: 2022-001 - Earmarking, Reporting (Performance Progress Reporting) – Material Weakness in Internal Controls Over Compliance and Instance of Noncompliance (Scope Limitation) Recommendation: We recommend that the Coalition develop policies and procedures for tracking actual expenditures rela...

Finding: 2022-001 - Earmarking, Reporting (Performance Progress Reporting) – Material Weakness in Internal Controls Over Compliance and Instance of Noncompliance (Scope Limitation) Recommendation: We recommend that the Coalition develop policies and procedures for tracking actual expenditures related to earmarking requirements and maintain all supporting documentation for the calculation of the earmarking percentages that are reported in the semi-annual performance progress reports. Corrective Action Plan: The Coalition’s staff has developed policies and procedures for tracking actual expenditures related to these requirements, and maintaining all supporting documentation for the calculation of the earmarking percentages that are reported in the semi-annual progress reports. The Coalition has developed an internal control process for reviewing and approving calculations required by Section 50 of the grant agreement and has strengthened its reporting management review controls to ensure that the review is effective to ensure the completeness and accuracy of reports, and that all elements are appropriately supported, prior to submission the federal agency. Anticipated Completion: Late Summer and Fall of 2023 Responsible Party: WCADVSA Co-Directors, Tiffany Eskelson-Maestas and Susie Markus

View Audit 316049

Finding 478699 (2022-001)

Material Weakness 2022

Mount Sinai Foundation, Incorporated 053-36322

NC

HUD Housing Programs Reporting Internal Control / Segregation of Duties § 200.302 § 200.303

Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN March 11, 2024 ...

Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN March 11, 2024 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully submits the following Corrective Action Plan for the year ended December 31, 2022. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings for the year ended December 31, 2022 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - Financial Statement Audit and Federal Award Program Audits Finding 2022-001 - U.S. Department of Housing and Urban Development, Mortgage Insurance Rental and Cooperative Housing for Moderate Income Families and Elderly, Market Interest Rate (Sections 221d(3) and (4) Multifamily - Market Rate Housing), CFDA #14.135 Recommendation: That management review/enhance its accounting and internal control procedures to ensure that all key accounts are reconciled and reviewed with supporting evidence of such review. Action Taken: We agree with Finding 2022-001 and the recommendation described in the accompanying schedule of findings and questioned costs. Management will review the accounting and financial procedures, system of internal controls and policies. If HUD has questions regarding this corrective action plan, please call (803) 873-2377. Sincerely yours, Dwayne Legrant President Omni Property Management and Development Managing Agent

View Audit 315370

Finding 478615 (2022-006)

Significant Deficiency 2022

Cicoa Aging & In-Home Solutions

IN

Cash Management Internal Control / Segregation of Duties Reporting § 200.303

FINDING 2022-006 Information on the federal program: Subject: Title III-E – Internal Controls Federal Agency: Department of Health and Human Services Federal Program: Title III-E Family Caregiver, COVID-19 – Title III-E Family Caregiver Assistance Listing Number: 93.052 Compliance Requirement: Cas...

FINDING 2022-006 Information on the federal program: Subject: Title III-E – Internal Controls Federal Agency: Department of Health and Human Services Federal Program: Title III-E Family Caregiver, COVID-19 – Title III-E Family Caregiver Assistance Listing Number: 93.052 Compliance Requirement: Cash Management Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Context: We noted that for two claims in a sample of two, there was no formal review/approval of the FSSA Contract Claim Reimbursement form outside of who is preparing the form. The CFO prepared and submitted the claims without a secondary review. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: CICOA created an additional position in our Fiscal department to help add capacity and address various segregation of duties concerns. On April 3, 2023, CICOA hired a Senior Director of Financial Reporting to fill this new position. The CFO has done/will continue various training with the Senior Director and other staff to transfer knowledge and responsibilities currently held by the CFO, including future preparation and submission of the FSSA Contract Claim Reimbursement documents. The CFO will serve as either the primary or secondary reviewer of such Claim Reimbursements after preparation by other Fiscal staff. Key item to note: this finding was made as part of the audit for the fiscal year ended June 30, 2022, and the hiring of the Senior Director was not made until late in the fiscal year ended June 30, 2023. Due to this timing, necessary changes did not exist until fiscal year 2024. Responsible Party and Timeline for Completion: To be completed by CFO (with assistance from Senior Director of Financial Reporting and other Fiscal staff), beginning no later than Claims Reimbursements submitted for services provided starting in fiscal year 2024.

View Audit 315238

Corrective Action Plans

Filters