Corrective Action Plans

Finding 500934 (2023-003)

Significant Deficiency 2023

ME

Significant Deficiency Internal Control / Segregation of Duties

2023-003- Significant Deficiency - Segregation of Duties WPHW understands this finding and recognizes that corrections that were planned for FY23 were not able to be fully implemented. Our prior year corrective actions and business process were redesigned to work with our new financial management ...

2023-003- Significant Deficiency - Segregation of Duties WPHW understands this finding and recognizes that corrections that were planned for FY23 were not able to be fully implemented. Our prior year corrective actions and business process were redesigned to work with our new financial management system, NetSuite. It was our plan to have the FY23 audit completed in both NetSuite and QuickBooks, and the NetSuite changes would have demonstrated our corrective action for the segregation of duties, since this was part of the software’s functionality. However, we encountered several issues with the implementation of the new system and WPHW decide to move away from NetSuite in May 2024. Since that time, we have fully committed to QuickBooks and have started engaging in systematic business process redesign of our financial system. WPHW has implemented the following process to ensure the separation of duties: 1) AR/AP Specialists and Accounting Specialists will have access to the accounting software and will not have any access to the bank accounts for entry of information. 2) Accountants, Accounting Manager and AR/AP Manager will have read-only access to the bank accounts and full access to the accounting software to verify and review day-to-day transactions. 3) The Director of Accounting will have full access to the bank and review only access to the accounting software to do the proper review process. 4) Tasks can be handed off between staff within each level, but to ensure appropriate separation of duties, task cannot cross levels With these implemented there will be clear separation of duties this will allow mitigating of procedures to be formed by somebody who has full access to both systems to help ensure that there is no cross between any possible chance of fraud and decrease risk of significant errors and/or misstated financial statements. Access for the Director of Accounting to make adjustments will be cut off by October 1, 2024, at which time the process will be fully implemented. With this process in place, we anticipate this issue being fully resolved in FY25.

View Audit 323235

Finding 500933 (2023-002)

Material Weakness 2023

Wabanaki Health and Wellness

ME

Material Weakness Internal Control / Segregation of Duties

2023-002 - Material Weakness - Year End Cutoff WPHW understands this finding and recognizes the corrections that were planned for FY23 did not come to fruition due to the challenges with implementing a new financial management system. Despite these challenges, WPHW has made strides in improving our...

2023-002 - Material Weakness - Year End Cutoff WPHW understands this finding and recognizes the corrections that were planned for FY23 did not come to fruition due to the challenges with implementing a new financial management system. Despite these challenges, WPHW has made strides in improving our year-end processes and acknowledges that there is additional improvement needed. For FY23, WPHW created a year-end check list and started the review process. Unfortunately, due to staff absences and NetSuite issues, we were not able to fully implement these changes. Both situations have provided us with lessons learned for how to correctly implement changes in the future. For FY24, WPWH implemented the following process: 1) Full year-end check list is distributed and review by staff (Accounting Specialists, Accountants, and AR/AP Specialists) prior to year-end for review and training, conducted by the Director of Accounting and Accounting Manager a. Review each step with staff and provide training on the expectation for each step 2) Accounting Specialists and Accountants complete necessary year-end tasks 3) Accounting Manager reviews all completed tasks to ensure accuracy and completeness 4) Director of Accounting conducts a final review and signs off at the end of the year With this clear process in place, we anticipate this issue being fully resolved in FY24.

View Audit 323235

Finding 500932 (2023-001)

Material Weakness 2023

Wabanaki Health and Wellness

ME

Material Weakness Internal Control / Segregation of Duties

2023-001 - Material Weakness - Material Adjusting Journal Entries WPHW understands this finding and recognizes that corrections that were planned for FY23 did not come to fruition. WPHW was in the process of implementing a new financial management system, NetSuite. It was our plan to implement new ...

2023-001 - Material Weakness - Material Adjusting Journal Entries WPHW understands this finding and recognizes that corrections that were planned for FY23 did not come to fruition. WPHW was in the process of implementing a new financial management system, NetSuite. It was our plan to implement new processes that would have fully addressed prior concerns. It was our plan to have the FY23 audit completed in both NetSuite and QuickBooks. However, we encountered several issues with the implementation of the new system, which delayed prior year corrected actions. In May 2024, WPHW decide to no longer work with NetSuite, due to the number of issues with the system and the company. Since that time, we have fully committed to QuickBooks and have started engaging in systematic business process redesign of our financial system. At the time of the transition back to QuickBooks fully, we also made significant staff role changes. Our accounting department now has a Director of Accounting and two new managers, AR/AP Manager and Accounting Manager. With these new positions, we have developed the following procedures for adjusting journal entries: 1) Accounting Director, Accounting Manager or AR/AP Manager identifying need for a journal entry 2) Accounting Specialist or AR/AP Specialist pulls the supporting documentation for the required entry, creates journal entry template in Excel, and prepares journal entry packet with supporting documentation for entry into QB. 3) Accountant or Accounting Manager reviews packet and determines who can enter journal a. If reviewed by Accountant, entry is entered QuickBooks by Accounting Specialist b. If reviewed by Accounting Manager, entry is entered into QuickBooks by Accountant 4) Once journal entry is entered into QuickBooks, entry is printed from QB system and added to packet. The packet is returned to the preparer to ensure all elements were completed corrected and signed off on 5) Completed packet goes to filing and are scanned into our electronic file system All adjustments must go through three different individuals to ensure separation of duties. This process will be implemented during Q4 of FY24. The Director of Accounting will go back over all the journals completed before this date to review how each were completed and delegate additional review to the Accounting Manager and Accounting Specialist to ensure each journal entry had appropriate review and support. With this process in place, we anticipate this issue being fully resolved in FY25.

View Audit 323235

Finding 500931 (2023-003)

Significant Deficiency 2023

Native Sun Community Power Development

MN

Subrecipient Monitoring Reporting Significant Deficiency

Planned Corrective Action: We will implement a process to ensure FSRS reporting is completed on a timely basis. It will be included in the monthly drawdown activities. Specific to 2023, this was filed by Lisa Daniels on 9/27/2024. Rhonda will oversee the submission of this reporting requirement goin...

Planned Corrective Action: We will implement a process to ensure FSRS reporting is completed on a timely basis. It will be included in the monthly drawdown activities. Specific to 2023, this was filed by Lisa Daniels on 9/27/2024. Rhonda will oversee the submission of this reporting requirement going forward. Name of Contact Person: Lisa Daniels, Program Director & Rhonda Conn, Program Director Anticipated Completion Date: October 1, 2024

View Audit 323232

Finding 500930 (2023-002)

Significant Deficiency 2023

Native Sun Community Power Development

MN

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

Planned Corrective Action: We will implement a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. This will be completed with each drawdown that is request where a cost match is reported. Name of Contact Person: Lisa Daniels, Pro...

Planned Corrective Action: We will implement a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. This will be completed with each drawdown that is request where a cost match is reported. Name of Contact Person: Lisa Daniels, Program Director & Rhonda Conn, Program Director Anticipated Completion Date: October 1, 2024

View Audit 323232

Finding 500929 (2023-001)

Significant Deficiency 2023

Native Sun Community Power Development

MN

Allowable Costs / Cost Principles Cash Management § 200.303

Planned Corrective Action: Executive Director will be tracking their time spent on specific grants on a weekly basis. The Board of Directors will review and approve the time summary at least quarterly. Executive Director non‐payroll reimbursements will also be reviewed and approved by at least one b...

Planned Corrective Action: Executive Director will be tracking their time spent on specific grants on a weekly basis. The Board of Directors will review and approve the time summary at least quarterly. Executive Director non‐payroll reimbursements will also be reviewed and approved by at least one board member. The Program Director will provide oversight of these two newly established processes. Name of Contact Person: Rhonda Conn, Program Director Anticipated Completion Date: October 1, 2024

View Audit 323232

Finding 500928 (2023-001)

Material Weakness 2023

Houston Area Urban League

TX

Reporting Internal Control / Segregation of Duties

RE: Management Response to 2023 Annual Audit We acknowledge the observations and recommendations made during the Houston Area Urban League's 2023 Annual Audit. The Board of Directors Audit Committee and the Houston Area Urban League's Executive Leadership Team have reviewed the recommendations. In r...

RE: Management Response to 2023 Annual Audit We acknowledge the observations and recommendations made during the Houston Area Urban League's 2023 Annual Audit. The Board of Directors Audit Committee and the Houston Area Urban League's Executive Leadership Team have reviewed the recommendations. In response to the recommendation, we have outlined the action items to support implementation. A review and update of our Financial Policies and Procedures and the Finance Manual is scheduled for completion by year-end. Simultaneously, as we deploy innovative technology to streamline operations and drive efficiencies, we will document workflow procedures to ensure compliance and controls. A key element to defining the written procedures will be the validation of process controls. The target date for completion is December 31 , 2024. As we analyze organizational changes that will ensure the adherence to the recommendations, we are assured that the finance team is knowledgeable of their respective roles and responsibilities to adequately perfonn duties. In response to the recommendations related to the Schedule of Expenditures of Federal A wards, (SEF A) we have designated a Grants Analyst who is responsible for ensuring the adhering to SEFA requirements as a component of the month-end closing process. We will also reference SEF A for recording of journal entries and the reconciliation process. Lastly, the Finance Department will also establish reviews with the Board of Directors ' Audit Committee and Finance Committee to simulate a high-level audit process. This review should support the identification of potential areas of concern for immediate resolution.

View Audit 323231

Finding 500927 (2023-001)

Material Weakness 2023

Coquille Watershed Association

OR

Material Weakness Internal Control / Segregation of Duties

Views of Responsible Officials and Planned Corrective Actions - We agree with this finding. CoqWA was successful in hiring an Executive Director in 2023, and an Office Manager in 2024 who provides bookkeeping services. Training was provided to both employees, and CoqWA will continue to schedule trai...

Views of Responsible Officials and Planned Corrective Actions - We agree with this finding. CoqWA was successful in hiring an Executive Director in 2023, and an Office Manager in 2024 who provides bookkeeping services. Training was provided to both employees, and CoqWA will continue to schedule trainings for new staff with an emphasis on accrual accounting for the Office Manager who performs the bookkeeping function.

View Audit 323230

Finding 500925 (2023-001)

Material Weakness 2023

City of Seymour

IN

Procurement, Suspension & Debarment § 200.303 § 200.317 § 200.318 § 200.319 § 200.320

Management will develop, adopt and implement a procurement policy for federal purchases that aligns with the requirement of the 2 CFR 200 Uniform Guidance. This process will include steps within the interview and application process to ensure contractors and subrecipients are eligible (not suspended...

Management will develop, adopt and implement a procurement policy for federal purchases that aligns with the requirement of the 2 CFR 200 Uniform Guidance. This process will include steps within the interview and application process to ensure contractors and subrecipients are eligible (not suspended, debarred, or otherwise excluded) to enter into an agreement, contract, or subaward with the City. The process will also include steps to ensure all necessary language, such as the Buy America Build America Provisions are included in the final contracts.

View Audit 323228

Finding 500918 (2023-003)

Significant Deficiency 2023

Search for Common Ground

DC

Procurement, Suspension & Debarment Subrecipient Monitoring

2023-003 Internal Control over Compliance and Compliance with Procurement, Suspension and Debarment Contact: Wajid Ali Title: Senior Manager Internal Policies and Compliance Phone Number: (202) 777-2297 Estimated Completion Date: June 30, 2025 Corrective Action Plan: We Agree with the fin...

2023-003 Internal Control over Compliance and Compliance with Procurement, Suspension and Debarment Contact: Wajid Ali Title: Senior Manager Internal Policies and Compliance Phone Number: (202) 777-2297 Estimated Completion Date: June 30, 2025 Corrective Action Plan: We Agree with the finding that background checks were done after the agreement date and before payment in few cases, during late 2023 and early 2024, we have rolled out a Global Procurement system (google sheet based internal workflow package) that is designed to mandate procurement steps in a systematic manner. This is already helping us streamline procurement in major countries. This system is planned to be fully rolled out by the Second Quarter of 2025 and is currently implemented in about half of the countries and 4 other countries will be included by end of 2024. This will enable us to complete the background checks before entering any commitment.

View Audit 323222

Finding 500905 (2023-002)

Significant Deficiency 2023

Search for Common Ground

DC

Cash Management

2022-002 Internal Control over Compliance and Compliance with Cash Management Contact: Karishma Borgohain-Menta Title: Senior Manager, HQ Accounting Phone Number: (202) 777-2297 Estimated Completion Date: December 31, 2024 Corrective Action Plan: Majority of the projects with the US gover...

2022-002 Internal Control over Compliance and Compliance with Cash Management Contact: Karishma Borgohain-Menta Title: Senior Manager, HQ Accounting Phone Number: (202) 777-2297 Estimated Completion Date: December 31, 2024 Corrective Action Plan: Majority of the projects with the US government where search is prime implementer, are on monthly drawdown based on field office projections. We typically spend these funds within a reasonable time. However, Projects where SFCG is not the prime recipient have quarterly advance arrangements with Prime recipients and therefore liquidation typically takes approximately the same time. Search have not kept that money in interest bearing account. Guidance identified by the auditors is well noted and we will convert our non-interest-bearing accounts into interest-bearing accounts. Any interest earned will be reported as program income in the respective award.

View Audit 323222

Finding 500498 (2023-002)

Material Weakness 2023

Icahn School of Medicine at Mount Sinai

NY

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

Identification on the Federal Program: Grantor: Department of Education Program Name: Federal Direct Student Loans Assistance Listing No.: 84.268 Views of responsible officials and planned corrective actions: The School’s Office of Student Financial Services has instituted comprehensive processes a...

Identification on the Federal Program: Grantor: Department of Education Program Name: Federal Direct Student Loans Assistance Listing No.: 84.268 Views of responsible officials and planned corrective actions: The School’s Office of Student Financial Services has instituted comprehensive processes and controls to ensure a timely review and submission of the FISAP, in accordance with the U.S. Department of Education’s FISAP instructions. The specific procedures will be documented in the School’s manual. With these protocols in place, we will adhere to the regulations set forth by the U.S. Department of Education. Name of responsible official: LaVerne Walker Director of Student Financial Services laverne.walker@mssm.edu Projected completion date: - September 26, 2024: Completed implementation of FISAP completion and signature submission. - October 7, 2024: Complete revision to procedure manual

View Audit 323221

Finding 500457 (2023-001)

Material Weakness 2023

Icahn School of Medicine at Mount Sinai

NY

Procurement, Suspension & Debarment

Information on the federal program: Grantor: Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing No.: Multiple Views of responsible officials and planned corrective actions: The Mount Sinai Health System has implemented a corrective action that ...

Information on the federal program: Grantor: Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing No.: Multiple Views of responsible officials and planned corrective actions: The Mount Sinai Health System has implemented a corrective action that includes a monthly reconciliation to ensure that all vendors are screened against various state and federal lists/registries checking for excluded, debarred and/or restricted vendors. The monthly process includes the generation of a file of all paid vendors are screened by Mount Sinai’s exclusion screening vendor OIG Compliance Now. Name of responsible official: Franco Sagliocca Corporate Director, Supply Chain Franco.sagliocca@mountsinai.org Projected completion date: The project was completed as of November 30, 2023. Completed process for generating a monthly file of paid vendors to submit to OIG Compliance Now for monthly screening against various state and federal lists/registries checking for excluded, debarred and/or restricted vendors

View Audit 323221

Finding 500456 (2023-001)

Significant Deficiency 2023

City of Lakewood

CO

The City agrees with the finding. Beginning

View Audit 323219

Finding 500456 (2023-001)

Significant Deficiency 2023

City of Lakewood

CO

immediately in 2024, an additional monthly review and reconciliation at the individual grant level will occur by the

View Audit 323219

Finding 500456 (2023-001)

Significant Deficiency 2023

City of Lakewood

CO

grant accountant. This process will include approval by the Controller or Accounting Supervisor. With this

View Audit 323219

Finding 500456 (2023-001)

Significant Deficiency 2023

City of Lakewood

CO

additional review, year-end efforts verifying late claims are in alignment with the general ledger, should be reduced.

View Audit 323219

Finding 500456 (2023-001)

Significant Deficiency 2023

City of Lakewood

CO

In turn, this will minimize the overall possibility of inconsistencies and ensure accurate and appropriate deferrals.

View Audit 323219

Finding 500455 (2023-003)

Material Weakness 2023

Housing Authority of the City of Greeley

CO

HUD Housing Programs

Management’s Response: Management will begin to comply with the applicable CFR regulations and begin annual reasonable rent determinations.

View Audit 323212

Finding 500454 (2023-002)

Significant Deficiency 2023

Housing Authority of the City of Greeley

CO

HUD Housing Programs Reporting Internal Control / Segregation of Duties

Management’s Response: Management will develop and install a journal voucher system which requires approval by a person other than the preparer.

View Audit 323212

Finding 500453 (2023-001)

Significant Deficiency 2023

Housing Authority of the City of Greeley

CO

Internal Control / Segregation of Duties HUD Housing Programs

Management’s Response: Management will adopt policies and procedures that will enhance the segregation of duties with the accounting functions.

View Audit 323212

Finding 500448 (2023-001)

Significant Deficiency 2023

Grady Memorial Hospital Corporation

GA

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

To: FY2023 Uniform Guidance Reporting Package From: Gina Smith, VP, Fiscal Service/Controller RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: 9/27/2024 Finding 2023-001 – Reporting Federal Program: Provider Relief Fund and American Rescue Plan Rural Distribution ALN: 93.498 Grady Memori...

To: FY2023 Uniform Guidance Reporting Package From: Gina Smith, VP, Fiscal Service/Controller RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: 9/27/2024 Finding 2023-001 – Reporting Federal Program: Provider Relief Fund and American Rescue Plan Rural Distribution ALN: 93.498 Grady Memorial Hospital Corporation’s (Grady) CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will revamp our controls and processes to include additional management review of the SEFA to include the prior of any submission and to provide evidence of the related review Grady’s corrective action plan: Grady Memorial Hospital Corporation has implemented a new review policy for the submissions of PRF reports which also includes a new reporting and review procedure that are performed by the Controller and Tax & Technical Accounting Manager. GMHC will implement controls and processes to ensure grant reports are reviewed prior to submission and that evidence of review is maintained within the timeline it was signed. Contact person/s responsible for the correction action: Gina Smith, VP, Fiscal Service/Controller Anticipated Completion Date: Grady Memorial Hospital Corporation has implemented controls and processes to ensure grant reports are reviewed prior to submission and that evidence of review is maintained.

View Audit 323207

Finding 500439 (2023-002)

Significant Deficiency 2023

Grady Memorial Hospital Corporation

GA

Reporting § 200.502 § 200.510

Finding 2023-002 Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Medicaid Assistance Program HIV Emergency Relief Project Grants ALN: 21.027 / 93.778 / 93.914 Grady Memorial Hospital Corporation’s CFO and VP of Fiscal Services/Controller have reviewed the reporting from K...

Finding 2023-002 Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Medicaid Assistance Program HIV Emergency Relief Project Grants ALN: 21.027 / 93.778 / 93.914 Grady Memorial Hospital Corporation’s CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will update our controls and processes to include additional review of expenses incurred during the relevant audit period. Grady’s corrective action plan: Going forward the SEFA will be reviewed to ensure that all related expenses for the audit period are incorporated. Contact person/s responsible for the corrective action: David Noble, Director, Grant Administration Anticipated Completion Date: Consistent with 2024 Financial Audit Reporting

View Audit 323207

Finding 500437 (2023-001)

Material Weakness 2023

City of Grandview

WA

Procurement, Suspension & Debarment § 200.318

Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). Procurement The City of Grandview will update our procurement policies to comply with federal procurement requirements. The p...

Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). Procurement The City of Grandview will update our procurement policies to comply with federal procurement requirements. The procurement policy update will include other required procedures for procuring transactions, such as contracting with small and minority business owners, women’s business enterprise and labor surplus area firms, domestic preferences, recovered materials, contract cost or price analysis and more. Going forward, the City will establish internal administrative controls to ensure that city staff receive the proper training and are aware of all procurement policies and guidelines. Suspension and Debarment The City of Grandview will establish internal controls on contract proposals exceeding $25,000, must be reviewed to ensure that contractors are not suspended or debarred. The City will verify this by adding a clause or condition into the contract that states the contractor is not suspended or debarred. The City will verify this before entering into a contract or purchasing goods and services, and it will maintain documentation demonstrating compliance with federal requirements.

View Audit 323206

Finding 500432 (2023-002)

Material Weakness 2023

Abused Adult Resource Center

ND

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Contact Person Michelle Erickson Corrective Action Plan The Abused Adult Resource Center’s payroll allocations for grants will be documented on timesheets and the hard copies will be filed or scanned onto a local drive kept by the Center. Completion Date Fiscal Year 2024

View Audit 323201 Questioned Costs: $1

Corrective Action Plans

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