Corrective Action Plans

Finding 403405 (2023-004)

Material Weakness 2023

TX

HUD Housing Programs Allowable Costs / Cost Principles

Corrective Action Plan Finding: 2023-004-Significantly large interfund account needs to be reduced-Allowable Costs/Principles Condition: (a) and (b)-It appears the enrollment, progress of participants to meet the established goals, and potential earning and disbursement of FSS and Set Aside fu...

Corrective Action Plan Finding: 2023-004-Significantly large interfund account needs to be reduced-Allowable Costs/Principles Condition: (a) and (b)-It appears the enrollment, progress of participants to meet the established goals, and potential earning and disbursement of FSS and Set Aside funds have been inadequately monitored for at least the last two years. (c)-Without both of these requested items noted above, we are unable to determine if the SEP contribution terms were adequately complied with. Corrective Action Planned: We will comply with the auditor’s recommendation. I do note that we were short of personnel for the entire audit period. I believe that I have staff presently that can do most of the assigned duties. I admit that not all of the deficiencies noted were due to being understaffed, but lack of training (being new to HUD) and understanding. But we will also correct those errors to the best of our ability. Person responsible for corrective action: Mary Grace Saenz, Executive Director Telephone: (915) 886-4650 Housing Authority of the Town of Anthony, Texas Fax: (915) 886-2296 1007 Franklin Anthony, TX 79821 Anticipated Completion Date: September 30, 2024

View Audit 310515

Finding 403404 (2023-003)

Material Weakness 2023

Anthony Housing Authority

TX

HUD Housing Programs Eligibility Internal Control / Segregation of Duties

Corrective Action Plan Finding: 2023-003-Tenant file deficiencies and SEMAP errors noted-Eligibility and Special Tests Condition: (a)-SEMAP was not filed before the regulatory deadline. Since the deadline was missed, the SEMAP could not be submitted. We requested the worksheets used to docume...

Corrective Action Plan Finding: 2023-003-Tenant file deficiencies and SEMAP errors noted-Eligibility and Special Tests Condition: (a)-SEMAP was not filed before the regulatory deadline. Since the deadline was missed, the SEMAP could not be submitted. We requested the worksheets used to document SEMAP. management brought in the files that they claim were used to review for SEMAP. the other thing available were twenty inspection forms that management claims were HQ’s. We were unable to determine whether the HQ’s covered both failed and passed initial inspections. Again, no worksheets were available to document the results of the tests. in the last two audit periods, we gave examples and explanations to management of an adequate way to document SEMAP. We recommended a couple of webcasts to attend on SEMAP. Management claims they viewed the webcasts. (b)-We reviewed twenty-five HCV files. Nine were current year move ins. sixteen were annual re-exams. Of the nine move ins tested, we could not locate three on the waiting lists (we asked management three weeks before we reviewed the files to tab the waiting list for the tested move ins). In addition, of one of the six that we did locate on the waiting list, we could not find an explanation of why the applicants listed before (above) were not admitted. We reviewed two move-ins for low rent, a non-major program. We located the applicants on the waiting list. however, there was no explanation why the applicants listed before (above) were not admitted. (c)-Of the twenty -five HCV files tested, the September 2023 HAP payment did not agree to the last available 50058 filed before September for two tenants. We asked if there were possibly interim 50058s that did not make it to the file, but we did not receive any. two were immaterial differences-one being $9 per month, the other $3 per month. (d)-Of the nine move-ins tested, we could not locate a reasonable rent survey for two. (e)-Of the sixteen re-exams we reviewed, we could not find an EIV for the re-exam of one tenant. (e)-Income Enterprise Verifications (EIV) should be documented for all tenants when their annual re-examination is done (f)-All 1099’s issued to landlords should be available for third party review. Corrective Action Planned: We will comply with the auditor’s recommendation. I do note that we were short of personnel for the entire audit period. I believe that I have staff presently that can do most of the assigned duties. I admit that not all of the deficiencies noted were due to being understaffed, but lack of training (being new to HUD) and understanding. But we will also correct those errors to the best of our ability. Person responsible for corrective action: Mary Grace Saenz, Executive Director Telephone: (915) 886-4650 Housing Authority of the Town of Anthony, Texas Fax: (915) 886-2296 1007 Franklin Anthony, TX 79821 Anticipated Completion Date: September 30, 2024

View Audit 310515

Finding 403403 (2023-002)

Material Weakness 2023

Anthony Housing Authority

TX

HUD Housing Programs Allowable Costs / Cost Principles Reporting

Corrective Action Plan Finding: 2023-002-Inadequate Administration of Facets of Programs-Allowable Costs/Principles Condition: (a) and (b)-It appears the enrollment, progress of participants to meet the established goals, and potential earning and disbursement of FSS and Set Aside funds have b...

Corrective Action Plan Finding: 2023-002-Inadequate Administration of Facets of Programs-Allowable Costs/Principles Condition: (a) and (b)-It appears the enrollment, progress of participants to meet the established goals, and potential earning and disbursement of FSS and Set Aside funds have been inadequately monitored for at least the last two years. (c)-Without both of these requested items noted above, we are unable to determine if the SEP contribution terms were adequately complied with. Corrective Action Planned: We will comply with the auditor’s recommendation. I do note that we were short of personnel for the entire audit period. I believe that I have staff presently that can do most of the assigned duties. I admit that not all of the deficiencies noted were due to being understaffed, but lack of training (being new to HUD) and understanding. But we will also correct those errors to the best of our ability. Person responsible for corrective action: Mary Grace Saenz, Executive Director Telephone: (915) 886-4650 Housing Authority of the Town of Anthony, Texas Fax: (915) 886-2296 1007 Franklin Anthony, TX 79821 Anticipated Completion Date: September 30, 2024

View Audit 310515

Finding 403402 (2023-001)

Material Weakness 2023

Anthony Housing Authority

TX

HUD Housing Programs Allowable Costs / Cost Principles Internal Control / Segregation of Duties

ANTHONY HOUSING AUTHORITY PHONE: 915-886-4650 ·FAX:915-886-2296 1007 FRANKLIN ANTHONY, TEXAS 79821 HOUSING AUTHORITY OF ANTHONY, TEXAS CORRECTIVE ACTION PLAN YEAR ENDED SEPTEMBER 30, 2023 Corrective Action Plan Finding: 2023-001-Inadequate Accounting and Documentation-Allowable Costs/Princip...

ANTHONY HOUSING AUTHORITY PHONE: 915-886-4650 ·FAX:915-886-2296 1007 FRANKLIN ANTHONY, TEXAS 79821 HOUSING AUTHORITY OF ANTHONY, TEXAS CORRECTIVE ACTION PLAN YEAR ENDED SEPTEMBER 30, 2023 Corrective Action Plan Finding: 2023-001-Inadequate Accounting and Documentation-Allowable Costs/Principles Condition: (a)-We noted $4,334 of travel costs that were improperly classified in either Maintenance Expense-Materials or Other Administrative Expenses-Other. The above amounts were reclassified by audit adjustment to travel costs. (b)-The adopted policy is for direct payments (ACH- without check) to be accompanied by an authorized check request. As a result of early exceptions we noted, we reviewed approximately 100% of the noted direct payments. Only a minority of the direct payments that we reviewed were accompanied by such an authorized written request. In addition, we do not know the documentation or explanation that was viewed by the authorized person, when the requests that we were able to review was signed. Approximately $55,051 of total payments were made by direct payments. $34,334 and $20,717 were charged to the HCV Fund and the General (Low Rent) Funds, respectively. $49,974 of the total was not supported by adequate documentation. This was $31,586 and $18,388 charged to the HCV and General (Low Rent) Funds, respectively. Much of the unsupported direct payments were travel costs. The total travel costs after reclassifications noted above were $21,336. Of the total travel costs, only $2,723 was paid by check. All tested check amounts contained adequate support. $18,613 of travel costs were paid by direct payments. (c)-We selected three credits at random on the Low Rent rental register that totaled $4,361 that was spread over three months. We requested documented explanations from management for these credits. However, we did not receive any. In addition, we noted in our review of month- to- month Low Rent rental revenue charged, that there was a large variance that may have not been initially detected by management. The average dwelling rent charged for 10 months was $5,800. However, the rent charged for January and February 2023 were $10,855 and $1,570, respectively. We received the accounting information without adjustment or comment on this. Management states that they subsequently found the errors. However, the January variance should have been noted by management before the February rent register was run. (d)-The unaudited financial statements were conditionally approved by REAC. One of the conditions was that PORTs reported on the VMS was $6,009. However, the amount reported on Financial Data Scheule (FDS) Line 97350 is zero. While this difference is immaterial to the financial statements, REAC expects these numbers to agree. To date, management has been unable to reconcile these numbers. (e)-In the current year, Accounting coded a $38,573 advance to a ROSS grant. However, the detailed ELOCCS indicates this is instead was an advance on the CFP 2020 program. In addition, a $46,710 advance was incorrectly classified to the 2021 CFP. Instead, it should have been credited to the 2019 CFP program. (f)-The fee accountant only partially completed their year- end unaudited checklist, that is prepared by a supervising accountant that reviews the year-end unaudited statements prepared by other members of the fee accounting firm. The fee accountant requested but did not receive the necessary information from management. Corrective Action Planned: We will comply with the auditor’s recommendation. I do note that we were short of personnel for the entire audit period. I believe that I have staff presently that can do most of the assigned duties. I admit that not all of the deficiencies noted were due to being understaffed, but lack of training (being new to HUD) and understanding. But we will also correct those errors to the best of our ability. Person responsible for corrective action: Mary Grace Saenz, Executive Director Telephone: (915) 886-4650 Housing Authority of the Town of Anthony, Texas Fax: (915) 886-2296 1007 Franklin Anthony, TX 79821 Anticipated Completion Date: September 30, 2024

View Audit 310515

Finding 403401 (2023-001)

Material Weakness 2023

Puerto Rico Industrial Development Company

PR

Reporting Material Weakness Matching / Level of Effort / Earmarking § 200.512

VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTION Management is responsible for designing and maintaining internal controls over financial reporting that is sufficient to provide reasonable assurance that management can prepare the financial statement and the Uniform Guidance Audit Report...

VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTION Management is responsible for designing and maintaining internal controls over financial reporting that is sufficient to provide reasonable assurance that management can prepare the financial statement and the Uniform Guidance Audit Report in conformity with US GAAP and federal regulations. Management will improve accounting and financial reporting policies and procedures to include timely issuance of the financial statement and the uniform guidance report. IMPLEMENTATION DATE March 31, 2025 RESPONSIBLE PERSON Jamille Muriente, CFO, Marjuli, David Mateo, Contract Coordinator Officer

View Audit 310512

Finding 403369 (2023-001)

Material Weakness 2023

Newmarket Housing Authority

NH

HUD Housing Programs Material Weakness Internal Control / Segregation of Duties § 200.514

Newmarket Housing Authority Audit Finding Response: Finding reviewed with program specialist and manager with following action plan in place to ensure key EIV reports are run on a scheduled basis and appropriate actions are taken; • Policies and procedures surrounding EIV reviewed. • Program special...

Newmarket Housing Authority Audit Finding Response: Finding reviewed with program specialist and manager with following action plan in place to ensure key EIV reports are run on a scheduled basis and appropriate actions are taken; • Policies and procedures surrounding EIV reviewed. • Program specialist implemented the use of "tickler" reminders on outlook calendar to prompt EIV reports within 90 days for new move-ins. • The Manager will monitor monthly and quarterly to ensure EIV report is run for all move-ins and recertifications.

View Audit 310501

Finding 403367 (2023-001)

Material Weakness 2023

City of Senoia, Ga

GA

MATERIAL AMOUNTS OF ACCOUNTS PAYABLE NOT RECORDED ON THE CITY'S BOOKS AT YEAR-END The City did not record $1,327,314 of accounts payable owed by the City as of year-end, of which $1,305,463 were related to major federal assistance programs. CORRECTIVE ACTION PLAN: Management agrees with the finding....

MATERIAL AMOUNTS OF ACCOUNTS PAYABLE NOT RECORDED ON THE CITY'S BOOKS AT YEAR-END The City did not record $1,327,314 of accounts payable owed by the City as of year-end, of which $1,305,463 were related to major federal assistance programs. CORRECTIVE ACTION PLAN: Management agrees with the finding. Management is training accounting personnel on the appropriate steps to record invoices through the City's accounts payable system. Management will also emphasize the importance of proper supervision over newly hired personnel. The City's finance director will be responsible for overseeing the improvements in the accounts payable system and the training of personnel.

View Audit 310500

Finding 403364 (2023-002)

Significant Deficiency 2023

Genesee Health System

MI

Allowable Costs / Cost Principles § 200.402

Finding 2023-002: Activities Allowed or Unallowed and Allowable Cost/Cost Principles Description of Finding: Significant Deficiency in Internal Control/Noncompliance – Expenditures charged to the grant were not authorized in the grant budget. Corrective Action: GHS agrees with the ...

Finding 2023-002: Activities Allowed or Unallowed and Allowable Cost/Cost Principles Description of Finding: Significant Deficiency in Internal Control/Noncompliance – Expenditures charged to the grant were not authorized in the grant budget. Corrective Action: GHS agrees with the finding and the recommendation. GHS grant reporting staff will do a detailed review of all grant agreements to obtain a thorough understanding of allowable costs in the grant budget. Then the following steps will be taken to ensure compliance: • Once the grant budget has been approved by the Board of Directors and submitted to HRSA, staff allocated to the grant will be coded in the payroll system directly to the grant cost center. • Any other costs included in the submitted grant budget will be directly coded to that cost center as incurred on a monthly basis as well. • A review of the costs assigned to the grant cost center will be completed, comparing the actual costs each month to allocated monthly budgeted amount that was approved and submitted to HRSA. • This review will be done by the accounting manager responsible for grant reporting as well as the accounting manager responsible for the FQHC financial reporting as a whole. The Executive Director of the FQHC and the CFO will provide the final review of the monthly expenditures charged to the grant. • Any questions or needed changes will be communicated to the grant accountant for explanation or modification each month. Name of Contact Person: Glen Chipman, CFO 1040 W Bristol Rd Flint, MI 48732 810-496-5487 gchipman@genhs.org Projected Completion Date: The above outlined steps have been put in place as of 6/15/2024 and will be reviewed periodically for continued efficiency.

View Audit 310494

Finding 403363 (2023-001)

Material Weakness 2023

Genesee Health System

MI

Allowable Costs / Cost Principles § 200.402

Finding 2023-001: Activities Allowed or Unallowed and Allowable Cost/Cost Principles Description of Finding: Material Weakness in Internal Control – CMHSP unable to provide supporting documentation for some expenses charged to the grant. Corrective Action: GHS agrees with the findi...

Finding 2023-001: Activities Allowed or Unallowed and Allowable Cost/Cost Principles Description of Finding: Material Weakness in Internal Control – CMHSP unable to provide supporting documentation for some expenses charged to the grant. Corrective Action: GHS agrees with the finding and that there were sufficient costs in other cost centers, allowable by the budget submitted to HRSA, to replace the unsupported expenses. We also acknowledge the fact that the controls in place were not effectively applied to identify the issue prior to the single audit testing began. GHS has already taken steps to eliminate the risk of such an issue in the future by automating the coding process through the payroll system and increasing the number of reviewers of grant related expenditures on a monthly basis. The following steps have been put in place for future years: • Once the grant budget has been approved by the Board of Directors and submitted to HRSA, staff allocated to the grant will be coded in the payroll system directly to the grant cost center. • Any other costs included in the submitted grant budget will be directly coded to that cost center as incurred on a monthly basis as well. • A review of the costs assigned to the grant cost center will be completed, comparing the actual costs each month to allocated monthly budgeted amount that was approved and submitted to HRSA. • This review will be done by the accounting manager responsible for grant reporting as well as the accounting manager responsible for the FQHC financial reporting as a whole. The Executive Director of the FQHC and the CFO will provide the final review of the monthly expenditures charged to the grant. • Any questions or needed changes will be communicated to the grant accountant for explanation or modification each month. Name of Contact Person: Glen Chipman, CFO 1040 W Bristol Rd Flint, MI 48732 810-496-5487 gchipman@genhs.org Projected Completion Date: The above outlined steps have been put in place as of 6/15/2024 and will be reviewed periodically for continued compliance.

View Audit 310494

Finding 403362 (2023-001)

Significant Deficiency 2023

Gerald L. Ignace Indian Health Center, Inc.

WI

Procurement, Suspension & Debarment § 200.318

Corrective Action Plan: Management has implemented controls to support the requirement to receive multiple number of price quotes for any purchases over the required threshold. Anticipated Corrective Action Plan Completion Date: Ongoing. Contact Information: For additional information regarding t...

Corrective Action Plan: Management has implemented controls to support the requirement to receive multiple number of price quotes for any purchases over the required threshold. Anticipated Corrective Action Plan Completion Date: Ongoing. Contact Information: For additional information regarding this finding please contact Jodi Bauer, Chief Financial Officer, at 414-316-5028.

View Audit 310492

Finding 403359 (2023-001)

Significant Deficiency 2023

Aids Resource Foundation for Children, Inc. and Affiliate

NJ

Reporting

Management plans on starting the June 2024 audit by December 1, 2024, which should give us enough time to complete the Uniform Guidance audit by March 31, 2025.

View Audit 310480

Finding 403358 (2023-006)

Significant Deficiency 2023

Mile Bluff Medical Center, Inc.

WI

Reporting Significant Deficiency

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP identified that the method used for reporting lost revenue was inaccurate. Method 2 wa...

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP identified that the method used for reporting lost revenue was inaccurate. Method 2 was reported, when it should’ve been method 3. Responsible Individuals: Dara Bartels, CEO Corrective Action Plan: Mile Bluff Medical Center has not had a lot of experience with a single audit prior to COVID grant funds. This year we experienced turnover in our CFO role, leaving the process to be re-created. We pulled together most of the information that was required but needed assistance/guidance from our auditors on how to pull the information together and report them on the required forms. We will continue to learn the layout and review the Schedule of Expenditures of Federal Awards prior to sending or addressing this with the Auditors. Anticipated Completion Date: Ongoing

View Audit 310474

Finding 403357 (2023-005)

Material Weakness 2023

Mile Bluff Medical Center, Inc.

WI

Allowable Costs / Cost Principles Eligibility Material Weakness § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP identified the lack of documentation of review processes surrounding the expenditures ...

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP identified the lack of documentation of review processes surrounding the expenditures of the federal award. Responsible Individuals: Dara Bartels, CEO Corrective Action Plan: We have a process that requires the Grant “owners” to review and sign off on the expenditures related to any Federal Awards and other expenditure in the organization. We will add a quarterly review in the Grants office to verify the expected purpose, compliance with federal statutes, regulations and conditions of the federal award. This will also be reviewed by the CFO to create checks and balances. Anticipated Completion Date: Ongoing

View Audit 310474

Finding 403356 (2023-004)

Material Weakness 2023

Mile Bluff Medical Center, Inc.

WI

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP assisted in the Preparation of Schedule of Expenditures of Federal Awards Responsible ...

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP assisted in the Preparation of Schedule of Expenditures of Federal Awards Responsible Individuals: Dara Bartels, CEO Corrective Action Plan: Mile Bluff Medical Center has not had a lot of experience with a single audit prior to COVID grant funds. This year we experienced turnover in our CFO role, leaving the process to be re-created. We pulled together most of the information that was required but needed assistance/guidance from our auditors on how to pull the information together and report them on the required forms. We will continue to learn the layout and review the Schedule of Expenditures of Federal Awards prior to sending or addressing this with the Auditors. Anticipated Completion Date: Ongoing

View Audit 310474

Finding 403355 (2023-001)

Significant Deficiency 2023

National Health Foundation and Subsidiary

CA

Procurement, Suspension & Debarment § 200.303 § 200.318

National Health Foundation and Subsidiary Corrective Action Plan For the Fiscal Year Ended December 31, 2023 U.S. Department of Housing and Urban Development Federal Awards Finding Item 2023-001 – Procurement and Suspension and Debarment – Significant Deficiency over Internal Controls over Complianc...

National Health Foundation and Subsidiary Corrective Action Plan For the Fiscal Year Ended December 31, 2023 U.S. Department of Housing and Urban Development Federal Awards Finding Item 2023-001 – Procurement and Suspension and Debarment – Significant Deficiency over Internal Controls over Compliance Conditions – The auditors selected two out of a universe of three vendors that had covered transactions over the covered transactions threshold. National Health Foundation and Subsidiary was unable to provide supporting evidence documenting that it had verified either entity was not excluded or disqualified before National Health Foundation and Subsidiary went under contract with those vendors. However, a subsequent review did show both vendors were not on the excluded or disqualified listing. The written policies at National Health Foundation and Subsidiary include the requirement to attach evidence of the debarment verification when submitting an invoice for payment. The procurement policy effective during the audit period did not include the required written ethics and conflicts of interest standard to avoid actual or apparent conflict of interest involving expenditures of federal grant awards. National Health Foundation and Subsidiary has a conflict-of-interest policy for employees to adhere to however, the specific consideration for anyone who participates in the selection, awarding, or administration of a contract with federal funding was not included. Corrective Action Plan: National Health Foundation will update the existing procurement policy and conflict-of-interest policy to strengthen compliance with federal funding guidelines. A checklist will be created and kept on file for vendors over $25,000. Checklist to include the following: 1) list of vendors and their proposal/quotes, 2) list of employees involved in the decision process and verified that no conflict of interest between employees and vendors under consideration, 3) document vendor selected, and 4) check federal site that the selected vendor is not suspended or debarred from federal contract. Name of Contact Person: Dr. Felita Jones, CEO/President (FJones@nhfca.org) Kristina Tran, CFO/Sr. Vice President Finance (ktran@hasc.org) Projected Completion Date: June 30, 2024

View Audit 310471

Finding 403354 (2023-037)

Significant Deficiency 2023

Government of the District of Columbia

DC

Matching / Level of Effort / Earmarking Special Tests & Provisions Subrecipient Monitoring § 200.303 § 200.508

The Department of Behavioral Health (DBH) agrees with the findings. DBH will work to ensure that the time management/payroll system accurately shows where an employee’s cost is being charged. An employee was not charged to the grant even though they were noted as key personnel (100% to be charged t...

The Department of Behavioral Health (DBH) agrees with the findings. DBH will work to ensure that the time management/payroll system accurately shows where an employee’s cost is being charged. An employee was not charged to the grant even though they were noted as key personnel (100% to be charged to the grant). DBH will work with the OCFO to make sure Peoplesoft can assign attributes that can be reported to show that they were charged to the grant. In addition, DBH will review with program staff the process to have a “Letter of Temporary Detail” noting when an employee is assigned to work on the grant so that their time can be charged to the grant. DBH will have the grants management system configured so that the PDF of the Letter of Temporary Detail can be attached to the grant file. Contact - PeopleSoft Set-up: Adran Reid, DBH Agency Fiscal Officer and Michael Neff, DBH Chief Operating Officer, Letter of Temporary Detail: Sharon Hunt, State Opioid Treatment Authority , Grants Management System Configuration: Michael Neff, DBH Chief Operating Officer Estimated Completion Date - Grants Management System, Uploading Documents to Grant File: January 1, 2025 See Corrective Action Plan for chart/table

View Audit 310468

Finding 403353 (2023-036)

Material Weakness 2023

Government of the District of Columbia

DC

Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303 § 200.331

The Department of Behavioral Health (DBH) agrees with the findings. Eligibility of Subrecipients: Training will take place for Fiscal Services Staff to ensure that screening for eligibility for the program takes place. The requirement for screening will be added as a required data element so screen...

The Department of Behavioral Health (DBH) agrees with the findings. Eligibility of Subrecipients: Training will take place for Fiscal Services Staff to ensure that screening for eligibility for the program takes place. The requirement for screening will be added as a required data element so screening can be monitored in the grants management system. Earmarking Requirements for Subrecipients: ICR will be set up based on allowable costs from the NOA in grants management system. Training will be conducted for Fiscal and Program Monitors so that they are aware of how ICR is determined and calculated. Monitoring of Subrecipients: DBH will conduct training to ensure that Fiscal and Program Monitors understand the requirements of on-going documentation to identify risk and compliance to the program. DBH will have the monitoring form created in the new grants management system so that failure to complete the documentation will trigger a system alert with an escalation process to ensure compliance. Contact - Eligibility of Subrecipients: Anthony Baffour, Director, Fiscal Services, Earmarking Requirements for Subrecipients: Sharon Hunt, State Opioid Treatment Authority and Anthony Baffour, Director, Fiscal Services, Monitoring of Subrecipients: Sharon Hunt, State Opioid Treatment Authority and Anthony Baffour, Director, Fiscal Services See Corrective Action Plan for chart/table Estimated Completion Date - Staffing Training: August 1, 2024, Grants Management System: January 1, 2025 See Corrective Action Plan for chart/table

View Audit 310468

Finding 403352 (2023-035)

Material Weakness 2023

Government of the District of Columbia

DC

Reporting Subrecipient Monitoring § 200.303 § 200.333 § 200.502 § 200.510

The Department of Behavioral Health (DBH) agrees with the findings. The 425 reports will be reviewed by both the Accounting Supervisor and the Accounting Officer prior to entering in the Payment and Management System (PMS) and will appropriately be signed by either one of the two. Documentation fro...

The Department of Behavioral Health (DBH) agrees with the findings. The 425 reports will be reviewed by both the Accounting Supervisor and the Accounting Officer prior to entering in the Payment and Management System (PMS) and will appropriately be signed by either one of the two. Documentation from PMS will provide a history of the approval flow. Accountants will not have the authority to certify the reports in PMS. The HSSC Comptroller, the Accounting Manager, the AFO and the Budget Staff will perform a detailed review and walk through of the SEFA to confirm the expenditures are correctly categorized by fund and grant, and appropriately identify expenditures for subrecipients, if applicable. Additionally, DBH is working with OCP (Office of Contracting and Procurement), to attach to DC Health’s contract to implement a grants management system that is on the Salesforce platform. The system will automate workflow and enable “alerts” to notify users when reports are due. If the notification is not acted on, the system will automatically escalate the alert to senior management. In the interim, DBH is working through the Districts Grants Management Advisory Board to identify DIFS reports (e.g., DIFS report for FFATA, Subrecipient Grant Report R071). To note, all programmatic data that was used for the PPR was available to the auditors. The supporting documentation for the chart that included spending for administrative and data costs had not been saved, which was the source of the finding. Contact - FAPIIS and FFATA: Renee Evans Jackman, Director of Grants Management, FFR (SF-425) and SEFA: Barbara Roberson, HSSC Accounting Officer, PPR: Sharon Hunt, State Opioid Treatment Authority Estimated Completion Date - Grants Management System is due to be implemented on January 1, 2025. See Corrective Action Plan for chart/table

View Audit 310468

Finding 403351 (2023-034)

Significant Deficiency 2023

Government of the District of Columbia

DC

Cash Management Reporting § 200.303

The Department of Behavioral Health (DBH) concurs with the finding. The Accounting Supervisor will require additional documentation upon the presentation of a draw request for all federal grants prior to submitting the request in the federal system. The accountant will be required to submit a repor...

The Department of Behavioral Health (DBH) concurs with the finding. The Accounting Supervisor will require additional documentation upon the presentation of a draw request for all federal grants prior to submitting the request in the federal system. The accountant will be required to submit a report reflecting summary and detailed reports for all draw requests. This report will include detailed payroll information as well as confirmation that all non-personal services expenditures have been disbursed. Contact - Adran Reid, DBH Agency Fiscal Officer Estimated Completion Date - July 1, 2024 See Corrective Action Plan for chart/table

View Audit 310468

Finding 403350 (2023-033)

Significant Deficiency 2023

Government of the District of Columbia

DC

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.403

The Department of Behavioral Health (DBH) concurs with the finding. The Accounting Supervisor will require additional documentation upon the presentation of requests for reimbursement for all federal grants prior to submitting the request in the federal system. The accountant will be required to su...

The Department of Behavioral Health (DBH) concurs with the finding. The Accounting Supervisor will require additional documentation upon the presentation of requests for reimbursement for all federal grants prior to submitting the request in the federal system. The accountant will be required to submit supporting documentation reflecting the summary and detailed personal and non-personal service expenditures. Contact - Adran Reid, DBH Agency Fiscal Officer Estimated Completion Date - July 1, 2024 See Corrective Action Plan for chart/table

View Audit 310468 Questioned Costs: $1

Finding 403341 (2023-032)

Material Weakness 2023

Government of the District of Columbia

DC

Internal Control / Segregation of Duties Eligibility Reporting § 200.303

The Economic Security Administration (ESA) concurs with this finding. As a corrective action, ESA will provide refresher training and reinforce oversight controls to ensure caseworkers and supervisors are processing applications within federally required timeframes. Contact - Melisa Byrd, Senior D...

The Economic Security Administration (ESA) concurs with this finding. As a corrective action, ESA will provide refresher training and reinforce oversight controls to ensure caseworkers and supervisors are processing applications within federally required timeframes. Contact - Melisa Byrd, Senior Deputy Director and Medicaid Director Estimated Completion Date - June 18, 2024 See Corrective Action Plan for chart/table

View Audit 310468

Finding 403340 (2023-031)

Significant Deficiency 2023

Government of the District of Columbia

DC

Allowable Costs / Cost Principles Period of Performance Reporting § 200.303

The Department of Health Care Finance (DHCF) agrees with the finding. The drug rebate vendor’s IT staff will test the calculation to see if there would have been interest calculated or if there is a system glitch that requires further attention. If additional interest should be billed for this invo...

The Department of Health Care Finance (DHCF) agrees with the finding. The drug rebate vendor’s IT staff will test the calculation to see if there would have been interest calculated or if there is a system glitch that requires further attention. If additional interest should be billed for this invoice, the vendor will add the interest that should have been billed. Currently, the drug rebate vendor calculates interest every Tuesday. The system is also calibrated to calculate interest on invoices that were paid in full that had outstanding balances based on the postmark date applied in the system. Contact - Melisa Byrd, Senior Deputy Director and Medicaid Director Estimated Completion Date - November 30, 2024 See Corrective Action Plan for chart/table

View Audit 310468

Finding 403339 (2023-030)

Significant Deficiency 2023

Government of the District of Columbia

DC

Internal Control / Segregation of Duties Eligibility Reporting § 200.303

The Economic Security Administration (ESA) concurs with this finding. As a corrective action, ESA will provide refresher training and reinforce oversight controls to ensure caseworkers and supervisors are processing applications within federally required timeframes. Contact- Melisa Byrd, Senior De...

The Economic Security Administration (ESA) concurs with this finding. As a corrective action, ESA will provide refresher training and reinforce oversight controls to ensure caseworkers and supervisors are processing applications within federally required timeframes. Contact- Melisa Byrd, Senior Deputy Director and Medicaid Director Estimated Completion Date - June 18, 2024 See Corrective Action Plan for chart/table

View Audit 310468

Finding 403338 (2023-029)

Material Weakness 2023

Government of the District of Columbia

DC

Special Tests & Provisions Student Financial Aid Reporting § 200.303

The Child and Family Services Agency (CFSA) concurs with the findings. The Business Services Administration will install correspondence protocols whereby the invoicing/cost reporting team will acknowledge the review and acceptance of quarterly cost reports from the provider community. Contact - Ja...

The Child and Family Services Agency (CFSA) concurs with the findings. The Business Services Administration will install correspondence protocols whereby the invoicing/cost reporting team will acknowledge the review and acceptance of quarterly cost reports from the provider community. Contact - James J. Murphy, Director, Business Services Administration Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table

View Audit 310468

Finding 403337 (2023-028)

Material Weakness 2023

Government of the District of Columbia

DC

Questioned Costs Student Financial Aid Eligibility § 200.303

The Child and Family Services Agency (CFSA) concurs with the findings. Corrective action for the licensing issue will be addressed in the development of the permanent CCWIS system, Standing Together Against Abuse and Neglect in the District (STAAND), wherein official foster care provider license ce...

The Child and Family Services Agency (CFSA) concurs with the findings. Corrective action for the licensing issue will be addressed in the development of the permanent CCWIS system, Standing Together Against Abuse and Neglect in the District (STAAND), wherein official foster care provider license certificates will be available for download on demand. STAAND is currently in development with expected completion in late 2025. Corrective action for the household composition issue will also occur in the development of the STAAND system, wherein foster parents will interact with the system directly and provide household composition information during each licensure cycle. In the meantime, starting immediately, CFSA licensing workers will sign and date checklists during each licensure cycle until STAAND has been fully implemented. CFSA will submit adjusting claims for questioned costs following HHS review of this finding. Contact - James J. Murphy, Director, Business Services Administration Estimated Completion Date - September 30, 2025 (with interim corrective action beginning immediately). See Corrective Action Plan for chart/table

View Audit 310468 Questioned Costs: $1

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