Corrective Action Plans

Agency’s response: We acknowledge that we are late for the fiscal year ended September 30, 2023. Our intent is to be current with all Data Collection Form filings by

View Audit 323484

Finding 501213 (2023-003)

Material Weakness 2023

North Central Organized Regionally for Total Health, Inc.

PA

September 30, 2024.

View Audit 323484

Finding 501212 (2023-002)

Material Weakness 2023

North Central Organized Regionally for Total Health, Inc.

PA

Corrective Action Plan:

View Audit 323484

Finding 501212 (2023-002)

Material Weakness 2023

North Central Organized Regionally for Total Health, Inc.

PA

Finding: 2023-002

View Audit 323484

Finding 501212 (2023-002)

Material Weakness 2023

North Central Organized Regionally for Total Health, Inc.

PA

Agency department: Accounting

View Audit 323484

Finding 501212 (2023-002)

Material Weakness 2023

North Central Organized Regionally for Total Health, Inc.

PA

Name of contact person and title: Ms. Sandra Brown, Finance Manager

View Audit 323484

Finding 501212 (2023-002)

Material Weakness 2023

North Central Organized Regionally for Total Health, Inc.

PA

Dr. Linda Kilby, Executive Director

View Audit 323484

Finding 501212 (2023-002)

Material Weakness 2023

North Central Organized Regionally for Total Health, Inc.

PA

Anticipated completion date: The finding will be corrected by 09/30/2024

View Audit 323484

Finding 501212 (2023-002)

Material Weakness 2023

North Central Organized Regionally for Total Health, Inc.

PA

Agency’s response: We acknowledge that we are late for the fiscal year ended September 30, 2023. Our intent is to be current with all Data Collection Form filings by

View Audit 323484

Finding 501212 (2023-002)

Material Weakness 2023

North Central Organized Regionally for Total Health, Inc.

PA

September 30, 2024.

View Audit 323484

Finding 501211 (2023-001)

Material Weakness 2023

North Central Organized Regionally for Total Health, Inc.

PA

Corrective Action Plan:

View Audit 323484

Finding 501211 (2023-001)

Material Weakness 2023

North Central Organized Regionally for Total Health, Inc.

PA

Finding: 2023-001

View Audit 323484

Finding 501211 (2023-001)

Material Weakness 2023

North Central Organized Regionally for Total Health, Inc.

PA

Agency department: Accounting

View Audit 323484

Finding 501211 (2023-001)

Material Weakness 2023

North Central Organized Regionally for Total Health, Inc.

PA

Name of contact person and title: Ms. Sandra Brown, Finance Manager

View Audit 323484

Finding 501211 (2023-001)

Material Weakness 2023

North Central Organized Regionally for Total Health, Inc.

PA

Dr. Linda Kilby, Executive Director

View Audit 323484

Finding 501211 (2023-001)

Material Weakness 2023

North Central Organized Regionally for Total Health, Inc.

PA

Anticipated completion date: The finding will be corrected by 09/30/2024

View Audit 323484

Finding 501211 (2023-001)

Material Weakness 2023

North Central Organized Regionally for Total Health, Inc.

PA

Agency’s response: Recently, our accounting personnel did do a fiscal year end closing for the audit period. They have compared the closing balances to the opening balances appearing in the general ledger for the new fiscal period without exception. They will conduct fiscal month-end closings to com...

Agency’s response: Recently, our accounting personnel did do a fiscal year end closing for the audit period. They have compared the closing balances to the opening balances appearing in the general ledger for the new fiscal period without exception. They will conduct fiscal month-end closings to compare account balances to external documentation. Any discrepancies will be investigated. The accounting software support did provide our accountants with the year-end procedures needed to conduct a closing

View Audit 323484

Finding 501211 (2023-001)

Material Weakness 2023

North Central Organized Regionally for Total Health, Inc.

PA

and to retroactively post transactions that affected the previous fiscal year.

View Audit 323484

Finding 501207 (2023-004)

Significant Deficiency 2023

Shasta Regional Transportation Agency

CA

Cash Management Reporting Significant Deficiency

Federal Agency: U.S. Department of Transportation Program/Cluster: Metropolitan Planning and Research Federal Assistance Listing Number: 20.505 Pass‐through: California Department of Transportation Award No. and Year: 74A0821, 2022/2023 Compliance Requirement: Reporting Type of Finding: Significant ...

Federal Agency: U.S. Department of Transportation Program/Cluster: Metropolitan Planning and Research Federal Assistance Listing Number: 20.505 Pass‐through: California Department of Transportation Award No. and Year: 74A0821, 2022/2023 Compliance Requirement: Reporting Type of Finding: Significant Deficiency over Compliance, Instance of Noncompliance Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. Delay in Caltrans approving the first quarter request for reimbursement and progress reports until January 24, 2023, as well as additional staff time needed to prepare the narrative information, resulted in the submittal of the second quarter reports nine days after the due date of January 30, 2023. Caltrans District 2 staff were notified early that there would be a delay in the reporting and indicated this was acceptable. This is an extraordinary occurrence, as it is SRTA’s common practice to submit all required reports before the deadline. Corrective Action Plan: The Agency will send a memorandum to all staff to ensure timely reporting of required quarterly reports in accordance with the agency’s established policies and procedures and compliance with the Master Fund Transfer Agreement that is active at the time of submittal. The Agency will also create reminders on the shared agency calendar that will be set to automatically alert the executive director, CFO, OWP manager, and relevant staff, of the deadline to submit the quarterly narratives to further eliminate the risk of late reporting. Responsible Individual(s): Sean Tiedgen, Executive Director and Jessica Carlson, Chief Fiscal Officer Anticipated Completion Date: June 30, 2024

View Audit 323480

Finding 501206 (2023-002)

Significant Deficiency 2023

Ufcw Charity Foundation, Inc.

DC

Reporting Subrecipient Monitoring Significant Deficiency § 200.328 § 200.329

Finding 2023-002: Reportable Finding Considered a Significant Deficiency – Reporting Assistance Listing Number: 10.181 Agency: U.S. Department of Agriculture Program: Pandemic Relief Activities: Farm and Food Worker Relief Program (FFWR) Award Number: AM22FFWDC0002-02 Grant Years: 2023 Views of Resp...

Finding 2023-002: Reportable Finding Considered a Significant Deficiency – Reporting Assistance Listing Number: 10.181 Agency: U.S. Department of Agriculture Program: Pandemic Relief Activities: Farm and Food Worker Relief Program (FFWR) Award Number: AM22FFWDC0002-02 Grant Years: 2023 Views of Responsible Officials – We acknowledge the finding regarding the reconciliation of Form SF-425 for the period November 4, 2022, through April 3, 2023. The issue arose because the preparer did not properly reconcile financial records or obtain a secondary review prior to submission. We are committed to maintaining compliance with 2 CFR sections 200.328 and 200.329 and have already taken corrective steps. Corrective Actions – Root Cause Analysis: The deficiency was caused by the preparer’s failure to review and reconcile Form SF-425 with the financial records prior to submission. The preparer submitted the form without verifying the accuracy of the data. Revised Reporting and Review Process: • Action: We have implemented a formal review process where all Forms SF-425 are reconciled with the financial records before submission. This process includes: o The preparer reconciles the financial data with the underlying financial records. o A mandatory review by the Finance Director or another senior finance officer before submission. o Final approval is given by the Program Director and then the President. • Results: This process was successfully implemented for the April 4, 2023, through October 3, 2023, filing, significantly improving accuracy and compliance. • Responsible Person: The Finance Director is responsible for overseeing the reconciliation and review process. • Timeline: The new process is already in place and was followed for the second filing in 2023. Documentation of Review and Approval: • Action: All review and approval process steps are documented through email communications, ensuring that each step—from reconciliation to final approval—is tracked and recorded. • Responsible Person: The Finance Director ensures that email approvals are completed and stored as part of the official documentation. • Timeline: This documentation process is currently in place and was followed for the April 4, 2023, through October 3, 2023, submission. Conclusion: The corrective actions outlined above have been implemented and are already showing positive results, as demonstrated by the successful filing of the April 4, 2023, through October 3, 2023, From SF-425. By ensuring that every Form SF-425 is reconciled and reviewed before submission, we are confident that these measures will prevent future discrepancies. Completion Timeline: The revised review and approval process is fully implemented and has been successfully applied to the April 4, 2023, through October 3, 2023, filing.

View Audit 323477

Finding 501205 (2023-001)

Material Weakness 2023

Ufcw Charity Foundation, Inc.

DC

Questioned Costs Eligibility Material Weakness

Finding 2023-001: Reportable Finding Considered a Material Weakness – Eligibility Assistance Listing Number: 10.181 Agency: U.S. Department of Agriculture Program: Pandemic Relief Activities: Farm and Food Worker Relief Program (FFWR) Award Number: AM22FFWDC0002-02 Grant Years: 2023 Views of Respons...

Finding 2023-001: Reportable Finding Considered a Material Weakness – Eligibility Assistance Listing Number: 10.181 Agency: U.S. Department of Agriculture Program: Pandemic Relief Activities: Farm and Food Worker Relief Program (FFWR) Award Number: AM22FFWDC0002-02 Grant Years: 2023 Views of Responsible Officials – The Charity Foundation acknowledges the finding regarding the improper payment of 9,424 benefit checks to ineligible beneficiaries due to insufficient verification of employment and identity documentation. This resulted in $5,654,400 in questioned costs. We understand the seriousness of this issue and have implemented corrective actions to prevent future occurrences. Corrective Actions – Root Cause Analysis: The deficiency arose because the Foundation’s application portal, designed and managed by consultant contractors, failed to accurately verify employment and identity documentation, leading to the approval of ineligible beneficiaries. Revised Eligibility Verification Process: In November 2023, the Charity Foundation implemented updated procedures to enhance the verification of applicant eligibility under the FFWR program: • Initial In-Person Screening: Applicants must now provide proof of employment, such as a paystub or W-2, in person at their place of work (farm, meatpacking facility, or grocery store). This initial screening is intended to ensure that workers are properly verified before accessing the application portal. • Unique Identifier Creation and Control: The Charity Foundation creates and controls unique identifier codes used for logging into the application portal. These identifiers ensure secure access and prevent duplicate applications. During the initial screening process, the consultants assisting with the sign-up process distribute these unique identifiers to each eligible worker in person at the plants. • Portal Access and Document Submission: After receiving the unique identifier, applicants log into the portal and are required to upload their identification documents. A dedicated team manually reviews each document to verify that the applicant’s identity and employment meet FFWR eligibility requirements and that the information matches the details entered by the applicant. Ongoing Monitoring and Compliance: To ensure the integrity of the process, the Foundation’s internal review team conducts regular compliance checks on the submitted documentation. This ongoing monitoring process ensures that all uploaded documentation meets program standards. Staff Training: The Foundation will continue to train team members responsible for verifying applications. This training covers FFWR program requirements, proper identification and employment records review, and how to flag potential discrepancies. Regular training ensures the team remains informed of program expectations and changes. Consultant Accountability: We have revised our contract with the consultant contractors managing the application portal to establish stricter accountability measures. This includes ongoing performance reviews and quality control checks to ensure the portal supports accurate identification and employment verification. Results: These changes were successfully implemented in November 2023 and are now the standard operating procedure for the Charity Foundation’s FFWR program. Responsible Person: The Director of Finance is responsible for overseeing the implementation of the updated eligibility verification process. The Director also ensures compliance with FFWR requirements through continuous monitoring and periodic internal audits. Completion Timeline: The corrective actions were fully implemented as of November 2023 and continue to be in effect for all FFWR program applicants moving forward.

View Audit 323477 Questioned Costs: $1

Finding 501204 (2023-001)

Significant Deficiency 2023

Church Housing for Fairfield, Inc.

CT

HUD Housing Programs Internal Control / Segregation of Duties

Finding 2023-001: The Organization did not retain a printed and dated copy of the Failed Verification and Failed EIV Prescreen reports for two out of twelve months of the year. Recommendations (2023-001-a): Auditor recommends that management reevaluate its system and procedures to ensure that the ...

Finding 2023-001: The Organization did not retain a printed and dated copy of the Failed Verification and Failed EIV Prescreen reports for two out of twelve months of the year. Recommendations (2023-001-a): Auditor recommends that management reevaluate its system and procedures to ensure that the required reports are printed and retained on the required schedule with clear dates of printing, going forward. View of Responsible Officials: Management concurs with this finding and agrees with the auditor’s recommendation. Management considers corrective action to be completed and will reevaluate its system to ensure future compliance.

View Audit 323476

Corrective Action Plans

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