Corrective Action Plans

Finding 479582 (2023-001)

Material Weakness 2023

CT

Special Tests & Provisions Subrecipient Monitoring Eligibility

To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2023 The findings from the October 31, 202...

To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2023 The findings from the October 31, 2023, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Federal Award Findings: Finding 2023.001 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken We will invest the time and resources into improving all areas related to the Sliding Fee Scale. We will implement the following steps to our process to ensure all federal guidelines and requirements are met. 1. Documented Process: Design and implement an internal control process to ensure sliding fee discounts are accurately calculated based on family size and income. 2. Documented Procedures: Establish clear procedures and guidelines for front desk staff to follow when determining discounts, including appropriate documentation requirements, eligibility criteria, and fee structure. These procedures will be aligned with our written policy to ensure consistency and accuracy in discount calculations. 3. Training and Education: Provide training to front desk staff members responsible for determining eligibility and applying sliding fee discounts to ensure they understand the process. 4. Regular Reviews: Implement regular reviews and monthly audits to verify that all discounts are properly supported and documented. Quarterly reviews will be conducted to verify compliance, identify areas for improvement, and evaluate the effectiveness of the sliding scale fee program to ensure it meets our patients' needs and complies with all federal guidelines. Responsible Parties: 1. The Controller and revenue cycle staff will develop the written procedure. 2. The Clinical Support Supervisor and revenue cycle staff will overseE3 the training. 3. The Revenue Cycle Manager_will monitor adherence to the procedure, conduct regular monthly audits, and report results to the Controller. 4. The Controller will conduct quarterly documentation reviews of the internal audit results. Timeline: 1. Procedure draft completion: Completed 2. Review and approval by senior management: July 24, 2024 3. Initial staff training session: July 25, 2024 4. Follow-up training sessions: As needed 5. Monthly compliance audits: Starting September 1, 2024

View Audit 316128

Finding 479550 (2023-001)

Significant Deficiency 2023

Lee County School District

MS

Contact person responsible for corrective action: Anthony Bryant, Special Education Director

View Audit 316101

Finding 479550 (2023-001)

Significant Deficiency 2023

Lee County School District

MS

Description of correction action to be taken: The district did obtain two quotes for the same contract for the 2023-24 school year. In addition, the Special Education Department has developed a checklist for all purchases that includes obtaining two quotes when required by state law and/or Uniform G...

Description of correction action to be taken: The district did obtain two quotes for the same contract for the 2023-24 school year. In addition, the Special Education Department has developed a checklist for all purchases that includes obtaining two quotes when required by state law and/or Uniform Guidance.

View Audit 316101

Finding 479550 (2023-001)

Significant Deficiency 2023

Lee County School District

MS

Anticipated completion date of corrective action: Corrective action was taken in October of 2023

View Audit 316101

Finding 479546 (2023-001)

Material Weakness 2023

Dayton's Bluff Neighborhood Housing Service, Inc.

MN

Reporting Subrecipient Monitoring Material Weakness

Dayton’s Bluff Neighborhood Housing Service and Subsidiary submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: January 1,...

Dayton’s Bluff Neighborhood Housing Service and Subsidiary submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: January 1, 2023 – December 31, 2023 The findings from the December 31, 2023 schedule of findings, questioned costs and recommendations. FINDINGS - FINANCIAL STATEMENT AUDIT Finding 2023-001 - Auditor Preparation of the Financial Statements Material Weakness Finding Summary: The Organization does not have an internal control system designed to provide for the preparation of the complete consolidated financial statements, including the accompanying footnotes, as required by GAAP. We were also requested to draft the financial statements and accompanying notes to the financial statements. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of financial statements and accompanying notes. We requested that our auditors Lethert, Skwira, Schultz & Co. LLP, prepare the financial statements and the accompanying notes to the financial statements as a part of their annual audit. We have designated a member of management to review the drafted financial statements and accompanying notes. Responsible Individuals: Jim Erchul, Executive Director, 651-774-6995 Anticipated Completion Date: Ongoing

View Audit 316095

Finding 479539 (2023-002)

Significant Deficiency 2023

Accountability Lab, Inc.

DC

Subrecipient Monitoring § 200.332

Views of Responsible Officials and Planned Corrective Actions: AL has a long-standing preassessment Questionnaire (sample attached) that we require each potential subgrantee to complete before they can receive any financial remuneration from us. In response to this finding, we will require all subgr...

Views of Responsible Officials and Planned Corrective Actions: AL has a long-standing preassessment Questionnaire (sample attached) that we require each potential subgrantee to complete before they can receive any financial remuneration from us. In response to this finding, we will require all subgrantees to complete this questionnaire on an annual basis. In addition we have included the following questions to the questionnaire:  Does the organization perform an annual audit of financial statements?  Annual amount of US Government Funds received?  Is the organization subject to a US compliance audit under 2 CFR 200 Subpart F?  If the organization is subject to a compliance audit under 2 CFR 200 Subpart F, please provide a copy of your most recent 2 CFR 200 Subpart F audit report. Anticipated Completion Date: We will submit the questionnaire to all subgrantees during the month of June 2024 and then perform it annually. Responsible Officials: Chief Innovation and Operations Officer and Finance Manager.

View Audit 316094

Finding 479536 (2023-001)

Significant Deficiency 2023

Accountability Lab, Inc.

DC

Reporting § 200.303 § 200.508 § 200.510

Views of Responsible Officials and Planned Corrective Actions: In 2024 during the SEFA analysis and in discussion with auditors it was determined that a USG-funded contract, attached to a grant, was incorrectly left off the SEFA. This was amended as soon as the mistake was noted. AL is required to s...

Views of Responsible Officials and Planned Corrective Actions: In 2024 during the SEFA analysis and in discussion with auditors it was determined that a USG-funded contract, attached to a grant, was incorrectly left off the SEFA. This was amended as soon as the mistake was noted. AL is required to submit financial statements to a non-US Government donor by June of each calendar year. To comply with this grant stipulation AL starts pre-audit document checks in early January and full fieldwork in mid-February following our financial year close on December 31. While the majority of our annual financial statement is complete by mid-January we have one outstanding USG grant which only reports at the end of February for an end-of-January quarter close. As a result, we are only able to provide a preliminary SEFA when the auditors request the first document checks in January. For FY 2025 we will request that the auditors start with a basic audit of Financial Statements and then submit the SEFA once all the quarterly reports have been submitted to USG. Anticipated Completion Date: Already decided for FY 2024 audit. Responsible Officials: Chief Innovation and Operations Officer and Finance Manager.

View Audit 316094

Finding 479534 (2023-006)

Significant Deficiency 2023

Worker Education & Resource Center INC

CA

Questioned Costs Allowable Costs / Cost Principles § 200.405

Internal controls for proper vetting and approval of spreadsheets are being implemented to safeguard the accuracy of payroll report totals that tie back to labor percentages allocated to individual employee labor totals, billed to the grant.

View Audit 316070 Questioned Costs: $1

Finding 479533 (2023-005)

Significant Deficiency 2023

Worker Education & Resource Center INC

CA

Questioned Costs Eligibility Subrecipient Monitoring

During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign...

During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign off on participant application forms and to be documented on the participants application before the participant can move forward in the program.

View Audit 316070 Questioned Costs: $1

Finding 479532 (2023-004)

Significant Deficiency 2023

Worker Education & Resource Center INC

CA

Allowable Costs / Cost Principles § 200.303

The approved account coding that was changed in the "condition" section mentioned above was done by the former Fiscal Consultant that was replaced by the current Director of Finance. Knowledge of that change with no documentation was not noticed until it was a selection picked during the audit. The ...

The approved account coding that was changed in the "condition" section mentioned above was done by the former Fiscal Consultant that was replaced by the current Director of Finance. Knowledge of that change with no documentation was not noticed until it was a selection picked during the audit. The current Director of Finance was not the manager of the Fiscal Consultant, the Executive Director was, and the current Director of Finance was not given any authority over the Fiscal Consultant. Currently the internal control implemented requires that no changes to grant coding are allowed to be done unless the Director of Finance deploys an accounting department team member to make the change by written request, it is then signed by the staff members in the accounting department making the change. If the Director of Finance makes the reclassification it is documented on the original invoice and signed off by the Director of Finance.

View Audit 316070

Finding 479531 (2023-003)

Significant Deficiency 2023

Worker Education & Resource Center INC

CA

Eligibility Subrecipient Monitoring Significant Deficiency § 200.303

During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign...

During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign off on participant application forms and to be documented on the participants application before the participant can move forward in the program.

View Audit 316070

Finding 479530 (2023-002)

Material Weakness 2023

Worker Education & Resource Center INC

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness

The Organization had a significant turnover in both Fiscal Manager Consultant and Executive Director during the year being audited. The Fiscal Manager Consultant was replaced by the Director of Finance in the later part of the fiscal year 2022-2023. This required the new Director of Finance to creat...

The Organization had a significant turnover in both Fiscal Manager Consultant and Executive Director during the year being audited. The Fiscal Manager Consultant was replaced by the Director of Finance in the later part of the fiscal year 2022-2023. This required the new Director of Finance to create and implement as many internal controls that were needed, that were not implemented, and/or recommended by our current CPA firm who had been previously auditing prior years. Additionally, our Director of Finance has engaged the Board of Directors in taking a more active role in the financial statement overview that was not previously recommended to them by our CPA firm.

View Audit 316070

Finding 479529 (2023-001)

Significant Deficiency 2023

Worker Education & Resource Center INC

CA

Reporting

In the year being audited (July 1, 2022-June 30, 2023), we have removed our Fiscal Audit Consultant and replaced that with a Director of Finance employee that has the skill, knowledge, and education for this matter to be resolved for subsequent audits. Also, moving forward each new grant contract wi...

In the year being audited (July 1, 2022-June 30, 2023), we have removed our Fiscal Audit Consultant and replaced that with a Director of Finance employee that has the skill, knowledge, and education for this matter to be resolved for subsequent audits. Also, moving forward each new grant contract will be discussed with our CPA firm for guidance on the proper application of the grant/contract as it relates to the proper classification of restricted and unrestricted funds. Moreover, since this was our first requirement for a single audit the SEFA form was a new introduction into our internal controls presented by our auditor during the audit and we believe assistance with this form in any subsequent audits will be limited, if needed at all.

View Audit 316070

Finding 479528 (2023-003)

Significant Deficiency 2023

Christmas Valley Domestic Supply District

OR

Procurement, Suspension & Debarment § 200.318 § 200.326

Management has already been working with legal counsel and the board to develop a formal policy to put in place, with a planned implementation date of July 25, 2024.

View Audit 316069

Finding 479527 (2023-003)

Significant Deficiency 2023

Wright County

MN

Procurement, Suspension & Debarment

SUSPENSION AND DEBARMENT – COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS (SLFRF) Recommendation: It is recommended the County ensure they follow their countywide policies regarding federal suspension and debarment and retain necessary documentation. Explanation of disagreement with au...

SUSPENSION AND DEBARMENT – COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS (SLFRF) Recommendation: It is recommended the County ensure they follow their countywide policies regarding federal suspension and debarment and retain necessary documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure they follow their policy related to suspension and debarment. Name of the contact person responsible for corrective action plan: Lindsey Meyer, Finance Director Planned completion date for corrective action plan: December 31, 2024

View Audit 316064

Finding 479525 (2023-003)

Material Weakness 2023

Missoula County

MT

Questioned Costs Reporting

Finding 2023-003 – Reporting U.S. Department of Treasury COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF)- ALN 21.027 Reporting – Missoula County has implemented a dual control process over CSLFRF reporting. As part of the month end process the accountant in finance will review al...

Finding 2023-003 – Reporting U.S. Department of Treasury COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF)- ALN 21.027 Reporting – Missoula County has implemented a dual control process over CSLFRF reporting. As part of the month end process the accountant in finance will review all expenditures related to obligated ARPA programs and reconcile this activity with each department. At the end of the quarter after all months have closed and prior to Treasury reporting an additional review of quarter will occur by the Senior Accountant in finance. This documentation will be reconciled to the Treasury quarterly reports to ensure accurate reporting. Contact Person Responsible for the Corrective Action: Michelle Denman, Deputy Financial Services Director Anticipated Completion Date of the Corrective Action: June 30, 2024

View Audit 316058 Questioned Costs: $1

Finding 479521 (2023-001)

Significant Deficiency 2023

End Domestic Abuse Wisconsin: the Wisconsin Coalition Against Domestic

WI

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

Condition and Cause: Due to staff turnover in Finance and the level of workload there were difficulties creating financial statements on a timely basis. Status: The Coalition is implementing a process to prepare, review, and approve financial statements to ensure that financials are reviewed and...

Condition and Cause: Due to staff turnover in Finance and the level of workload there were difficulties creating financial statements on a timely basis. Status: The Coalition is implementing a process to prepare, review, and approve financial statements to ensure that financials are reviewed and approved by Management on a regular basis. Corrective Action: End Abuse will take the following corrective actions: (1) End Abuse will create a process that involves the creation, review, and approval of financial statements. (2) The Finance Director will create the financial statements; the Executive Director or the Associate Director will review and approve them. (3) The Finance Director is currently recruiting for a staff accountant to help ease the workload. (4) The Board of Directors will review financial statements and/or financial reports on a quarterly basis to ensure that proper procedures are followed. Expected Completion Date: September 30, 2024

View Audit 316053

Finding 479516 (2023-001)

None 2023

Carolina University

NC

Reporting

Management agrees with the finding of the auditor's report concerning the failure to timely submit our 2023 single audit reporting package and data collection form in a timely manner. We have suffered changes in personnel which had a significant impact on our ability to gather information needed to ...

Management agrees with the finding of the auditor's report concerning the failure to timely submit our 2023 single audit reporting package and data collection form in a timely manner. We have suffered changes in personnel which had a significant impact on our ability to gather information needed to finalize our accounting records. New staff members who have taken on these responsibilities are in the process of learning those procedures and adapting to our organization's specific requirements. Additionally, there were some communication challenges during the audit process which led to misunderstandings and further delays. In addressing these challenges, we are providing additional training and support for our new staff members and reevaluating our financial closing processes to ensure that reporting deadlines are met in future periods. In addition, we were awaiting two significant financial transactions that will have a direct and substantial impact on our 2022-2023 financial reports. The most significant of those transactions was a very large estate gift that was pending at the close of the fiscal year (gift receivable). The value of this gift was difficult to assess because of the nature of the gift as part of a sizeable and complicated trust (as well as a very lengthy liquidation process). The gift finally arrived in April 2024 which provided us with the correct valuations (an increase in net assets without donor restrictions of over $4 million). A gift of this magnitude had such a substantial financial impact that we needed to wait for its completion in order to properly assess our financial position. The second transaction (a sale of unused property) closed in late May which enabled us to accurately reflect the impact of these previously pending items. Responsible Official: Chris Ronk, Chief Financial Officer (800) 937-5097

View Audit 316046

Finding 479514 (2023-004)

None 2023

Christian Community Health Center

IL

Reporting

SF-425 Federal Financial Report (FFR) Reporting Planned Corrective Action: CCHC's finance department has contacted the HR.SA grants specialist, regarding the carryover of unobligated funds of $1,989,278, and the carryover funds have been approved and successfully moved into the current budget peri...

SF-425 Federal Financial Report (FFR) Reporting Planned Corrective Action: CCHC's finance department has contacted the HR.SA grants specialist, regarding the carryover of unobligated funds of $1,989,278, and the carryover funds have been approved and successfully moved into the current budget period. The grant compliance manager will assure CCHC's intention to conduct carryover of any unobligated funds by indicating it in the SF-425 reports comments section. This change will strengthen internal controls related to grant management and reporting to prevent future noncompliance incidents. Lastly, CCHC will also review and revise internal procedures for SF- 425 reporting to ensure clarity and adherence to deadlines. Person Responsible for Corrective Action Plan: Isai Ruacho, Grant Compliance Manager Anticipated Date of Completion: 07/31/2024

View Audit 316037

Finding 479513 (2023-003)

Material Weakness 2023

Christian Community Health Center

IL

Material Weakness Internal Control / Segregation of Duties

Finding Number: 2023-003 Sliding Scale Assessment Planned Corrective Action: CCHC has created a workflow for staff as a guide in processing the sliding fee scale. This workflow is approved by the Head Nurse Supervisor and signed. Please see attached workflow sheet. CCHC will verify with Athena EHR...

Finding Number: 2023-003 Sliding Scale Assessment Planned Corrective Action: CCHC has created a workflow for staff as a guide in processing the sliding fee scale. This workflow is approved by the Head Nurse Supervisor and signed. Please see attached workflow sheet. CCHC will verify with Athena EHR system to make sure that the most up to date poverty guidelines are in the system that is being used to calculate sliding fee discounts. Person Responsible for Corrective Action Plan: Pasue Mahan, Chief Clinic Officer Anticipated Date of Completion: 07/01/2024

View Audit 316037

Finding 479512 (2023-001)

Significant Deficiency 2023

City of Hermantown

MN

Procurement, Suspension & Debarment

Highway Planning and Construction – Assistance Listing No. 20.205 Recommendation: We recommend the City implement a procurement policy that complies with the Uniform Guidance. We recommend the city includes suspension and debarment procedures that comply with the Uniform Guidance Explanation of disa...

Highway Planning and Construction – Assistance Listing No. 20.205 Recommendation: We recommend the City implement a procurement policy that complies with the Uniform Guidance. We recommend the city includes suspension and debarment procedures that comply with the Uniform Guidance Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City will work to implement a procurement policy that complies with the Uniform Guidance. Name of the contact person responsible for corrective action: Kevin Orme Planned completion date for corrective action plan: December 31, 2024.

View Audit 316036

Finding 479502 (2023-001)

None 2023

Independent Training & Apprenticeship Program

CA

Management has implemented policies and procedures to ensure the accurate calculation of the 90/10 revenue calculation in the future.

View Audit 316026

Finding 479500 (2023-003)

Material Weakness 2023

Stoddard County Public Health Center

MO

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring

Name of Contact Person: Ben Godwin, Director. Recommendation: We recommendthe Center verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000. Corrective Action: We will verify...

Name of Contact Person: Ben Godwin, Director. Recommendation: We recommendthe Center verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000. Corrective Action: We will verify all vendors' status using the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000. Proposed Completion Date: Immediately.

View Audit 316025

Finding 479493 (2023-001)

Significant Deficiency 2023

Summit Community Care Clinic, Inc.

CO

Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee ra...

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization acknowledges the error identified in the sliding fee discount. To address this issue and prevent future occurrences, the following corrective actions will be implemented: • Internal Audit Procedure o An internal audit procedure will be established to review 10% of the applications processed by each eligibility worker. This review will include verification of application accuracy, calculation correctness, and appropriate selection of sliding fee scales. • Identification of Errors o During the internal audit, if any errors are found, immediate action will be taken to rectify the identified mistakes. • Retraining and Testing o In cases where errors are detected, affected staff will undergo retraining. This retraining will cover all relevant processes and guidelines to ensure a thorough understanding. o Post-retraining, the staff will be subjected to a period of testing to confirm their competence in handling the sliding fee discount applications accurately. These steps will help ensure the integrity and accuracy of the Sliding Fee Discount program moving forward. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Dan Becker, CEO, at 970-423-8833.

View Audit 316020

Finding 479489 (2023-003)

Significant Deficiency 2023

City of Torrington, Connecticut

CT

Procurement, Suspension & Debarment § 200.318 § 200.326

Finding 2023-003 - Procurement, Suspension and Debarment (COVID-19 American Rescue Plan Act Local Fiscal Recovery) Significant Deficiency – Internal Control over Compliance Other Matters (Noncompliance) Description of Finding - The City’s procurement standards do not include the essential elements...

Finding 2023-003 - Procurement, Suspension and Debarment (COVID-19 American Rescue Plan Act Local Fiscal Recovery) Significant Deficiency – Internal Control over Compliance Other Matters (Noncompliance) Description of Finding - The City’s procurement standards do not include the essential elements as outlined in 2 CFR sections 200.318 through 200.326. Statement of Concurrence or NonConcurrence - Management agrees with this finding. Corrective Action - The City has implemented a revised procurement policy which addresses the essential elements of uniform guidance, including suspension and debarment. However, the policy was not in place for all of the current year. Name of Contact Person - John Monks, Comptroller Projected Completion Date - June 30, 2024

View Audit 316014

Corrective Action Plans

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