Corrective Action Plans

Finding 480512 (2023-001)

Material Weakness 2023

PA

The Authority Manager did not disclose the grant receivable as it was not yet received at the end of 2023 and should have been booked as an accrual and not a cash basis receipt. The Manager will ensure that going forward items are booked based on the accrual and not the cash basis.

View Audit 316706

Finding 480511 (2023-002)

Significant Deficiency 2023

Southwest Ohio Regional Transit Authority

OH

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring

Views of Responsible Official: The Project Grant Administrator did prepare and submit the FRA quarterly reports. This person was the official reviewer of the project progress for the FRA quarterly report submission. The financial information for the report was first compiled by the Capital Project...

Views of Responsible Official: The Project Grant Administrator did prepare and submit the FRA quarterly reports. This person was the official reviewer of the project progress for the FRA quarterly report submission. The financial information for the report was first compiled by the Capital Projects and Grant Tracking (CPGT) Administrator Accountant. (Note that CPGT is reconciled with CODA, the SORTA accounting system, before this information is provided.) The Project Grant Administrator received project implementation information from the Construction Project Manager. The Grant Administrator married this information with what was provided by the CPGT Administrator/Accountant, as well as what was in Maximo (the SORTA procurement system), The Project Grant Administrator also visited the project site to verify progress of the FRA project(s) when needed. The final quarterly reports were used by the Director of Grants as well as FRA to keep up with the implementation progress of the project(s). Any actual draw down of funding for the project was prepared separately by the CPGT Administrator/Accountant and signed off by the Director of Accounting. We concur with the finding that the FFATA report for reporting of an award to a subrecipient above a certain dollar threshold was submitted in November of 2023, which was after the regulatory date for submission. Description of Corrective Action Plan: The Federal Railroad Administration (FRA) CRISI Grant- that this finding relates to has been completed and is now closed. Thus, there will not be any further Quarterly reports prepared or submitted under this particular Grant. And, it is not anticipated that SORTA will be administering any other FRA CRISI Grants in the foreseeable future. In relation to the FFATA reporting, the Grants Department will add the FFATA reporting requirements to the Grants Processes and Procedures so that should SORTA encounter a grant subrecipient situation with a future grant, Grants staff will have a reminder and reference to help ensure the reporting requirements are performed in a timely manner. Responsible Party and Timeline for Completion: Federal regulation requires name and title of person overseeing corrective action plan and anticipated completion date. The Director or Grants, Mary Huller, will complete the modification to the Processes and Procedures to include FFATA reporting requirements by the end of August 2024.

View Audit 316703

Finding 480510 (2023-001)

Significant Deficiency 2023

Montgomery County Housing Authority

TX

HUD Housing Programs Special Tests & Provisions Significant Deficiency

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority has updated the practice to follow the HUD compliance supplement. Amanda Bone, Chief Executive Officer, is responsible for implementing this corrective action by Dece...

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority has updated the practice to follow the HUD compliance supplement. Amanda Bone, Chief Executive Officer, is responsible for implementing this corrective action by December 31, 2024.

View Audit 316701

Finding 480509 (2023-003)

Significant Deficiency 2023

City of Syracuse, New York

NY

Procurement, Suspension & Debarment

The City is actively developing improved processes and procedures around procurement, including reviewing the current process and identifying potential technology enhancements. The City is currently in the process of revising the procurement manual to establish a standard process. Additionally, the ...

The City is actively developing improved processes and procedures around procurement, including reviewing the current process and identifying potential technology enhancements. The City is currently in the process of revising the procurement manual to establish a standard process. Additionally, the City is undergoing additional training for all employees involved in the procurement process.

View Audit 316698

Finding 480508 (2023-001)

Material Weakness 2023

County of Adams

PA

Reporting Internal Control / Segregation of Duties

The County should implement internal control procedures to ensure the Project and Expenditure Report is properly reviewed prior to submission. Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The County of Adams has developed and imp...

The County should implement internal control procedures to ensure the Project and Expenditure Report is properly reviewed prior to submission. Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The County of Adams has developed and implemented a process to ensure all respective reports submitted to the respective granting agency reflect accurate amounts in the period of benefit as of July 2024.

View Audit 316697

Finding 480498 (2023-001)

Significant Deficiency 2023

The Link

MN

Significant Deficiency Internal Control / Segregation of Duties

The Link updated RRH policies and procedures Manual to include: i. Updated Housing Identification Section (Page 9) to reflect that rent reasonableness will be conducted prior to lease signing. ii. Updated Rent Reasonableness form to match policy. Determine whether the rent charged for the unit rec...

The Link updated RRH policies and procedures Manual to include: i. Updated Housing Identification Section (Page 9) to reflect that rent reasonableness will be conducted prior to lease signing. ii. Updated Rent Reasonableness form to match policy. Determine whether the rent charged for the unit receiving rental assistance is reasonable in relation to rents being charged for comparable units. Complete Rent Reasonableness Form using 3 comparable apartments (Appendix F). iii. Attach printouts from the 3 comparable units. • One of the units must be for the same owner to ensure reasonable rent will not exceed rents currently being charged by the same owner for Name of Contact Person: Pheng Vang, Finance Director, pvang@thelinkmn.org, 612-767-4468 Anticipated Completion Date: September 25, 2023

View Audit 316696

Finding 480497 (2023-002)

Significant Deficiency 2023

Shawano County, Wisconsin

WI

Cash Management Internal Control / Segregation of Duties

Finding 2023-002 AL No. 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Agency U.S. Department of Treasury Pass-through Agency Not applicable Award Number / Year 2023 Department Shawano County Department of Finance Criteria: The Uniform Guidance and State Single Audit Gui...

Finding 2023-002 AL No. 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Agency U.S. Department of Treasury Pass-through Agency Not applicable Award Number / Year 2023 Department Shawano County Department of Finance Criteria: The Uniform Guidance and State Single Audit Guidelines require that local entities receiving federal and state awards establish and maintain internal control designed to reasonably ensure compliance with laws, regulations and program compliance requirements. The Uniform Guidance and State Single Audit Guidelines further require auditors to obtain an understanding of the local entity's internal control over federal and state programs. To minimize the risk of errors, internal controls should be in place for all program compliance requirements, including the preparation and submission of monthly reports, which should be reviewed and approved by a responsible party other than the original preparer before they are submitted to the granting agency. Condition/Context: During our testing, it was noted that the 2023 project and expenditure report was not reviewed by an independent person before submission for reimbursement. Our sample was not statistically valid. Cause: The county did not have internal control procedures in place requiring an independent person to review the reports before submission to ensure the report was accurate. Questioned Costs: None noted. Effect: Reports submitted could contain errors. Recommendation: We recommend that an employee other than the preparer review all reports before they are submitted to grantors. Management’s Response: Internal guidance has been provided to all departments for documented reviews of compliance requirements. An update will be made to the financial policy.

View Audit 316691

Finding 480494 (2023-001)

None 2023

Children First Community Homes and Services, INC

FL

Subrecipient Monitoring Reporting § 200.512

VIEWS OF RESPONSIBLE OFFICIALS & CORRECTIVE ACTION PLAN: Management will begin the single audit process as soon as possible when the books close. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The Organization ...

VIEWS OF RESPONSIBLE OFFICIALS & CORRECTIVE ACTION PLAN: Management will begin the single audit process as soon as possible when the books close. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The Organization will implement the recommendation. Officials Responsible for Ensuring CAP: The Organization’s appointed staff member is the official responsible for ensuring corrective action. Planned Completion Date for CAP: The planned completion date for the CAP is June 30, 2024. Plan to Monitor Completion of CAP: The Board of Directors will be monitoring this corrective action plan.

View Audit 316682

Finding 480493 (2021-001)

Significant Deficiency 2023

New Mexico Rural Water Association

NM

Procurement, Suspension & Debarment Cash Management Internal Control / Segregation of Duties

It is management's policy to update and distribute travel reimbursement forms with new mileage and per diem rates the first of each calendar year, and at any other time the rates may change. Federal per diem and travel rates will be verified on a monthly basis to ensure that the most current rates a...

It is management's policy to update and distribute travel reimbursement forms with new mileage and per diem rates the first of each calendar year, and at any other time the rates may change. Federal per diem and travel rates will be verified on a monthly basis to ensure that the most current rates are being used. Formulas in travel vouchers will be checked to make sure that they have not been changed and that they calculate properly. A staff person will review all travel vouchers to verify that rates and calculations are correct prior to the vouchers being paid.

View Audit 316679

Finding 480492 (2023-003)

Material Weakness 2023

County of Scott

IL

Internal Control / Segregation of Duties

Recommendation: Procedures should be implemented to segregate duties where possible including a cross training or rotating of job duties to ensure one person does not have complete unsupervised control over one particular area. Action Taken: We concur with the recommendation, and we will begin th...

Recommendation: Procedures should be implemented to segregate duties where possible including a cross training or rotating of job duties to ensure one person does not have complete unsupervised control over one particular area. Action Taken: We concur with the recommendation, and we will begin this process immediately. This implementation process will be ongoing.

View Audit 316673

Finding 480491 (2023-001)

Significant Deficiency 2023

Lantern Organization, Inc.

NY

Procurement, Suspension & Debarment Significant Deficiency

Ensure that the Organization's tenant compliance policies are strictly adhered to, complying with FHA Guidance and that proper procurement documentation maintained.

View Audit 316666

Finding 480490 (2023-001)

Material Weakness 2023

Lorna Doone Associates, LLC

UT

HUD Housing Programs

a. An inspection will be held at least two times per year (semi-annual inspection).

View Audit 316665

Finding 480486 (2023-002)

Significant Deficiency 2023

Richland Medical Center, Inc. D/b/a Central Ozarks Medical Center

MO

Allowable Costs / Cost Principles HUD Housing Programs Matching / Level of Effort / Earmarking § 200.430

Item 2023-002 - Activities Allowed and Unallowed Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that all labor reports are reviewed and show formal approval before payroll is submitted. Repeat Finding No Action Taken As of July 20...

Item 2023-002 - Activities Allowed and Unallowed Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that all labor reports are reviewed and show formal approval before payroll is submitted. Repeat Finding No Action Taken As of July 20, 2024, we have added the Payroll Summary by grant to the grant draw down packet. In addition, we have changed the procedure to reflect that the payroll summary must have either the CFO and/or CEO approval signature prior to grant draw. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Sabrina McAfee, CFO at (573) 836-7079.

View Audit 316663

Finding 480482 (2023-001)

Significant Deficiency 2023

Richland Medical Center, Inc. D/b/a Central Ozarks Medical Center

MO

Special Tests & Provisions Subrecipient Monitoring Eligibility

Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health...

Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program and COVID-19 Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Item 2023-001- Special Tests Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken As of May 1, 2023, the Director of Revenue and/or designee runs a slide fee report daily the reflects everyone that applied the day before. Billing personnel separate the report and audit the files to ensure the correct slide has been applied. The paper application is forwarded to the billing department for a third audit if the application is in order and has been uploaded into the patients' files and then it is manually filed. The CFO will perform random audits and will present to the Board and CEO a quarterly report with the results. In addition, As of July 1, 2023, the Access Coordinators who normally collect and process the slide fee discount program applications are now reporting to the finance department with the Director of Revenue supervising and training staff. In addition, there will now be a Lead Access Coordinator in very clinic that will audit and perform additional training where necessary.

View Audit 316663

Finding 480465 (2023-001)

Material Weakness 2023

Arbor Place INC

WI

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

We recommend Arbor Place to implement internal controls over reporting and allowable costs to ensure all financial records are complete and accurate.

View Audit 316660

Finding 480460 (2023-001)

Significant Deficiency 2023

American Physical Society

MD

Subrecipient Monitoring § 200.303 § 200.331 § 200.332 § 200.521

In June 2023, following the completion of the 2022 Single Federal Audit, APS immediately implemented additional policies, procedures, and controls to ensure that all subrecipients submit programmatic and financial reports in a timely manner and that these reports are reviewed by the Principal Invest...

In June 2023, following the completion of the 2022 Single Federal Audit, APS immediately implemented additional policies, procedures, and controls to ensure that all subrecipients submit programmatic and financial reports in a timely manner and that these reports are reviewed by the Principal Investigator/Program Manager and Grant Administrator through a new reporting form. This form logs electronic signatures from both the sub-awardee and APS staff. In addition, APS implemented a procedure to review the single federal audit of each sub-awardee annually. APS will review and monitor award amounts and for the required filings annually to ensure that the award amounts are accurate and updated timely to meet all reporting requirements set forth under the Transparency Act. APS implemented the corrective action plan on June 5, 2023. Management's contact responsible for the implementation of the Corrective Action Plan: Name: Jane Hopkins Gould Position: Chief Financial & Operating Officer Telephone number: 301-209-3276

View Audit 316657

Finding 480458 (2023-003)

Significant Deficiency 2023

Placer Hills Union School District

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Cash Management

The District will review the CNIPS report going forward and maintain the necessary supporting documentation of approvals.

View Audit 316649

Finding 480453 (2023-002)

Material Weakness 2023

Placer Hills Union School District

CA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

The district will ensure that all federally paid employees have a supporting and accurate Federal Time Certification record.

View Audit 316649 Questioned Costs: $1

Finding 480451 (2023-010)

Significant Deficiency 2023

People (projects to Empower & Organ Psychiatrically Labeled), Inc.

NY

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Significant Deficiency

Per the Organizations fiscal policies and procedures all purchase orders/credit card payments or cash payment forms are to be signed by supervisor and CFO noting approval of expenses. Payroll registers are reviewed and signed by the CFO. Statement of Concurrence or Nonconcurrence: Concur Corrective ...

Per the Organizations fiscal policies and procedures all purchase orders/credit card payments or cash payment forms are to be signed by supervisor and CFO noting approval of expenses. Payroll registers are reviewed and signed by the CFO. Statement of Concurrence or Nonconcurrence: Concur Corrective Action: All Check Requests for rents will be signed by supervisor and CFO. All other bill payments will be approved and signed off by the CFO. Payroll Registers will be reviewed and approved via email by the CFO. Fiscal Policy and procedures manual will be reviewed, revised and updated to meet current operations and processes and responsibilities. These policies will also include PII policy and annual self-assessment. Responsible Person to Oversee Corrective Action Plan: George Thomas Chief Financial Officer 845-452-2728 ext. 224 Date Corrective Plan will be put in Place: Starting today immediately June 13, 2024

View Audit 316636

Finding 480450 (2023-009)

Significant Deficiency 2023

People (projects to Empower & Organ Psychiatrically Labeled), Inc.

NY

Reporting Significant Deficiency

Per grant contract for Covid Peer Vaccine Education Organization was required to submit quarterly report detailing analyzing the quantitative aspects of the program. Statement of Concurrence or Nonconcurrence: Concur Corrective Action: Organization will create a better overall system of tracking all...

Per grant contract for Covid Peer Vaccine Education Organization was required to submit quarterly report detailing analyzing the quantitative aspects of the program. Statement of Concurrence or Nonconcurrence: Concur Corrective Action: Organization will create a better overall system of tracking all contracts and grants with reporting periods reviewed timely. We will also submit quarterly expenditure reports when they are due to the Office of Mental Health. Responsible Person to Oversee Corrective Action Plan: George Thomas Chief Financial Officer 845-452-2728 ext. 224 Date Corrective Plan will be put in Place: Starting today immediately June 13, 2024

View Audit 316636

Finding 480447 (2023-008)

Material Weakness 2023

People (projects to Empower & Organ Psychiatrically Labeled), Inc.

NY

Material Weakness Period of Performance

Organization submitted expenses outside of period of performance and was unable to provide proof of extension. Statement of Concurrence or Nonconcurrence: Concur Corrective Action: Although we did receive information via email and phone conversations intimating that extension for said grant was immi...

Organization submitted expenses outside of period of performance and was unable to provide proof of extension. Statement of Concurrence or Nonconcurrence: Concur Corrective Action: Although we did receive information via email and phone conversations intimating that extension for said grant was imminent, we will no longer continue to submit expenses without documented approval for extension in writing. We will also ensure that all expenses for said contracts will be posted to proper period so that we will comply Responsible Person to Oversee Corrective Action Plan: George Thomas Chief Financial Officer 845-452-2728 ext. 224 Date Corrective Plan will be put in Place: Starting today immediately June 13, 2024

View Audit 316636

Finding 480446 (2023-007)

Significant Deficiency 2023

People (projects to Empower & Organ Psychiatrically Labeled), Inc.

NY

Reporting Significant Deficiency

Controls over Records Per the Westchester County Contract the Organization did not keep individual records of program participants Statement of Concurrence or Nonconcurr nce: Concur 1. Corrective Action: Team Leader Chris Rivera will review all notes on a weekly basis and sign off on documentation a...

Controls over Records Per the Westchester County Contract the Organization did not keep individual records of program participants Statement of Concurrence or Nonconcurr nce: Concur 1. Corrective Action: Team Leader Chris Rivera will review all notes on a weekly basis and sign off on documentation after review. 2. Best practice standards are that notes should be entered by the end of the next business day for the previous day's encounters. 3. The deadline for notes to be entered for the previous week's encounters is Monday at noon. If staff have not completed notes by Monday morning, they are mandated to complete notes prior to leaving the office for visits and other staff members will help with coverage needs. 4. Staff will identify an hour on their schedule daily to stay up to date on documentation. 5. The Program Assistant will run a monthly report of open participants in the Westchester Crisis Stabilization Team program on the last day of every month. Inactive participants or discharges will be completed at the time of discharge. Review of the monthly open participants will ensure that any inactive participants are quickly identified, and proper discharge process will occur by the 5th of every month. 6. Current caseload rosters will be provided to team members and Team Leader for review and printed out by Program Assistant by the 1st of every month. 7. Program Assistant will provide an update of completed discharges to the Team Leader upon completing discharge. 8. Quarterly waste, fraud, abuse audits will be completed by Quality Assurance and the Team Leader 9. Routine monthly audits of 2 charts at random will be completed by the Team Leader Responsible Person to Oversee Corrective Action Plan: Tammy Robson Assistant Executive Director 845-264-7399 Christopher River Westchester Crisis Stabilization Team Date Corrective Plan will be put in Place: Corrective action measures are currently being implemented and will be in effect as of 7/1/24. Chart audits and discharges of inactive participants will be completed by 7/15/24.

View Audit 316636

Finding 480443 (2023-006)

Material Weakness 2023

People (projects to Empower & Organ Psychiatrically Labeled), Inc.

NY

Reporting Material Weakness

Organization was unable to provide Schedule of Expenditures of Federal Awards (SEFA) Statement of Concurrence or Nonconcurrence: Concur Corrective Action: We were unaware of the responsibility to provide this and did not know the origin of all grants received. Due to the information learned we are n...

Organization was unable to provide Schedule of Expenditures of Federal Awards (SEFA) Statement of Concurrence or Nonconcurrence: Concur Corrective Action: We were unaware of the responsibility to provide this and did not know the origin of all grants received. Due to the information learned we are now aware and have taken measures to inquire about the origin of all grants received going forward. With the help of the newly hired compliance officer, we will not have such a finding again because we will track revenues and expenditures for all grants prominently federal awards when they are received and spent to properly record them on the SEFA Responsible Person to Oversee Corrective Action Plan: George Thomas Chief Financial Officer 845-452-2728 ext. 224

View Audit 316636

Finding 480441 (2023-002)

Material Weakness 2023

The Association of Brewers, Inc. Dba Brewers Association, Inc.

CO

Procurement, Suspension & Debarment

Foreign Market Development Cluster – Assistance Listing No. 10.601 and 10.618 Recommendation: We recommend that the Organization revise its procurement process so that procurement procedures apply to all transactions using thresholds and procurement methods specified by federal regulations, and mai...

Foreign Market Development Cluster – Assistance Listing No. 10.601 and 10.618 Recommendation: We recommend that the Organization revise its procurement process so that procurement procedures apply to all transactions using thresholds and procurement methods specified by federal regulations, and maintain documentation required by such regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Brewers Association will work with their contracted third-party, Bryant Christie Inc., to document the procurement method followed and maintain documentation required prior to vendor selection and claim submission. Name of the contact person responsible for corrective action: Drew Rosanova Planned completion date for corrective action plan: August 2024

View Audit 316631

Finding 480439 (2023-001)

Material Weakness 2023

The Association of Brewers, Inc. Dba Brewers Association, Inc.

CO

Procurement, Suspension & Debarment

Foreign Market Development Cluster – Assistance Listing No. 10.601 and 10.618 Recommendation: We recommend that the Association maintain evidence of suspension and debarment procedures to support compliance with federal regulations and to ensure that all potential vendors are not suspended or debar...

Foreign Market Development Cluster – Assistance Listing No. 10.601 and 10.618 Recommendation: We recommend that the Association maintain evidence of suspension and debarment procedures to support compliance with federal regulations and to ensure that all potential vendors are not suspended or debarred. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Brewers Association will work with their contracted third-party, Bryant Christie Inc., to document verification of good standing prior to vendor selection and claim submission. Name of the contact person responsible for corrective action: Drew Rosanova Planned completion date for corrective action plan: August 2024

View Audit 316631

Corrective Action Plans

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