Corrective Action Plans

Finding 499893 (2023-003)

Significant Deficiency 2023

OH

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

LMM agrees that 4 out of 40 tested non-payroll costs did not have evidence of approval for payment. While the payments were for contracted services that were received by LMM the written approval for payment was not able to be located. LMM has recently adopted Concur for expense management. With this...

LMM agrees that 4 out of 40 tested non-payroll costs did not have evidence of approval for payment. While the payments were for contracted services that were received by LMM the written approval for payment was not able to be located. LMM has recently adopted Concur for expense management. With this platform all approvals are required electronically and evidence of approval will be able to be submitted.

View Audit 322823

Finding 499888 (2023-002)

Significant Deficiency 2023

Lutheran Metropolitan Ministry

OH

Procurement, Suspension & Debarment § 200.303

LMM will ensure that documentation of the https://sam.gov/content/home Exclusions: Ineligible, Prohibition/Restriction search will be available for review. Each search will be completed as required with the results of the search printed and/or saved electronically for audit review. The report will s...

LMM will ensure that documentation of the https://sam.gov/content/home Exclusions: Ineligible, Prohibition/Restriction search will be available for review. Each search will be completed as required with the results of the search printed and/or saved electronically for audit review. The report will show the entity searched, the result of the search and the date of the search. The CFO will be responsible for maintaining these reports.

View Audit 322823

Finding 499887 (2023-003)

Material Weakness 2023

Noble County

IN

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

FINDING 2023-003 Finding Subject: Suspension and Debarment Summary of Finding: Due to the lack of effective internal controls, Suspension and Debarment requirements were not met during the audit period. Contact Person Responsible for Corrective Action: Shelley Mawhorter, County Auditor Contact Phone...

FINDING 2023-003 Finding Subject: Suspension and Debarment Summary of Finding: Due to the lack of effective internal controls, Suspension and Debarment requirements were not met during the audit period. Contact Person Responsible for Corrective Action: Shelley Mawhorter, County Auditor Contact Phone Number and Email Address: (260) 636-2658; shelley.mawhorter@nobleco.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Noble County Auditor’s office will implement effective internal controls in reference to Suspension and Debarment requirements related to subawards and covered transactions to ensure that one of the three allowable methods of verifying that a vendor is not suspended or debarred is completed prior to entering into the contract or transaction. Anticipated Completion Date: We will have the Corrective Action Plan implemented by December 31, 2024.

View Audit 322810

Finding 499886 (2023-001)

Significant Deficiency 2023

Skagit County Public Hospital District 2 D/b/a Island Health

WA

Procurement, Suspension & Debarment § 200.318 § 200.326

The Organization will document a procurement policy to ensure it fully complies with the Uniform Guidance requirements.

View Audit 322808

Finding 499885 (2023-002)

Significant Deficiency 2023

Special Health Resources for Texas, Inc.

TX

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

To ensure that the Sliding Fee Discount Form is being completed for all patients, the Revenue Cycle Manager will conduct new onsite trainings at all locations. The Revenue Cycle Manager will work closely with front line support staff, Clinic Managers, Director of Operations and the Director of Quali...

To ensure that the Sliding Fee Discount Form is being completed for all patients, the Revenue Cycle Manager will conduct new onsite trainings at all locations. The Revenue Cycle Manager will work closely with front line support staff, Clinic Managers, Director of Operations and the Director of Quality. They will conduct weekly audits to 5% of patient charts to ensure that the trainings are being successful.

View Audit 322795 Questioned Costs: $1

Finding 499883 (2023-002)

Material Weakness 2023

Montgomery County

MS

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

FINDING 2023-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Audit Finding: Material Weakness, Noncompliance Contact Person Responsible for Corrective Action: Mindy Byers Contact Phone Number: 765-364-6401 Contact Email Address: mindy.byers@montgomerycou...

FINDING 2023-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Audit Finding: Material Weakness, Noncompliance Contact Person Responsible for Corrective Action: Mindy Byers Contact Phone Number: 765-364-6401 Contact Email Address: mindy.byers@montgomerycounty.in.gov Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Auditor and her Chief Deputy completed the P&E report together. Moving forward, the Auditor will print the report and have the Chief Deputy sign off on the report prior to submission. Anticipated Completion Date: April 1, 2025. If applicable: Document reason issue will NOT be corrected within six months: The 2024 Project & Expenditure report is not due until April 1, 2025.

View Audit 322791

Finding 499882 (2023-001)

Material Weakness 2023

Montgomery County

MS

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2023-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Mindy Byers Contact Phone Number: 765-364-6401 Contact Email Address: mi...

FINDING 2023-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Mindy Byers Contact Phone Number: 765-364-6401 Contact Email Address: mindy.byers@montgomerycounty.in.gov Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Because the contracts are outside Auditor control, the Auditor has forwarded to county management to request a policy/internal control be created to be put in place. The County has adopted a Suspension and Debarment Policy in August 2023. A certification will be collected from the vendor in the current audit period. In addition, language regarding obtaining a certification that a vendor is not suspended or debarred has been added to the standard language in the contracts. Anticipated Completion Date: December 31, 2024

View Audit 322791

Finding 499881 (2023-002)

Significant Deficiency 2023

Jobs for America's Graduates

VA

Subrecipient Monitoring Reporting Significant Deficiency § 200.332

Management agrees with the recommendation and has added this report filing requirement to the grant onboarding checklist. The FFATA report was submitted and uploaded by the Director of Grants & Compliance on August 28 2024. This process will be overseen by the Director of Grants & Compliance and is...

Management agrees with the recommendation and has added this report filing requirement to the grant onboarding checklist. The FFATA report was submitted and uploaded by the Director of Grants & Compliance on August 28 2024. This process will be overseen by the Director of Grants & Compliance and is in place as of the date of this corrective action plan.

View Audit 322785

Finding 499880 (2023-001)

Material Weakness 2023

Mercy Haven Inc.

NY

Cash Management HUD Housing Programs Reporting

Material Weakness ? Internal Control over Compliance & Compliance Testing The Organization will reach out to HUD again to seek assistance to resolve the REAC system technical issues in order to move forward.

View Audit 322764

Finding 499878 (2023-002)

Significant Deficiency 2023

Augustana Lutheran Homes Inc. Dba: Gloria Dei Manor

MN

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Section 202 Direct Loan and Flexible Subsidy Assistance Loan Assistance No. 14.157 Security Deposits: The Project is required to maintain a separate security deposit cash account equal to or greater than the security deposit liability. The security deposit cash account was underfunded by $8,700 as o...

Section 202 Direct Loan and Flexible Subsidy Assistance Loan Assistance No. 14.157 Security Deposits: The Project is required to maintain a separate security deposit cash account equal to or greater than the security deposit liability. The security deposit cash account was underfunded by $8,700 as of December 31, 2023. Recommendation: All security deposit activity should be run through this account to ensure it is being properly utilized. Comparisons should be performed monthly to ensure the balance is maintained at a minimum equal to the security deposit liability. There is no disagreement with the audit finding. Action taken in response to finding: Management will continue to monitor the account to ensure properly funded. Management has transferred the $8,700 deficiency into the security deposit account on June 13, 2024. Name of the contact person responsible for corrective action: Cassandra Johnson Planned completion date for corrective action plan: June 13, 2024.

View Audit 322755

Finding 499871 (2023-004)

Material Weakness 2023

Fayette County

IN

Procurement, Suspension & Debarment § 200.317 § 200.319 § 200.320 § 200.327

Additional training and review of the procurement process will take place. This office will coordinate with other departments with training and expectations.

View Audit 322739

Finding 499868 (2023-005)

Material Weakness 2023

Fayette County

IN

County to develop plan to track expenditures of airport-generated revenue.

View Audit 322739

Finding 499867 (2023-002)

Material Weakness 2023

Thompson House Inc.

MA

Questioned Costs HUD Housing Programs Material Weakness

2023-002 Federal agency: Department of Housing and Urban Development Federal program: Section 811 - Supportive Housing for Persons with Disabilities CFDA Number: 14.181 Type of Finding: • Material Weakness in Internal Control over Compliance • Compliance – Material Criteria or Specific Requireme...

2023-002 Federal agency: Department of Housing and Urban Development Federal program: Section 811 - Supportive Housing for Persons with Disabilities CFDA Number: 14.181 Type of Finding: • Material Weakness in Internal Control over Compliance • Compliance – Material Criteria or Specific Requirement: The HUD regulatory agreement requires that surplus cash should be deposited into a residual receipts account within 60 days of year end. Condition: At December 31, 2023 the Project had surplus cash totaling $44,704 and the amount was not deposited into a residual receipts account. Questioned Costs. $44,704 Context: A computation of surplus cash was performed as of December 31, 2023 resulting in surplus cash of $44,704. Cause: Controls were not followed to ensure that surplus cash amounts were computed and transferred to a residual receipts account in a timely fashion. Effect: A timely deposit was not made to a residual receipts account. Repeat Finding: Yes, this is a repeat finding from 2020. Recommendation: A deposit of $44,704 should be made to the residual receipts account. Views of Responsible Officials and Corrective Action: Management intends to make a deposit of $44,704 to the residual receipts account within the next 30 days.

View Audit 322738 Questioned Costs: $1

Finding 499866 (2023-001)

Material Weakness 2023

Thompson House Inc.

MA

Questioned Costs HUD Housing Programs Material Weakness

Response for Correction of 2023-001: In March 2024, management deposited $69,000 into the Replacement Reserve. Management intends to deposit the $22,000 withing the next week. A monthly process has been established to insure that the monthly required deposits to the Replacement Reserve are made on ...

Response for Correction of 2023-001: In March 2024, management deposited $69,000 into the Replacement Reserve. Management intends to deposit the $22,000 withing the next week. A monthly process has been established to insure that the monthly required deposits to the Replacement Reserve are made on a current basis.

View Audit 322738 Questioned Costs: $1

Finding 499865 (2023-001)

Significant Deficiency 2023

Housing Authority of the City of Dothan

AL

HUD Housing Programs Subrecipient Monitoring Eligibility

2023-001 ALN 14.881 – Moving to Work Demonstration Program – Eligibility Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Samuel Crawford, Chief Executive Projec...

2023-001 ALN 14.881 – Moving to Work Demonstration Program – Eligibility Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Samuel Crawford, Chief Executive Projected Completion Date: December 31, 2024

View Audit 322737

Finding 499864 (2023-001)

None 2023

County of Tioga

NY

Eligibility Subrecipient Monitoring

In response to the finding that Medicaid expenses could potentially be paid to ineligible individuals whose citizenship status was not documented in the IDR system, the Unit supervisor, Julie Whipple, is working with the NYS Department of Health for the correct process to receive notifications when ...

In response to the finding that Medicaid expenses could potentially be paid to ineligible individuals whose citizenship status was not documented in the IDR system, the Unit supervisor, Julie Whipple, is working with the NYS Department of Health for the correct process to receive notifications when the verification does not flag a code but instead remains blank. Following the discussion with the auditors in June 2024, Supervisors immediately began monitoring for the cases that are not verifying in the IDR system and reaching out to the individuals for proof of citizenship.

View Audit 322726

Finding 499863 (2023-001)

Significant Deficiency 2023

Home Builders Care, Inc.

AZ

Procurement, Suspension & Debarment § 200.320

Home Builders Care, Inc. will update its procurement policy in accordance with the recommendations.

View Audit 322723

Finding 499862 (2023-004)

Significant Deficiency 2023

City of Reedsburg

WI

Procurement, Suspension & Debarment

Corrective Action Plan: When purchasing inventory materials that may be used in the ARPA projects, RUC purchasing staff will request certification from the vendor that they are not suspended or debarred from federally funded projects and also request material country of origin documentation or Build...

Corrective Action Plan: When purchasing inventory materials that may be used in the ARPA projects, RUC purchasing staff will request certification from the vendor that they are not suspended or debarred from federally funded projects and also request material country of origin documentation or Build America, Buy America (BABA) qualifications when receiving quotes. Planned Completion Date for the Corrective Action: On-going Contact Persons Responsible for the Corrective Action Plan: The following Reedsburg Utility staff members are responsible for items outlined above in the Corrective Action Plan: • Brett Schuppner, Reedsburg Utility General Manager • Ken Las, Communications System Supervisor

View Audit 322720

Finding 499861 (2023-003)

Significant Deficiency 2023

City of Reedsburg

WI

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

Corrective Action Plan: The Utility Commission General Manager or Communications System Supervisor will review the quarterly progress reports prepared by someone else. Section II of the Project Status Report instructions states “Answer each question to the best of your ability.” The work orders do...

Corrective Action Plan: The Utility Commission General Manager or Communications System Supervisor will review the quarterly progress reports prepared by someone else. Section II of the Project Status Report instructions states “Answer each question to the best of your ability.” The work orders do not include all costs related to labor benefits and taxes, and also the electronics and customer premise equipment associated with the projects. These costs are calculated and added in when the project is completed and is being closed out. Estimating these items for the quarterly Project Status Report is providing the project costs spent through the respective quarter to the best of our ability due to the limitations of the work order reporting process. Planned Completion Date for the Corrective Action: On-going Contact Persons Responsible for the Corrective Action Plan: The following Reedsburg Utility staff members are responsible for items outlined above in the Corrective Action Plan: • Brett Schuppner, Reedsburg Utility General Manager • Ken Las, Communications System Supervisor

View Audit 322720

Finding 499859 (2023-001)

Significant Deficiency 2023

County of Clarion

PA

Questioned Costs Subrecipient Monitoring § 200.332

CORRECTIVE ACTION PLAN September 26, 2024 Clarion County respectfully submits the following corrective action plan for the year ending December 31, 2023. MaherDuessel 503 Martindale Street, Suite 600 Pittsburgh, PA 15212 Audit period: January 1, 2023 to December 31, 2023 The finding from the sched...

CORRECTIVE ACTION PLAN September 26, 2024 Clarion County respectfully submits the following corrective action plan for the year ending December 31, 2023. MaherDuessel 503 Martindale Street, Suite 600 Pittsburgh, PA 15212 Audit period: January 1, 2023 to December 31, 2023 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Finding 2023-001 Subrecipient Monitoring U.S. Department of Health and Human Services, Foster Care Title IV-E - ALN 93.658 Recommendation: We recommend that procedures be implemented to ensure all subrecipients are notified of subawards and implement a process to ensure all subrecipients audits are reviewed and deficiencies be followed up on. In addition, we recommend implementation of procedures to formally document and complete a risk assessment of subrecipients. Based on the risk assessment performed, the County should develop monitoring procedures to address the risks noted, which should be include a documented review of subrecipients audits. Action Taken: The Children and Youth Agency will require that all placement providers (all providers who have to potential to receive federal funds) submit their latest audit for review. We will develop a risk assessment tool with the help of our auditors and document the results. The agency will also develop a letter to notify those providers of any federal funds that they may have received for the fiscal year, the letter will be sent no later than October 31st.

View Audit 322718 Questioned Costs: $1

Finding 499858 (2023-003)

Material Weakness 2023

County of Mifflin

PA

Reporting Internal Control / Segregation of Duties

Finding 2023-003: Emergency Rental Assistance Program (ERAP). Contact Person: Jenaya L. Mellinger, Director of Fiscal Affairs. Recommendation: The County should establish internal controls procedures over reporting requirements. Response: The County agrees with the finding and will work with the Hum...

Finding 2023-003: Emergency Rental Assistance Program (ERAP). Contact Person: Jenaya L. Mellinger, Director of Fiscal Affairs. Recommendation: The County should establish internal controls procedures over reporting requirements. Response: The County agrees with the finding and will work with the Human Services Director and Human Services Financial Manager to revise and, where necessary, establish procedures to insure proper approval by all required parties prior to submission of said reports. Action Planned: Post-audit submission, the County Director of Fiscal Affairs will meet and discuss with the Human Services Director and Human Services Financial Manager all upcoming reporting requirement, and implement reporting procedures that require multiple signatures and approvals, including those required under the reporting guidelines and requirements, and the initials of the County Director of Fiscal Affairs, prior to submission of the subject reports. Date for Completion: December 31, 2024.

View Audit 322717

Finding 499854 (2023-002)

Material Weakness 2023

County of Mifflin

PA

Cash Management Matching / Level of Effort / Earmarking

Finding 2023-002: Cash Management / Matching / Interest Earned. Contact Person: Jenaya L. Mellinger, Director of Fiscal Affairs. Recommendation: The County should establish a separate fund to account for the activity of the Children and Youth program. Response: The County agrees with the finding and...

Finding 2023-002: Cash Management / Matching / Interest Earned. Contact Person: Jenaya L. Mellinger, Director of Fiscal Affairs. Recommendation: The County should establish a separate fund to account for the activity of the Children and Youth program. Response: The County agrees with the finding and will create a new fund – Fund 07 – in the County’s accounting software and will begin creating corresponding revenue and expense accounts to match the existing structure within the new fund. The County also opened a separate checking account at The Juniata Valley Bank for the Children and Youth Fund for all revenue and expenses beginning January 1, 2025. The County continues to engage an external third-party contractor provider familiar with Children and Youth Agency financial matters to assist in the transition, as well as with recent turnover in the financial positions within the Children and Youth Department. The County also made the affirmative decision to capitalize that fund with the prior year’s County-match at the start of the calendar year and continue to fund, as needed, throughout the year to insure the necessary County match is attained. The Children and Youth Agency will continue to insure compatibility and proper recording in MUNIS, the County accounting system, of all financial transactions to match with the internal accounting system maintained by the Children and Youth Agency. Action Planned: Post-audit submission, the County Director of Fiscal Affairs will meet and discuss with the engaged external service provider and the Children and Youth Finance Director and overall Child and Youth Agency Director to formulate the proper procedure for establishment of a separate fund balance as of January 1, 2025, and monitor proper posting of financial transactions in the appropriate fund to match all transactions posted in the internal accounting system maintained by the Children and Youth Agency. Date for Completion: January 1, 2025.

View Audit 322717

Finding 499853 (2023-003)

Material Weakness 2023

Montana Alliance of Boys & Girls Clubs, Inc.

MT

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303 § 200.332

Individual Responsible for Corrective Action Plan: Alliance Director – Brian Dennis Corrective Action: The Organization will enhance its procedures and internal controls with respect to monitoring over subrecipient activities and reimbursement payments by working with the State of Montana grantor t...

Individual Responsible for Corrective Action Plan: Alliance Director – Brian Dennis Corrective Action: The Organization will enhance its procedures and internal controls with respect to monitoring over subrecipient activities and reimbursement payments by working with the State of Montana grantor to ensure local clubs are using subawards for authorized purposes. Anticipated Completion Date: December 31, 2024

View Audit 322714

Finding 499852 (2023-002)

Significant Deficiency 2023

Montana Alliance of Boys & Girls Clubs, Inc.

MT

Questioned Costs Subrecipient Monitoring Cash Management § 200.305 § 200.332

Individual Responsible for Corrective Action Plan: Alliance Director and staff – Brian Dennis Corrective Action: The Organization will enhance its procedures and internal controls with respect to monitoring over subrecipient activities and reimbursement payments by working with the State of Montana...

Individual Responsible for Corrective Action Plan: Alliance Director and staff – Brian Dennis Corrective Action: The Organization will enhance its procedures and internal controls with respect to monitoring over subrecipient activities and reimbursement payments by working with the State of Montana grantor to ensure local clubs are using subawards for authorized purposes. Anticipated Completion Date: December 31, 2024

View Audit 322714 Questioned Costs: $1

Finding 499850 (2023-001)

None 2023

Montana Alliance of Boys & Girls Clubs, Inc.

MT

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.414 § 200.502

Individuals Responsible for Corrective Action Plan: BGCA Fiscal Team – Shelby Mahoney, Senior Accounting Manager Corrective Action: Alliance team will enhance procedures and internal controls with respect to preparation and review of the SEFA by reviewing detail of expenses included in prior year w...

Individuals Responsible for Corrective Action Plan: BGCA Fiscal Team – Shelby Mahoney, Senior Accounting Manager Corrective Action: Alliance team will enhance procedures and internal controls with respect to preparation and review of the SEFA by reviewing detail of expenses included in prior year with current year expenses, to prevent duplicate entries being reported. Anticipated Completion Date: December 31, 2024

View Audit 322714

Corrective Action Plans

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