Corrective Action Plans

Finding 480286 (2022-006)

Material Weakness 2022

ND

Questioned Costs

Responsible Individual: Ambrosia Ermenc, Business Manager Corrective Action Plan: The district will create / implement requirements within policy and internal controls for time allocation / time logs to be utilized for every staff member salaried out of federal funds. Anticipated Completion Date: on...

Responsible Individual: Ambrosia Ermenc, Business Manager Corrective Action Plan: The district will create / implement requirements within policy and internal controls for time allocation / time logs to be utilized for every staff member salaried out of federal funds. Anticipated Completion Date: ongoing

View Audit 316501 Questioned Costs: $1

Finding 480235 (2022-001)

None 2022

Christian Valley Park Community Service District

CA

Questioned Costs Reporting Matching / Level of Effort / Earmarking § 200.329

While discussing this issue with the USDA over email it was agreed that other expenses that were previously paid by the district and not covered by the USDA loan would be acceptable to use instead of the miscalculated, overage of the interest expense. The district had spent several hundred thousand ...

While discussing this issue with the USDA over email it was agreed that other expenses that were previously paid by the district and not covered by the USDA loan would be acceptable to use instead of the miscalculated, overage of the interest expense. The district had spent several hundred thousand dollars in funds above the originally budgeted district contribution towards the Water Storage Tank Project previous to acquiring the loan with the USDA.

View Audit 316460 Questioned Costs: $1

Finding 480053 (2022-007)

Material Weakness 2022

Cornerstones Inc, Cornerstones Housing Corporation & Rihc Partners, Lp

VA

Eligibility Material Weakness Internal Control / Segregation of Duties

Cornerstones acknowledges that our files were incomplete. It is our position that the COVID-19 pandemic created immense need to which Cornerstones responded by expanding rapidly and mobilizing funding and program requests that did not receive the benefit of comprehensive planning; the focus was on h...

Cornerstones acknowledges that our files were incomplete. It is our position that the COVID-19 pandemic created immense need to which Cornerstones responded by expanding rapidly and mobilizing funding and program requests that did not receive the benefit of comprehensive planning; the focus was on health prevention, isolation and quarantine activities, and temporary shelter for homeless and other low-income, vulnerable seniors and disabled persons. We served those in need and our intake processes and recordkeeping did not keep pace. Additionally, given the time that has passed since the services in question, it is possible that records that did exist were misplaced. Staff turnover, resulting from the pandemic burden, made it challenging to go back to the work that had been done. In the time since these events Cornerstones has further emphasized the compliance and documentation needs of the case management process, and we have filled turned-over positions with experienced staff that also understand intake and documentation requirements. We have also hired a Senior Director, Finance with over 20 years of federal contracts experience that is an integral part of increased program compliance and operational oversight responsibilities within the Finance/Operations function. This Senior Director and Cornerstones’ Chief Financial & Operating Officer, Executive Vice President of Housing and Community Programs, and other program leaders and staff, will all work together to ensure that the file construction process is complete and timely for all participants. Due to timing of receiving this finding, remediation processes began in fiscal year 2024 and will be applied fully to the fiscal year 2025, beginning 7/1/2024, files.

View Audit 316339

Finding 480052 (2022-005)

Significant Deficiency 2022

Cornerstones Inc, Cornerstones Housing Corporation & Rihc Partners, Lp

VA

Questioned Costs Cash Management Allowable Costs / Cost Principles § 200.414

The Organization has taken steps to ensure that the calculation of indirect costs is executed properly and reviewed for compliance in accordance with the contract agreement. Management brought the error in the contracted indirect rate to the funders attention initially, but unfortunately a misstep b...

The Organization has taken steps to ensure that the calculation of indirect costs is executed properly and reviewed for compliance in accordance with the contract agreement. Management brought the error in the contracted indirect rate to the funders attention initially, but unfortunately a misstep back to the original contract terms was made before close-out. The development and application of indirect rates will be conducted by the Sr. Director of Finance with oversight by the Chief Financial & Operating Officer and is in place as of the date of this corrective action plan.

View Audit 316339 Questioned Costs: $1

Finding 480051 (2022-004)

Significant Deficiency 2022

Cornerstones Inc, Cornerstones Housing Corporation & Rihc Partners, Lp

VA

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303 § 200.334

Management agrees with the recommendation and will implement stronger processes to ensure that all records are organized and maintained for ease of timely and complete review and consultation when needed. The processes to organize and secure files will be executed by program staff, with oversight by...

Management agrees with the recommendation and will implement stronger processes to ensure that all records are organized and maintained for ease of timely and complete review and consultation when needed. The processes to organize and secure files will be executed by program staff, with oversight by the Vice President of Community Building and Neighborhood Resources, Executive Vice President of Housing and Community Programs, Vice President of Family Empowerment and Self Sufficiency, Chief Financial & Operating Officer, and Sr. Director of Finance. Due to timing of receiving this finding, remediation processes began in fiscal year 2024 and will be applied fully to the fiscal year 2025, beginning 7/1/2024, files.

View Audit 316339

Finding 480050 (2022-003)

Significant Deficiency 2022

Cornerstones Inc, Cornerstones Housing Corporation & Rihc Partners, Lp

VA

Significant Deficiency Internal Control / Segregation of Duties § 200.303 § 200.334

Management agrees with and will implement the recommendation that processes be in place to review and confirm the completeness and accuracy of intake forms within the regulations while also considering the needs and choices of the program participants. These file completeness processes will be execu...

Management agrees with and will implement the recommendation that processes be in place to review and confirm the completeness and accuracy of intake forms within the regulations while also considering the needs and choices of the program participants. These file completeness processes will be executed by program staff, with oversight by the Vice President of Community Building and Neighborhood Resources, Executive Vice President of Housing and Community Programs, Vice President of Family Empowerment and Self Sufficiency, Chief Financial & Operating Officer, and Sr. Director of Finance. Due to timing of receiving this finding, remediation processes began in fiscal year 2024 and will be applied fully to the fiscal year 2025, beginning 7/1/2024, files.

View Audit 316339

Finding 480049 (2022-001)

Material Weakness 2022

Cornerstones Inc, Cornerstones Housing Corporation & Rihc Partners, Lp

VA

Questioned Costs Allowable Costs / Cost Principles § 200.430

Management acknowledges that it is necessary to more specifically itemize employee time that is applicable to the federal grants and contracts that partially fund broad programs and services and has instituted infrastructure to ensure that this is done and documented correctly in the future. The nec...

Management acknowledges that it is necessary to more specifically itemize employee time that is applicable to the federal grants and contracts that partially fund broad programs and services and has instituted infrastructure to ensure that this is done and documented correctly in the future. The necessary codes are in place in our payroll system and guidance and leadership of the timesheet process will be provided by all program executives (EVP, VP) to all staff that are impacted, with oversight by the Chief Financial & Operating Officer and Sr. Director of Finance. This is in place as of the date of this corrective action plan.

View Audit 316339 Questioned Costs: $1

Finding 479763 (2022-004)

Material Weakness 2022

Cambria Heights School District

PA

School Nutrition Programs Internal Control / Segregation of Duties Reporting

CONDITION: The District did not maintain a general ledger system of accounting for its Cafeteria Fund which reports the financial activity of the federal National School Lunch and School Breakfast Programs. The financial activity occurring in this Fund is maintained in checkbook fashion during the f...

CONDITION: The District did not maintain a general ledger system of accounting for its Cafeteria Fund which reports the financial activity of the federal National School Lunch and School Breakfast Programs. The financial activity occurring in this Fund is maintained in checkbook fashion during the fiscal year. This is a repeat finding (2021-004) from the previous fiscal year. CRITERIA: Prudent internal control over accounting for federal program funds requires non-federal organizations such as the School District to maintain financial records which account for federal funds in such a manner as to be able to properly track the receipt and use of federal funds as stated in Section 2 CFR Part 200 of the Uniform Guidance. Best practices suggest that the use of a general ledger system of accounting would enable the District to aggregate financial information involving federal funds during the fiscal year in such a manner to properly manage, monitor, and report the financial activity in compliance with federal program guidelines. RECOMMENDATION: The District’s accounting software can readily account for the financial activity of all Funds in a manner like the District’s General Fund. I am recommending that the management of the School District utilize the accounting software to enter the financial activity (Receipts and Disbursements) of the Cafeteria Fund in a manner like the General Fund. This procedure will significantly enhance the District-wide internal controls over financial reporting for the Cafeteria Fund, as well as provide management the ability to produce meaningful financial reports reflecting the activity in the Cafeteria Fund for prudent oversight by the Board of Education. In addition, this procedure will enable the District to comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200 of the Uniform Guidance. MANAGEMENT’S CORRECTIVE ACTION PLAN: District management is reviewing its current system of processing the transactions for the Cafeteria Fund to determine the most efficient and effective manner for implementation of a general ledger system of accounting for this Fund as opposed to its current manual process. It is anticipated that the conversion of this Fund into the District’s accounting software can be completed during the 2024-2025 fiscal year to enable the District to comply with the recordkeeping requirements for federal funds as specified in 2 CFR Part 200 of the Uniform Guidance.

View Audit 316303

Finding 479756 (2022-007)

Material Weakness 2022

Cambria Heights School District

PA

Questioned Costs Procurement, Suspension & Debarment § 200.318 § 200.320

CONDITION: During my review of the District’s compliance with the requirements for noncompetitive procurement, I noted the District did not document its rationale for purchases made from four (4) vendors - CJAWS, Inc., Edmentum, Inc., Savvas Learning Company, and Technology Resource Advisors, Inc. T...

CONDITION: During my review of the District’s compliance with the requirements for noncompetitive procurement, I noted the District did not document its rationale for purchases made from four (4) vendors - CJAWS, Inc., Edmentum, Inc., Savvas Learning Company, and Technology Resource Advisors, Inc. This is a repeat finding (2021-007) from the previous fiscal year for CJAWS, Inc. CRITERIA: In accordance with Section 2 CFR 200.318(i) of the Uniform Guidance, the District must maintain records sufficient to detail the history of procurement. These records include but are not limited to the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Furthermore, Section 2 CFR 200.320(c’) of the Uniform Guidance details five (5) circumstances in which noncompetitive procurement can be used. RECOMMENDATION: I recommend that the School District update their policies to include those most recent related to ‘federal fiscal compliance’ in accordance with the Uniform Guidance, in particular, procurement policies to address the requirements of Section 2 CFR 200.318(i) and 320(c). In addition, I would recommend that District personnel responsible for expenditures related to federal funding receive updated training related to ‘procurement’ policies and procedures as they relate to federal funding. MANAGEMENT’S PLANNED CORRECTIVE ACTION: Management of the School District will review and update as necessary its ‘federal fiscal compliance policies’ to comply with the requirements of the Uniform Guidance. Particularly as it relates to procurement procedures, for acquisitions of property or services in which the aggregate dollar amount is greater than the micro-purchase threshold but does not exceed the simplified acquisition threshold, the District will obtain and document price or rate quotations from at least three qualified sources. In addition, management of the District will obtain training where available and applicable to enhance their internal controls over the management of federal program funds. The District’s timeframe for implementation is effective immediately.

View Audit 316303 Questioned Costs: $1

Finding 479753 (2022-009)

Material Weakness 2022

Cambria Heights School District

PA

Questioned Costs Procurement, Suspension & Debarment § 200.214

CONDITION: In connection with the Cambria Heights School District’s RTU Replacement Project, the District did not perform debarment and suspension checks for contractors through SAM.gov. CRITERIA: In accordance with Section 2 CFR 200.214 of the Uniform Guidance, the District is subject to the non-pr...

CONDITION: In connection with the Cambria Heights School District’s RTU Replacement Project, the District did not perform debarment and suspension checks for contractors through SAM.gov. CRITERIA: In accordance with Section 2 CFR 200.214 of the Uniform Guidance, the District is subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. These regulations restrict the awarding of contracts to certain parties that are debarred, suspended, or otherwise ineligible to participate in federal assistance programs. RECOMMENDATION: I am recommending that the management of the School District utilize the SAM.gov website for determining whether contractors/vendors are debarred or suspended from participating in federal assistance programs on all future applicable contract awards to ensure compliance with Section 2 CFR 200.214 of the Uniform Guidance. MANAGEMENT’S CORRECTIVE ACTION PLAN: Effective immediately, management will implement the practice of properly vetting future third-party contractors for debarment and suspension in federal assistance programs by utilizing the SAM.gov website, to ensure compliance with Section 2 CFR 200.214 of the Uniform Guidance and Executive Orders 12549 and 12689, 2 CFR part 180.

View Audit 316303 Questioned Costs: $1

Finding 479752 (2022-008)

Material Weakness 2022

Cambria Heights School District

PA

Questioned Costs Procurement, Suspension & Debarment § 200.321

CONDITION: In connection with the Cambria Heights School District’s RTU Replacement Project, the District did not take affirmative action steps to ensure that minority businesses, women’s business enterprises, and labor surplus area firms were used, when possible, in the procurement process. CRITERI...

CONDITION: In connection with the Cambria Heights School District’s RTU Replacement Project, the District did not take affirmative action steps to ensure that minority businesses, women’s business enterprises, and labor surplus area firms were used, when possible, in the procurement process. CRITERIA: In accordance with Section 2 CFR 200.321(a) of the Uniform Guidance, the District must take all necessary affirmative action steps to assure that minority businesses, women’s business enterprises, and labor surplus area firms are used when possible. Section 2 CFR 200.321(a) of the Uniform Guidance outlines the six (6) affirmative steps to follow. RECOMMENDATION: I am recommending that the management of the School District implement, as a matter of policy, the six (6) affirmative action steps as stated Section 2 CFR 200.321(a) of the Uniform Guidance. MANAGEMENT’S CORRECTIVE ACTION PLAN: Management of the School District will review and update as necessary its ‘federal fiscal compliance policies’ to comply with the requirements of the Uniform Guidance. As a matter of policy, the District will implement the six (6) recommended affirmative action steps to ensure compliance with Section 2 CFR 200.321(a) of the Uniform Guidance. The timeframe for implementation of the updated policy will occur during the first six-months of the District’s 2024-2025 fiscal year, and the practice of applying the affirmative action steps will be effective immediately.

View Audit 316303 Questioned Costs: $1

Finding 479751 (2022-006)

Material Weakness 2022

Cambria Heights School District

PA

Matching / Level of Effort / Earmarking § 200.302

CONDITION: During my sample review of the District’s completion of its federal grant program ‘Quarterly Cash On Hand Reconciliations’ for the 2021-2022 4th fiscal quarter for the ESSER II and ARP ESSER grants, I noted that the amounts reported to date for ‘total disbursements’ could not be ascertain...

CONDITION: During my sample review of the District’s completion of its federal grant program ‘Quarterly Cash On Hand Reconciliations’ for the 2021-2022 4th fiscal quarter for the ESSER II and ARP ESSER grants, I noted that the amounts reported to date for ‘total disbursements’ could not be ascertained from the coding of these expenditures in the District’s general ledger (See Finding 2022-005) and did not reconcile to the separate spreadsheets maintained by the School District. This is a repeat finding (2021-006) from the previous fiscal year. CRITERIA: Section 2 CFR 200.302(a) and 302(b) of the Uniform Guidance requires non-federal organizations such as the School District to maintain financial records which account for federal funds in such a manner as to be able to properly track the identification and use of federal funds. RECOMMENDATION: I am recommending that the School District properly follow the guidance contained within the PA Office of the Budget, Office of Comptroller Operations Chart of Accounts for recording all expenditures of the School District, most specifically, federal program grant expenditures to comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance, to allow for the proper completion of the ‘quarterly cash on hand reconciliations’. MANAGEMENT’S CORRECTIVE ACTION PLAN: District management is in the process of revising its chart of accounts in the general ledger to properly reflect the funding source codes for federal program expenditures, and other available funding source codes (state and local) as applicable to the District. It is anticipated that the updated chart of accounts will be utilized by the District starting with the 2024-2025 fiscal year to enable the District to effectively access the necessary federal expenditure totals, by individual grant program, to document and support amounts reported as ‘total cash disbursed’ on the quarterly cash on hand reconciliations. This procedure will enable the District to comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance and PDE regulations.

View Audit 316303

Finding 479749 (2022-005)

Material Weakness 2022

Cambria Heights School District

PA

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.302

CONDITION: The District did not properly record its federal program expenditures for the GEER, ESSER, and ARP ESSER federal grant programs using the various federal funding source expenditure codes as prescribed by the Chart of Accounts for PA Local Educational Agencies maintained by the PA Office o...

CONDITION: The District did not properly record its federal program expenditures for the GEER, ESSER, and ARP ESSER federal grant programs using the various federal funding source expenditure codes as prescribed by the Chart of Accounts for PA Local Educational Agencies maintained by the PA Office of the Budget, Office of Comptroller Operations. This is a repeat finding (2021-005) from the previous fiscal year. CRITERIA: The Pennsylvania Department of Education (PDE), through the PA Office of the Budget, Office of Comptroller Operations Chart of Accounts requires School Districts to utilize specific funding source codes for federal program expenditures. In addition, Section 2 CFR 200.302(a) and 302(b) of the Uniform Guidance requires non-federal organizations such as the School District to maintain financial records which account for federal funds in such a manner as to be able to properly track the identification and use of federal funds. RECOMMENDATION: I am recommending that the School District properly follow the guidance contained within the PA Office of the Budget, Office of Comptroller Operations Chart of Accounts for recording all expenditures of the School District, most specifically, federal program grant expenditures to 1) enhance internal controls for tracking and monitoring federal program expenditures and 2) comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance and PDE regulations. MANAGEMENT’S CORRECTIVE ACTION PLAN: District management is in the process of revising its chart of accounts in the general ledger to properly reflect the funding source codes for federal program expenditures, and other available funding source codes (state and local) as applicable to the District. It is anticipated that the updated chart of accounts will be utilized by the District starting with the 2024-2025 fiscal year to enable the District to enhance its internal controls for tracking and monitoring federal program expenditures and to comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance and PDE regulations.

View Audit 316303

Finding 479700 (2022-003)

Significant Deficiency 2022

Ozarks Medical Center

MO

Reporting Significant Deficiency Internal Control / Segregation of Duties

U.S. Department of Health and Human Services Ozarks Medical Center (“Medical Center”) respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: January 1, 2022 – December 31, 2022 The findings from the schedule of findings and questioned costs are...

U.S. Department of Health and Human Services Ozarks Medical Center (“Medical Center”) respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: January 1, 2022 – December 31, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS— FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL PROGRAMS DEPARTMENT OF HEALTH AND HUMAN SERVICES 2022 – 003 COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Recommendation: We recommend the Hospital design controls to ensure that reporting is completed in accordance with latest HHS guidelines. Action taken in response to finding: The Hospital will ensure that the required timing of reporting is met in future reporting periods. Name of the contact person responsible for corrective action: Bryan Coffey, Director of Finance. Planned completion date for corrective action plan: July 31, 2024 If the Department of Health and Human Services has questions regarding this plan, please call Bryan Coffey, Director of Finance at (417) 256 - 9111 ext 6003.

View Audit 316257

Finding 479648 (2022-013)

Significant Deficiency 2022

Municipality of Anchorage, Alaska

AK

Equipment & Real Property Management § 200.313

Finding 2022-013 Equipment and Real Property Management - Noncompliance and Significant Deficiency in Internal Control Over Compliance Corrective Action Plan: Management agrees with this finding and will work to achieve compliance with the requirements outlined in 2 CRF Sections 200.313. Specificall...

Finding 2022-013 Equipment and Real Property Management - Noncompliance and Significant Deficiency in Internal Control Over Compliance Corrective Action Plan: Management agrees with this finding and will work to achieve compliance with the requirements outlined in 2 CRF Sections 200.313. Specifically, Management will enhance controls over the review and disposal of equipment and real property and enhance supervisory reviews over this accounting function. Anticipated Completion Date: December 31, 2024

View Audit 316214

Finding 479646 (2022-012)

Significant Deficiency 2022

Municipality of Anchorage, Alaska

AK

Equipment & Real Property Management § 200.313

Finding 2022-012 Equipment and Real Property Management - Noncompliance and Significant Deficiency in Internal Control Over Compliance Corrective Action Plan: Management agrees with this finding and will strive to create and to maintain a complete and accurate equipment and real property listing. Fu...

Finding 2022-012 Equipment and Real Property Management - Noncompliance and Significant Deficiency in Internal Control Over Compliance Corrective Action Plan: Management agrees with this finding and will strive to create and to maintain a complete and accurate equipment and real property listing. Further, staff will perform regular reconciliations for the equipment and real property listing to ensure that its accuracy is maintained. Anticipated Completion Date: December 31, 2024

View Audit 316214

Finding 479645 (2022-011)

Material Weakness 2022

Municipality of Anchorage, Alaska

AK

Equipment & Real Property Management § 200.313

Finding 2022-011 Equipment and Real Property Management - Material Noncompliance and Material Weakness in Internal Controls Over Compliance Corrective Action Plan: Management agrees with this finding and will strive to create and to maintain a complete and accurate equipment and real property listin...

Finding 2022-011 Equipment and Real Property Management - Material Noncompliance and Material Weakness in Internal Controls Over Compliance Corrective Action Plan: Management agrees with this finding and will strive to create and to maintain a complete and accurate equipment and real property listing. Further, staff will perform regular reconciliations for the equipment and real property listing to ensure that its accuracy is maintained. Anticipated Completion Date: December 31, 2024

View Audit 316214

Finding 479637 (2022-010)

Significant Deficiency 2022

Municipality of Anchorage, Alaska

AK

Procurement, Suspension & Debarment Subrecipient Monitoring

Finding 2022-010 Procurement and Suspension and Debarment – Noncompliance and Significant Deficiency in Internal Control Over Compliance Corrective Action Plan: Management concurs with the finding and will adhere to the corrective action plan. Management plans to perform reviews of procurement contr...

Finding 2022-010 Procurement and Suspension and Debarment – Noncompliance and Significant Deficiency in Internal Control Over Compliance Corrective Action Plan: Management concurs with the finding and will adhere to the corrective action plan. Management plans to perform reviews of procurement contracts in place. Anticipated Completion Date: December 31, 2024

View Audit 316214

Finding 479634 (2022-009)

Material Weakness 2022

Municipality of Anchorage, Alaska

AK

Subrecipient Monitoring § 200.332 § 200.501

Finding 2022-009 Subrecipient Monitoring – Material Noncompliance and Material Weakness in Internal Controls Over Compliance Corrective Action Plan: Management concurs with the finding and will adhere to the corrective action plan included in this report. Management plans to revise policies and proc...

Finding 2022-009 Subrecipient Monitoring – Material Noncompliance and Material Weakness in Internal Controls Over Compliance Corrective Action Plan: Management concurs with the finding and will adhere to the corrective action plan included in this report. Management plans to revise policies and procedures related to subrecipient monitoring. Anticipated Completion Date: December 31, 2024

View Audit 316214

Finding 479622 (2022-008)

Material Weakness 2022

Municipality of Anchorage, Alaska

AK

Material Weakness Reporting Internal Control / Segregation of Duties § 200.512

Finding 2022-008 Reporting - Deadline for Federal Single Audit - Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan: Management concurs with the finding and will strive to endure future audits are completed timely and reporting packages are submitted to th...

Finding 2022-008 Reporting - Deadline for Federal Single Audit - Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan: Management concurs with the finding and will strive to endure future audits are completed timely and reporting packages are submitted to the FAC within the required timeframes. Anticipated Completion Date: December 31, 2024

View Audit 316214

Finding 479604 (2022-003)

Significant Deficiency 2022

Iron County Hospital District Dba: Iron County Medical Center

IL

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

U.S. Department of Agriculture Iron County Hospital District dba: Iron County Medical Center (“Medical Center”) respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 – June 30, 2022 The findings from the schedule of findings and quest...

U.S. Department of Agriculture Iron County Hospital District dba: Iron County Medical Center (“Medical Center”) respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 – June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF HEALTH AND HUMAN SERVICES 2022 – 2023 Community Facilities Loans and Grants Recommendation: We recommend the Hospital design controls to ensure that reporting is completing in accordance with latest USDA guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Medical Center will ensure that controls are put into place to ensure timely reporting in accordance with the USDA guidelines. Name of the contact person responsible for corrective action: Steve Weiss, Interim CFO Planned completion date for corrective action plan: July 1, 2022

View Audit 316187

Finding 479574 (2022-018)

Material Weakness 2022

Mental Health Association of Columbia-Greene Counties Inc.

NY

Questioned Costs Procurement, Suspension & Debarment § 200.317 § 200.326

The administration will review the procurement policy in the next management meeting. Division Directors will review the procurement policy with all Program Directors and Managers. Also, see actions for 2022-017

View Audit 316102 Questioned Costs: $1

Finding 479570 (2022-017)

Material Weakness 2022

Mental Health Association of Columbia-Greene Counties Inc.

NY

Questioned Costs Period of Performance § 200.1 § 200.308 § 200.309 § 200.344

Invoices that are received will be scanned to “invoices”. This will direct them to our electronic software, Docuware. The item will then be forwarded to the appropriate Program Director for approval, and they will indicate the appropriate cost centers / allocations. Bookers will then review the ap...

Invoices that are received will be scanned to “invoices”. This will direct them to our electronic software, Docuware. The item will then be forwarded to the appropriate Program Director for approval, and they will indicate the appropriate cost centers / allocations. Bookers will then review the approved coding and entered fiscal software. If there is a question or concern about approved coding by the bookkeeper they will speak with Director of Finance, Ethan Terrio. Once invoices are entered into fiscal software, checks will be printed. The check stub and invoice will be attached to each other and filed in the fiscal department. Paper documents will continue to be maintained in fiscal until we go 100% paperless, then all documents will be stored in Docuware.

View Audit 316102 Questioned Costs: $1

Finding 479566 (2022-016)

Material Weakness 2022

Mental Health Association of Columbia-Greene Counties Inc.

NY

Matching / Level of Effort / Earmarking

On the 15th of each month the Residential Division Director will meet with the Director of Finance to review the prior months match and year to date match and sign off on the report. This will assist in ensuring all match (cash/inkind) are accounted for accurately and that MHACG meets the required ...

On the 15th of each month the Residential Division Director will meet with the Director of Finance to review the prior months match and year to date match and sign off on the report. This will assist in ensuring all match (cash/inkind) are accounted for accurately and that MHACG meets the required 25% match.

View Audit 316102

Finding 479562 (2022-015)

Material Weakness 2022

Mental Health Association of Columbia-Greene Counties Inc.

NY

HUD Housing Programs Special Tests & Provisions

The Division Director of Residential Services, Susie Cody, will obtain the rent reasonable checklists, a signed lease, and any other required forms when a new client is accepted into the program. Division Director, Susie Cody, will provide the Fiscal Director, Ethan Terrio, with a copy of the follo...

The Division Director of Residential Services, Susie Cody, will obtain the rent reasonable checklists, a signed lease, and any other required forms when a new client is accepted into the program. Division Director, Susie Cody, will provide the Fiscal Director, Ethan Terrio, with a copy of the following items when an apartment is brought online, there is some other change requiring the completion of these forms, or the first week of January each year: Lease, Rent Reasonableness. All forms for new apartments are to be supplied to Director of Finance prior to the issuing of any check forrent or security deposit without Executive Director approval. All forms will be scanned and placed in the resident’s electronic health record (AWARDS). The forms will also be scanned and kept in a shared finance folder.

View Audit 316102

Corrective Action Plans

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