Corrective Action Plans

Finding 2086 (2022-003)

Significant Deficiency 2022

MD

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303

Reporting Emergency Rental Assistance Program - Federal Assistance Listing Number: 21.023 Recommendation: We recommend that the Organization implement the proper policies and procedures to ensure compliance with 2 CFR section 200.303. Explanation of disagreement with audit finding: There is no dis...

Reporting Emergency Rental Assistance Program - Federal Assistance Listing Number: 21.023 Recommendation: We recommend that the Organization implement the proper policies and procedures to ensure compliance with 2 CFR section 200.303. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: JCS will adopt a two-step process for grant reporting to ensure that deadlines are properly met. Grant reporting process begin will once the month ends and reports will be reviewed two days before the submission is due to ensure all reporting requirements are satisfied. Name of the contact person responsible for corrective action: Nicole Wheeler, Controller Planned completion date for corrective action plan: June 30, 2024

View Audit 3645

Finding 1848 (2022-006)

Significant Deficiency 2022

Jackson City School District

OH

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

Salaries and benefits for the Fiscal Year in the audit were approved by a prior interim treasurer. New procedures have been put in place the prevent this from happening with the current Treasurer. Anticipated Completion Date: 6/30/2023 Responsible Contact Person: Jared M. Bunting, Treasurer/CFO

View Audit 3216

Finding 1810 (2022-001)

Significant Deficiency 2022

Healthy Relationships California

CA

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

The bookkeeper and external accountant of Healthy Relationships California will collaborate to produce accurate reliable accounting records and financial reports.

View Audit 3151

Finding 1798 (2022-002)

Material Weakness 2022

National Alliance Against Disparities in Patient Health

VA

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303 § 200.68

Timesheets are reviewed by project managers before they are submitted to payroll processing. Additionally, a reconciliation of actual to budgeted hours will be performed on a monthly basis. Documentation of the timesheet reviews will be maintained electronically. Staff time for federal grants will b...

Timesheets are reviewed by project managers before they are submitted to payroll processing. Additionally, a reconciliation of actual to budgeted hours will be performed on a monthly basis. Documentation of the timesheet reviews will be maintained electronically. Staff time for federal grants will be supported by a completed timesheet signed by a project manager. The National Alliance Against Disparities in Patient Health does acknowledge that an additional level of review is justified as our grant volume continues to expand. The verification of work performed on a monthly basis will ensure accuracy. Project managers will meet weekly with the executive team to address any transitional issues. Evidence of this allocation review will be maintained electronically for future inspection and/or presentation to grantors or others with a need to know.

View Audit 3140

Finding 1797 (2022-001)

Material Weakness 2022

National Alliance Against Disparities in Patient Health

VA

Allowable Costs / Cost Principles HUD Housing Programs Matching / Level of Effort / Earmarking § 200.303 § 200.431

Timesheets are reviewed by project managers before they are submitted to payroll processing. Additionally, a reconciliation of actual to budgeted hours will be performed on a monthly basis. Documentation of the timesheet reviews will be maintained electronically. Staff time for federal grants will b...

Timesheets are reviewed by project managers before they are submitted to payroll processing. Additionally, a reconciliation of actual to budgeted hours will be performed on a monthly basis. Documentation of the timesheet reviews will be maintained electronically. Staff time for federal grants will be supported by a completed timesheet signed by a project manager. The National Alliance Against Disparities in Patient Health does acknowledge that an additional level of review is justified as our grant volume continues to expand. The verification of work performed on a monthly basis will ensure accuracy. Project managers will meet weekly with the executive team to address any transitional issues. Evidence of this allocation review will be maintained electronically for future inspection and / or presentation to grantors or others with a need to know.

View Audit 3140

Finding 1782 (2022-004)

Material Weakness 2022

Kanabec County

MN

Eligibility Material Weakness Internal Control / Segregation of Duties § 200.303

2022-004 U.S. Department of Health and Human Services Medical Assistance – Assistance Listing No. 93.778 Recommendation: It is recommended that a supervisor or team lead perform regular internal reviews on MAXIS and METS casefiles to determine that proper policies and procedures are being followed ...

2022-004 U.S. Department of Health and Human Services Medical Assistance – Assistance Listing No. 93.778 Recommendation: It is recommended that a supervisor or team lead perform regular internal reviews on MAXIS and METS casefiles to determine that proper policies and procedures are being followed in determining eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Additional training will be provided to case workers and a reminder communication will be provided as well. Name of the contact person responsible for corrective action: Tim Dahlberg, Financial Assistance Supervisor Planned completion date for corrective action plan: December 31, 2023

View Audit 3071

Finding 1558 (2022-008)

Significant Deficiency 2022

Sangamon County, Illinois

IL

Eligibility Internal Control / Segregation of Duties Significant Deficiency § 200.303

Action taken in response to finding: County department personnel changes have been implemented which address this deficiency. New department personnel have been properly trained by County Auditor staff as well as State grantor personnel to ensure correct grant reporting. Department supervising staff...

Action taken in response to finding: County department personnel changes have been implemented which address this deficiency. New department personnel have been properly trained by County Auditor staff as well as State grantor personnel to ensure correct grant reporting. Department supervising staff will monitor grant reporting documentation. All manual adjusting entries will be requested through the County Auditor’s office to ensure proper supporting documentation is provided. Name(s) of the contact person(s) responsible for corrective action: Dave MacDonna, Community Resources Director. Eric Black, Chief Deputy Auditor. Planned completion date for corrective action plan: October 2, 2023

View Audit 2802

Finding 1557 (2022-007)

Material Weakness 2022

Sangamon County, Illinois

IL

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

Action taken in response to finding: County department personnel changes have been implemented which address this deficiency. New department personnel have been properly trained by County Auditor staff as well as State grantor personnel to ensure correct grant reporting. Department supervising staff...

Action taken in response to finding: County department personnel changes have been implemented which address this deficiency. New department personnel have been properly trained by County Auditor staff as well as State grantor personnel to ensure correct grant reporting. Department supervising staff will monitor grant reporting documentation. All manual adjusting entries will be requested through the County Auditor’s office to ensure proper supporting documentation is provided. Name(s) of the contact person(s) responsible for corrective action: Dave MacDonna, Community Resources Director. Eric Black, Chief Deputy Auditor. Planned completion date for corrective action plan: October 2, 2023

View Audit 2802

Finding 1556 (2022-006)

Material Weakness 2022

Sangamon County, Illinois

IL

Questioned Costs Cash Management § 200.303

Action taken in response to finding: County department personnel changes have been implemented which address this deficiency. New department personnel have been properly trained by County Auditor staff as well as State grantor personnel to ensure correct grant reporting. Department supervising staff...

Action taken in response to finding: County department personnel changes have been implemented which address this deficiency. New department personnel have been properly trained by County Auditor staff as well as State grantor personnel to ensure correct grant reporting. Department supervising staff will monitor draw request documentation. Name(s) of the contact person(s) responsible for corrective action: Dave MacDonna, Community Resources Director. Eric Black, Chief Deputy Auditor. Planned completion date for corrective action plan: October 2, 2023

View Audit 2802 Questioned Costs: $1

Finding 1555 (2022-005)

Material Weakness 2022

Sangamon County, Illinois

IL

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.303

Action taken in response to finding: County department personnel changes have been implemented which address this deficiency. New department personnel have been properly trained by County Auditor staff as well as State grantor personnel to ensure correct grant reporting. Department supervising staff...

Action taken in response to finding: County department personnel changes have been implemented which address this deficiency. New department personnel have been properly trained by County Auditor staff as well as State grantor personnel to ensure correct grant reporting. Department supervising staff will monitor grant reporting documentation. All manual adjusting entries will be requested through the County Auditor’s office to ensure proper supporting documentation is provided. Name(s) of the contact person(s) responsible for corrective action: Dave MacDonna, Community Resources Director. Eric Black, Chief Deputy Auditor. Planned completion date for corrective action plan: October 2, 2023

View Audit 2802 Questioned Costs: $1

Finding 1554 (2022-004)

Significant Deficiency 2022

Sangamon County, Illinois

IL

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Action taken in response to finding: All required reporting of the Coronavirus State & Local Fiscal Recovery Fund will be sent to the County Administrator for review and approval in a timely manner of the reports being submitted to the Federal reviewing agency. Documentation of review and approval w...

Action taken in response to finding: All required reporting of the Coronavirus State & Local Fiscal Recovery Fund will be sent to the County Administrator for review and approval in a timely manner of the reports being submitted to the Federal reviewing agency. Documentation of review and approval will be kept along with other supporting documentation for the program. Name(s) of the contact person(s) responsible for corrective action: Eric Black, Chief Deputy Auditor Planned completion date for corrective action plan: November 1, 2023

View Audit 2802

Finding 1542 (2022-011)

Significant Deficiency 2022

State of Iowa

IA

Subrecipient Monitoring Reporting § 200.303

The Department will establish policies and procedures to ensure first-tier subawards of $30,000 or more are reported to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). Policies and procedures will ensure the reporting is reviewed and approved by an independ...

The Department will establish policies and procedures to ensure first-tier subawards of $30,000 or more are reported to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). Policies and procedures will ensure the reporting is reviewed and approved by an independent person who is knowledgeable about the program. This independent review will be documented by the reviewer’s signature or initials and date of review prior to submission. The Department plans to begin this process in October 2023.

View Audit 2795

Finding 1277 (2022-001)

Significant Deficiency 2022

Memorial Hospital at Gulfport

MS

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Significant Deficiency § 200.303 § 200.430

Management's Action Plan: Kevin Holland, Vice-President-Stone County and Operations will oversee the supervisory review and approval of timesheets for the next few pay cycles to ensure management is reviewing 100% of the records. He will also work to ensure none of them are being missed through spec...

Management's Action Plan: Kevin Holland, Vice-President-Stone County and Operations will oversee the supervisory review and approval of timesheets for the next few pay cycles to ensure management is reviewing 100% of the records. He will also work to ensure none of them are being missed through special circumstances as has happended in the past in order to achieve and sustain 100% compliance. Name of Person Responsible for the Plan: Kevin Holland, Vice-President Stone County & Operations. Anticipated Completion Date of the Plan: 3 payroll cycles spanning six weeks. Approximately mid-December 2023 for completion.

View Audit 2411

Finding 1195 (2022-003)

Material Weakness 2022

Latin American Association, Inc.

GA

Matching / Level of Effort / Earmarking § 200.303 § 200.306

Grantee Response and Corrective Action Plan: We concur with this finding and have implemented measures to mitigate the repetition of additional occurrences. In July 2023, the Accounting Manager, Grants Manager, and Grants Supervisor attended the 2023 Southern Grants Forum in Nashville, TN. This in...

Grantee Response and Corrective Action Plan: We concur with this finding and have implemented measures to mitigate the repetition of additional occurrences. In July 2023, the Accounting Manager, Grants Manager, and Grants Supervisor attended the 2023 Southern Grants Forum in Nashville, TN. This investment in training assisted these key employees in understanding and implementing procedures to effectively match Federal Grant awards. We have updated our Policy and Procedures Manual to reflect a new policy of matching Federal Grant awards with non-federal funding. The Grants Supervisor reviews all invoices submitted by the Grants Manager to ensure compliance with this new policy.

View Audit 2270

Finding 1186 (2022-002)

Material Weakness 2022

Latin American Association, Inc.

GA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.430

Grantee Response and Corrective Action Plan: We concur with this finding and have implemented measures to mitigate the repetition of additional occurrences. In July 2023, a new policy was implemented that requires employees to record their time as a percentage across all grants in which they work....

Grantee Response and Corrective Action Plan: We concur with this finding and have implemented measures to mitigate the repetition of additional occurrences. In July 2023, a new policy was implemented that requires employees to record their time as a percentage across all grants in which they work. The employee records this allocation at least weekly within a time keeping software system. Employees and supervisors are now required to review and acknowledge payroll allocations across grants by signing weekly timesheets. Timesheets will be retained and used as backup by the Grants Department when invoicing the Grantor for expense reimbursement. In addition, we have updated our Policy and Procedures Manual to reflect this policy.

View Audit 2270

Finding 1126 (2022-001)

Significant Deficiency 2022

Horizon House, Inc.

PA

Reporting Subrecipient Monitoring Significant Deficiency § 200.303 § 200.403

Information on Federal Program(s) - Department of Health and Human Services, Assistance Listing Number 93.498 COVID-19 - Provider Relief Fund and American Rescue Plan Rural Distribution, Schedule of Expenditures of Federal Awards Reporting Periods 2 and 3, Agency Fiscal Year-Ended June 30, 2022. M...

Information on Federal Program(s) - Department of Health and Human Services, Assistance Listing Number 93.498 COVID-19 - Provider Relief Fund and American Rescue Plan Rural Distribution, Schedule of Expenditures of Federal Awards Reporting Periods 2 and 3, Agency Fiscal Year-Ended June 30, 2022. Management’s Corrective Action Plan In response to the deficiency identified, the Agency will modify its existing internal control protocols in the following ways: • Develop emergency internal control protocols to be implemented during emergency situations whereby all items recoded by accounting staff are reviewed and signed off by the Controller or Director of Finance to ensure appropriate treatment. Train all accounting staff on this expectation. • Ensure adherence of record retention policies and procedures which are consistent with regulatory requirements. • Modify its petty cash protocols to include the review and adequate documentation of all receipts to verify allowability prior to reimbursement. Train all petty cash reviewers on this expectation. Individual Responsible for Corrective Action Plan Auston Johnson Controller 215-386-3838 Anticipated Completion Date: October 31, 2023

View Audit 2149

Finding 994 (2022-002)

Material Weakness 2022

Newfound Area School District

NH

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303 § 200.430

BA has worked with Accountant to ensure all employees complete Time and Effort sheets. These requirements have been reviewed with Building Administrators and all federally paid employees will sign the certifications. BA will review to ensure all employees have completed and will report any missing s...

BA has worked with Accountant to ensure all employees complete Time and Effort sheets. These requirements have been reviewed with Building Administrators and all federally paid employees will sign the certifications. BA will review to ensure all employees have completed and will report any missing signatures with employee’s supervisors.

View Audit 1892 Questioned Costs: $1

Finding 825 (2022-006)

Material Weakness 2022

National Governors Association Center for Best Practices

DC

Reporting § 200.303

2022-006- Internal Control Over Compliance and Compliance - Reporting Contact: Jordan Kramer Title: Chief Financial Officer Phone Number: 202-624-7787 Anticipated Completion Date: April 2024 Management’s Corrective Action Plan: NGA has developed a grant reporting procedure to document all the requ...

2022-006- Internal Control Over Compliance and Compliance - Reporting Contact: Jordan Kramer Title: Chief Financial Officer Phone Number: 202-624-7787 Anticipated Completion Date: April 2024 Management’s Corrective Action Plan: NGA has developed a grant reporting procedure to document all the required steps including retention of support documents. This policy was finalized in August 2023 and the NGA grants management team plans to roll out and implement this process with all internal stakeholders responsible for the management of federal funds. We will continue to socialize the importance of accurate and timely grant reporting including ensuring that all federal grant reimbursements are reported following applicable federal contracts.

View Audit 1570

Finding 817 (2022-005)

Material Weakness 2022

National Governors Association Center for Best Practices

DC

Cash Management § 200.303 § 200.305

2022-005- Internal Control Over Compliance and Compliance – Cash Management Contact: Jordan Kramer Title: Chief Financial Officer Phone Number: 202-624-7787 Anticipated Completion Date: June 2024 Management’s Corrective Action Plan:NGA has developed procedures to capture all required documentation...

2022-005- Internal Control Over Compliance and Compliance – Cash Management Contact: Jordan Kramer Title: Chief Financial Officer Phone Number: 202-624-7787 Anticipated Completion Date: June 2024 Management’s Corrective Action Plan:NGA has developed procedures to capture all required documentation during the federal disbursement request process. Staff were informed in January 2023 of the requirements for federal drawdown documentation and the CFO proceeded with a desk audit of compliance for the first and second quarter of fiscal year 2023 in April 2023. The CFO will continue to monitor compliance and adequate document retention in the second half of the fiscal year and provide training to staff when documents are not available in shared drive folders. We will also implement a regular review of the SEFA beginning in September 2023 and use that review to ensure that revenue and cash transactions correspond to the expense reports they were based on.

View Audit 1570

Finding 809 (2022-004)

Material Weakness 2022

National Governors Association Center for Best Practices

DC

Allowable Costs / Cost Principles § 200.303 § 200.430

2022-004- Internal Control Over Compliance and Compliance – Activities Allowed or Unallowed and Allowable Costs/ Cost Principles Contact: Jordan Kramer Title: Chief Financial Officer Phone Number: 202-624-7787 Anticipated Completion Date: Done. Management’s Corrective Action Plan: Since August 2022...

2022-004- Internal Control Over Compliance and Compliance – Activities Allowed or Unallowed and Allowable Costs/ Cost Principles Contact: Jordan Kramer Title: Chief Financial Officer Phone Number: 202-624-7787 Anticipated Completion Date: Done. Management’s Corrective Action Plan: Since August 2022, in response to technical issues with an import file that caused some timesheet allocations to not be correctly coded, the CFO has added a layer of review for payroll entries to match import file values to approved timesheets. NGA accounting team members began to train and reach out to employees to reinforce the importance of completing timesheets accurately and promptly following NGA employee policies. NGA accounting since February 2023, has completed the indirect cost, compensated absences, and fringe calculations as a part of the same process for uploading payroll entries. This ensures that the calculations are accurately calculated based on the payroll file. This has ensured that these entries are produced each payroll period and correspond to supervisor-approved timesheets under 2 CFR 200.430 Compensation – Personal Services.

View Audit 1570

Finding 805 (2022-003)

Material Weakness 2022

New York State Sheriffs' Association

NY

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

• Invoices received by NYSSA pertaining to Federal Grants will be given a supervisory designee for review (current procedure) and logged on a spreadsheet prior to being delivered to the Finance Office for processing. [New procedure implemented] • Invoices to be paid will be entered into Quickbooks f...

• Invoices received by NYSSA pertaining to Federal Grants will be given a supervisory designee for review (current procedure) and logged on a spreadsheet prior to being delivered to the Finance Office for processing. [New procedure implemented] • Invoices to be paid will be entered into Quickbooks financial software by the Finance Manager (current procedure). • Checks for payment to grant vendors follow the same procedures and processes as listed

View Audit 1558

Finding 659 (2022-003)

Material Weakness 2022

Indianapolis Housing Agency

IN

Internal Control / Segregation of Duties HUD Housing Programs Allowable Costs / Cost Principles § 200.303

Recommendation: See finding 2022-001. The recommendations noted for achieving appropriate oversight in the finance department apply as key individuals with knowledge of the compliance are considered critical for developing an appropriate control environment for internal controls over compliance. Pl...

Recommendation: See finding 2022-001. The recommendations noted for achieving appropriate oversight in the finance department apply as key individuals with knowledge of the compliance are considered critical for developing an appropriate control environment for internal controls over compliance. Planned Corrective Action: We agree with the recommendation. Since year end the Agency has hired a COO, and CFO to fill vacancies within the Agency. Under this new leadership structure, the Agency will continue to work on establishing appropriate controls.

View Audit 1234

Finding 409 (2022-005)

Material Weakness 2022

Pioneercare

MN

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303

Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: During testing, there were two debt covenants, net worth and the amount of capital expenditures, that w...

Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: During testing, there were two debt covenants, net worth and the amount of capital expenditures, that were not included in the monthly covenant report included in the financial packet for monitoring. There was also no control in place to seek approval prior to reaching the capital expenditure threshold of $100,000. Responsible Individuals: Nathan Johnson, CEO and Dan Stone, CFO Corrective Action Plan: We will update our monthly covenant report to include the net worth calculation and the amount of capital expenditures. We will actively seek lender approval prior to exceeding capital expenditures over $100,000. Anticipated Completion Date: December 31, 2023

View Audit 857

Finding 408 (2022-004)

Significant Deficiency 2022

Pioneercare

MN

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

Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: There was no formal documented review over the reserve fund reconciliation for the federal program. Re...

Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: There was no formal documented review over the reserve fund reconciliation for the federal program. Responsible Individuals: Nathan Johnson, CEO and Dan Stone, CFO Corrective Action Plan: We have adopted a policy to enhance internal control to ensure the reserve fund reconciliation has a secondary review and approval that is documented. Anticipated Completion Date: August 31, 2023

View Audit 857

Finding 406 (2022-003)

Material Weakness 2022

Pioneercare

MN

Reporting Allowable Costs / Cost Principles Material Weakness § 200.303

Federal Agency Name: U.S. Department of Agriculture Department of Health and Human Services Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 COVID‐19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Federal Financial...

Federal Agency Name: U.S. Department of Agriculture Department of Health and Human Services Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 COVID‐19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: Eide Bailly LLP prepared our consolidated schedule of expenditures of federal awards (Schedule) and accompanying notes to the Schedule. Responsible Individuals: Nathan Johnson, CEO Corrective Action Plan: Having auditors assist with preparing the consolidated schedule of expenditures of federal awards (Schedule) is not unusual. We will continue to be aware of the financial reporting requirements relating to PioneerCare’s consolidated schedule of expenditures of federal awards and internal control that impact financial reporting. Anticipated Completion Date: Ongoing

View Audit 857

Corrective Action Plans

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