Corrective Action Plans

Finding 403243 (2023-001)

Significant Deficiency 2023

WI

Internal Control / Segregation of Duties HUD Housing Programs

#2023-001 – Segregation of Duties – The Organization is aware of the lack of segregation of duties caused by the limited size of its staff, and will continue to use other controls, where practical to compensate for this limitation. Responsible Official: Jenna Van Den Wildenberg, Executive Director...

#2023-001 – Segregation of Duties – The Organization is aware of the lack of segregation of duties caused by the limited size of its staff, and will continue to use other controls, where practical to compensate for this limitation. Responsible Official: Jenna Van Den Wildenberg, Executive Director Anticipated Completion Date: This finding will not completely resolve itself given the cost/benefits basis the Organization continues to base this decision on.

View Audit 310399

Finding 403242 (2023-001)

None 2023

Southcoast Health System, Inc.

MA

Subrecipient Monitoring

2023-001 Congressional Directives Principal Investigator Cluster: Not applicable Grantor: U.S. Department of Health and Human Services Award Names: Congressional Directives Award Year: August 1, 2022-July 31, 2025 Award Number: 1 CE1HS46621‐01‐00 Assistance Listing Numbers: 93.493 Pass-through enti...

2023-001 Congressional Directives Principal Investigator Cluster: Not applicable Grantor: U.S. Department of Health and Human Services Award Names: Congressional Directives Award Year: August 1, 2022-July 31, 2025 Award Number: 1 CE1HS46621‐01‐00 Assistance Listing Numbers: 93.493 Pass-through entity: Not applicable Management’s Views and Corrective Action Plan Management’s View Management agrees with the Auditors’ assessment of the System’s internal controls over compliance in regard to the requirement to notify the GMO and OPDIV of the change in the Principal Investigator (PI) role. Management did not inform the GMO and OPDIV of the change in PI in a timely manner after the original PI left the System. Management believes this delay in notification did not lead to any mismanagement of funding. Corrective Action Plan The System has created a process of having two System representatives associated with the program. The System now has a Program Director (PD) and a PI approved by HRSA and the System received a revised NOA on May 15, 2024 naming the new PD and PI. Further, Management updated our policy on future federal funding to ensure that there will be two or more System representatives assigned to a project to mitigate timely notification delays should one of those employees leave the organization. Responsible Official: Ross Replogle, Corporate Controller Completion Date: May 15, 2024

View Audit 310398

Finding 403239 (2023-004)

Significant Deficiency 2023

Chief Dull Knife College

MT

Reporting Matching / Level of Effort / Earmarking

Reporting Requirements: Chief Dull Knife College will continue to review reporting requirements for all grants received. HEERF reports were posted to the College’s website, but the third quarter 2023 report was posted in the Financial Section rather than the IHE’s activities section. This procedur...

Reporting Requirements: Chief Dull Knife College will continue to review reporting requirements for all grants received. HEERF reports were posted to the College’s website, but the third quarter 2023 report was posted in the Financial Section rather than the IHE’s activities section. This procedure is being corrected and will be reviewed for all grants.

View Audit 310397

Finding 403236 (2023-003)

Material Weakness 2023

Chief Dull Knife College

MT

Questioned Costs Cash Management

Cash Management: As is the case with most higher education institutions and governmental entities, the College has struggled with the COVID pandemic and its aftermath. Essential functions were disrupted, including several key accounting, finance, functions due to employees being out sick. Chief D...

Cash Management: As is the case with most higher education institutions and governmental entities, the College has struggled with the COVID pandemic and its aftermath. Essential functions were disrupted, including several key accounting, finance, functions due to employees being out sick. Chief Dull Knife College had a discrepancy occur when drawing down funds in which it was done in error twice and an aggregate difference from the previous year was carried over. This was discovered and the difference was sent back to HEERF. The HEERF funding has been reconciled and concluded. The College had more than sufficient money in the bank to cover all of their expenses so this money was not used to cover any expenses. Chief Dull Knife College takes the responsibility of drawing money from Grant Programs very crucial and will make all efforts and policies to ensure this type of error does not occur.

View Audit 310397 Questioned Costs: $1

Finding 403233 (2023-005)

Significant Deficiency 2023

Chief Dull Knife College

MT

Allowable Costs / Cost Principles

Allowability of Expenditures: Chief Dull Knife College has reviewed and updated the policies for expenditures and will continue to review, scrutinize and calculate all expenditure requests to eliminate any expenditures being paid without proper support or inaccurately added totals. All departments ...

Allowability of Expenditures: Chief Dull Knife College has reviewed and updated the policies for expenditures and will continue to review, scrutinize and calculate all expenditure requests to eliminate any expenditures being paid without proper support or inaccurately added totals. All departments have been made aware of the policies and procedures.

View Audit 310397

Finding 403232 (2023-002)

Significant Deficiency 2023

Arkoma School District No. I-91

OK

Questioned Costs Procurement, Suspension & Debarment

The District will follow proper fiscal procedure

View Audit 310392 Questioned Costs: $1

Finding 403231 (2023-008)

Material Weakness 2023

Low Rent Housing Agency of Fort Madison

IA

To ensure compliance with findings the FMHA will review all applicable compliance requirements and controls over processes to determine the appropriate controls are implemented in order to remain in compliance.

View Audit 310390

Finding 403230 (2023-007)

Material Weakness 2023

Low Rent Housing Agency of Fort Madison

IA

FMHA has taken the recommendation of our auditor and obtained a new depository agreement with Two Rivers Bank & Trust. This information is now available upon request.

View Audit 310390

Finding 403229 (2023-006)

Material Weakness 2023

Low Rent Housing Agency of Fort Madison

IA

FMHA Director and Maintenance Director are making a concentrated effort with internal controls for our procurement procedures. All documentation will include the procurement rationale, selection of contract type, selection or rejection and the basis for the contract type. Board minutes in addition t...

FMHA Director and Maintenance Director are making a concentrated effort with internal controls for our procurement procedures. All documentation will include the procurement rationale, selection of contract type, selection or rejection and the basis for the contract type. Board minutes in addition to

View Audit 310390

Finding 403229 (2023-006)

Material Weakness 2023

Low Rent Housing Agency of Fort Madison

IA

rejection and the basis for the contract type. Board minutes in addition to all other supporting documents will be available.

View Audit 310390

Finding 403228 (2023-005)

Material Weakness 2023

Low Rent Housing Agency of Fort Madison

IA

FMHA staff new staff are aware of the importance of dual controls. We have taken the recommendation of our auditor and have discussed dual control when working on tenant files.

View Audit 310390

Finding 403227 (2023-004)

Material Weakness 2023

Low Rent Housing Agency of Fort Madison

IA

Questioned Costs

FMHA has taken the recommendation of our auditor. All tenants have been notified that during our internal audit we discovered that tenants were not being charged appropriately to cover cable expenses. A notice was sent to all tenants that during the internal audit brought awareness to the

View Audit 310390 Questioned Costs: $1

Finding 403227 (2023-004)

Material Weakness 2023

Low Rent Housing Agency of Fort Madison

IA

Questioned Costs

Housing Authority that an increase was necessary to stay in compliance. Remedying cost concerns for cable.

View Audit 310390 Questioned Costs: $1

Finding 403225 (2023-003)

Material Weakness 2023

Low Rent Housing Agency of Fort Madison

IA

Our agency has re-evaluated its internal control procedures over the significant areas of our structure. Controls will be documented to ensure the controls are identifiable and traceable during the audit process.

View Audit 310390

Finding 403224 (2023-002)

Material Weakness 2023

Thlopthlocco Tribal Town Governmental Services Department

OK

Subrecipient Monitoring Material Weakness Reporting

Finding 2023-002 – Program Reporting Requirements – Internal Control Over Compliance – Material Weakness Federal Program Information: Funding Agency: Department of Treasury Title: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Award year and Number(s): 2021 ...

Finding 2023-002 – Program Reporting Requirements – Internal Control Over Compliance – Material Weakness Federal Program Information: Funding Agency: Department of Treasury Title: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Award year and Number(s): 2021 and SLFRP2505 and SLFRP4740 Pass-through entity: Not applicable Type of Finding: Material Weakness in internal control over compliance (reporting) Name of the contact person responsible for corrective action: Sam Rowe, Accounting Manager Phone number of the contact person responsible for corrective action: (405) 395-5000 Anticipated completion date for corrective action: July 15, 2024 Action to be taken in response to the finding: The Department will review the reporting deadlines outlined in all award documents/contracts and setup automated reminders and sign-offs to document the completion and submission of the reports. Management view of the finding: There is no disagreement with the audit finding.

View Audit 310388

Finding 403223 (2023-001)

Material Weakness 2023

Thlopthlocco Tribal Town Governmental Services Department

OK

Reporting

Finding 2023-001 – Program Reporting Requirements – Internal Control Over Compliance – Material Weakness Federal Program Information: Funding Agency: Economic Development Administration Title: Economic Adjustment Assistance Assistance Listing Number: 11.307 Award year and number: 2020 and 08-79...

Finding 2023-001 – Program Reporting Requirements – Internal Control Over Compliance – Material Weakness Federal Program Information: Funding Agency: Economic Development Administration Title: Economic Adjustment Assistance Assistance Listing Number: 11.307 Award year and number: 2020 and 08-79-05447 Pass-through entity: Not applicable Type of Finding: Material Weakness in internal control over compliance (reporting) Name of the contact person responsible for corrective action: Sam Rowe, Accounting Manager Phone number of the contact person responsible for corrective action: (405) 395-5000 Anticipated completion date for corrective action: July 15, 2024 Action to be taken in response to the finding: The Department will review the reporting deadlines outlined in all award documents/contracts and setup automated reminders and sign-offs to document the completion and submission of the reports. Management view of the finding: There is no disagreement with the audit finding.

View Audit 310388

Finding 403213 (2023-001)

Material Weakness 2023

County of Monterey

CA

Reporting Internal Control / Segregation of Duties

Review and Update Internal Controls: We conducted a comprehensive review of our current internal controls related to WIOA grants. This review included identifying any gaps or areas for improvement and implementing necessary updates to strengthen controls. Provide Additional Training: Recognizing the...

Review and Update Internal Controls: We conducted a comprehensive review of our current internal controls related to WIOA grants. This review included identifying any gaps or areas for improvement and implementing necessary updates to strengthen controls. Provide Additional Training: Recognizing the critical nature of compliance with reporting requirements, we had a training session for our staff regarding WIOA. This session will focus on enhancing their understanding of reporting guidelines and requirements, as well as emphasizing the importance of timely and accurate reporting. Enhance Supervision and Review Processes: We have reinforced our review processes to ensure that all reports are thoroughly reviewed before submission. This includes the implementation of a procedure to verify the accuracy and completeness of reports prior to filing.

View Audit 310379

Finding 403212 (2023-001)

Material Weakness 2023

Houston County Board of Education

AL

Questioned Costs Allowable Costs / Cost Principles Special Tests & Provisions § 200.303 § 200.326

Item 2023‐001 – Special Tests and Provisions – Wage Rate Requirements Recommendation: 2 CFR 200.303 requires the non‐Federal entity to “(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non‐Federal entity is managing the Federa...

Item 2023‐001 – Special Tests and Provisions – Wage Rate Requirements Recommendation: 2 CFR 200.303 requires the non‐Federal entity to “(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non‐Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award.” 2 CFR 200.326 and 29 CFR Part 5, Labor Standards Provisions Applicable to Contracts Governing Federally Financed and Assisted Construction (DOL Regulations) require the contractor or subcontractor to submit to the nonfederal entity weekly, for each week in which any contract work is performed, a copy of the payroll and a statement of compliance (certified payrolls). We recommend the strengthening of controls to ensure the prevailing wage rate clauses are included in the contracts and that certified payrolls are received for each week in which construction work is performed. The Chief School Financial Officer, Kerry Bedsole, should review documentation for inclusion of the prevailing wage rate clauses in construction contracts as part of the bid process prior to expenditures being made. She should also review all invoices received from contractors and subcontractors to ensure that the certified payroll information is received for all weeks for which construction work is performed. Action Taken: Management has reviewed the requirements of 2 CFR Section 200.303 and 2 CFR 200.326 relating to wage rate requirements and agrees with the recommendation. Management has already communicated with all contractors and subcontractors regarding the wage rate requirements and has implemented additional procedures, effective October 1, 2023, stating that the Chief School Financial Officer, Kerry Bedsole, will review documentation for inclusion of the prevailing wage rate clauses in construction contracts as part of the bid process prior to expenditures being made. She will also review all invoices received from contractors and subcontractors to ensure that the certified payroll information is received for all weeks for which construction work is performed.

View Audit 310378 Questioned Costs: $1

Finding 403182 (2023-001)

Significant Deficiency 2023

Saint Alban's Housing Corporation

MD

HUD Housing Programs

Condition: The Corporation did not make any required monthly deposits to the reserve for replacements as required by the housing assistance payments contract. Status: The delinquent deposits for 2023 of $43,332 were made to the reserve on March 29, 2024. Management has put procedures into place to e...

Condition: The Corporation did not make any required monthly deposits to the reserve for replacements as required by the housing assistance payments contract. Status: The delinquent deposits for 2023 of $43,332 were made to the reserve on March 29, 2024. Management has put procedures into place to ensure that deposits are made timely in the future and deposits for January through April 2024 have been made as of the report date.

View Audit 310371

Finding 403180 (2023-002)

Material Weakness 2023

Harrison Hills City School District

OH

Matching / Level of Effort / Earmarking Subrecipient Monitoring Cash Management

Even though prevailing wage was paid, contract was bid and awarded as such, in the future, the Treasurer will ensure that prevailing wage rate requirements of necessary clauses are included within all applicable contracts.

View Audit 310361

Finding 403179 (2023-002)

None 2023

Gulf Coast Community Services Association

TX

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

ASSISTANCE LISTING 93.569 – COMMUNITY SERVICES BLOCK GRANT FEDERAL GRANT AWARD NUMBERS: 2101TXCOSR AND 2201TXCOSR PASS-THROUGH ENTITY IDENTIFYING NUMBERS: 61220003647 AND 61230003800 FINDING NO. 2023-002: ALLEGED USE OF FEDERAL FUNDS IN FRAUDULENT MANNER Planned Corrective Action Plan: The Organizat...

ASSISTANCE LISTING 93.569 – COMMUNITY SERVICES BLOCK GRANT FEDERAL GRANT AWARD NUMBERS: 2101TXCOSR AND 2201TXCOSR PASS-THROUGH ENTITY IDENTIFYING NUMBERS: 61220003647 AND 61230003800 FINDING NO. 2023-002: ALLEGED USE OF FEDERAL FUNDS IN FRAUDULENT MANNER Planned Corrective Action Plan: The Organization is committed to combatting fraud by creating an organizational culture and structure conducive to focusing on control activities, fraud-awareness initiatives, reporting mechanisms and employee integrity activities including:Revise programmatic and departmental approval authority-related guidelines designed to counter the previously encountered fraud schemes. • Maximize the functionality of the existing client software systems (e.g., NewGen and Fastrack) to minimize the dependency on external documents. • Use multiple methods to reinforce key antifraud messages through education and training on an ongoing basis to increase managers’ and employees’ awareness of potential fraud schemes. • Provide a hotline and other options for potential reporters of fraud to communicate and ensure that the Organization’s stakeholders (e.g., employees, vendors, program beneficiaries, and the public) are aware of the Organization’s access points to report potential fraud. • Implement mandatory virtual conflict of interest trainings. • Develop a board-approved policy regarding the Organization’s employees receiving services. • Revise the Conflict-of-Interest Policy in the Employee Handbook to serve as a coaching guide that clearly conveys that anyone in the Organization may develop a conflict of interest, whether they are entry-level or a member of the leadership team. Anticipated Implementation Date: December 31, 2024 Contact Person Responsible for Corrective Action: Dr. Jonita Reynolds, Chief Executive Officer

View Audit 310350 Questioned Costs: $1

Finding 403178 (2023-001)

Significant Deficiency 2023

Gulf Coast Community Services Association

TX

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

FINDING NO. 2023-001: NON-COMPLIANCE WITH SPECIAL TESTS AND PROVISIONS RELATED TO TRI-PARTITE BOARD COMPLIANCE AND SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER NONCOMPLIANCE WITH THE RELEVANT SPCIAL TESTS AND PROVISIONS Planned Corrective Action Plan: Key members of the Organization’s management ...

FINDING NO. 2023-001: NON-COMPLIANCE WITH SPECIAL TESTS AND PROVISIONS RELATED TO TRI-PARTITE BOARD COMPLIANCE AND SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER NONCOMPLIANCE WITH THE RELEVANT SPCIAL TESTS AND PROVISIONS Planned Corrective Action Plan: Key members of the Organization’s management will work with the Board of Directors to develop a plan for board recruitment, developing, and training to fill the vacant public sector seat and strengthen monitoring of compliance with the CSBG Act, Texas Administrative Code, and corporate bylaws. The results of the monitoring efforts will be reported to the Governance & Operations Committee and/or the Board of Directors at least on an annual basis. Anticipated Implementation Date: December 31, 2024 Contact Person Responsible for Corrective Action: Dr. Jonita Reynolds, Chief Executive Officer

View Audit 310350

Finding 403177 (2023-101)

None 2023

Valley Health Systems, Inc.

MA

Allowable Costs / Cost Principles Cash Management

Unallowable Costs Criteria: The Organization must submit only allowable costs for reimbursement under the accounting principles contained in Uniform Guidance. Condition: During compliance testing, it was noted that one out of twenty five selections improperly included alcohol in the balances submit...

Unallowable Costs Criteria: The Organization must submit only allowable costs for reimbursement under the accounting principles contained in Uniform Guidance. Condition: During compliance testing, it was noted that one out of twenty five selections improperly included alcohol in the balances submitted for expense reimbursements. Context: One expense reimbursement was found to have reimbursed alcohol. Cause: There was a lack of consistent review of the receipt before submission for expense reimbursement. Effect: As a result of the condition, one reimbursement was overpaid. Recommendation: In the future, the Organization should review reimbursements closely to ensure unallowable costs are not submitted for reimbursement. Contact: Erin Spaulding, Senior Director of Finance. Corrective Actions Taken or Planned: Management acknowledges the finding and will take action to ensure that no unallowable costs are being reimbursed.

View Audit 310342

Finding 403176 (2023-002)

Significant Deficiency 2023

Public Health - Madison and Dane County

WI

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

City of Madison Fire Department will coordinate with the City of Madison, Internal Audit and Grants function of the Finance Department, for an independent person to review the reports before submission to ensure the loss revenue calculation and amounts reported are accurate. This additional internal...

City of Madison Fire Department will coordinate with the City of Madison, Internal Audit and Grants function of the Finance Department, for an independent person to review the reports before submission to ensure the loss revenue calculation and amounts reported are accurate. This additional internal control procedure will ensure there are proper review and approval processes over completeness and accuracy of reports before submissions to federal agencies.

View Audit 310331

Finding 403175 (2023-003)

Significant Deficiency 2023

Public Health - Madison and Dane County

WI

Subrecipient Monitoring Reporting

On the 1st Quarter 2024 Quarterly Project and Expenditure (P&E) Report, the Grant Supervisor reported all expenditures related to the Revenue Recovery Replacement Category and submitted the report through the Treasury Portal. This correction was made prior to the auditor’s finding for 2023. Going fo...

On the 1st Quarter 2024 Quarterly Project and Expenditure (P&E) Report, the Grant Supervisor reported all expenditures related to the Revenue Recovery Replacement Category and submitted the report through the Treasury Portal. This correction was made prior to the auditor’s finding for 2023. Going forward, expenditures related to Revenue Recovery Replacement will be reported under Category 6 per the “Compliance and Reporting Guidance, State and Local Fiscal Recovery Fund”, dated March 28, 2024.

View Audit 310331

Corrective Action Plans

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