Corrective Action Plans

Finding 20392 (2022-004)

Material Weakness 2022

AZ

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Finding 2022-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Hospital did not properly include 340B reve...

Finding 2022-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Hospital did not properly include 340B revenues and final audit adjustments in net patient service revenue. In addition, the Hospital did not properly report payor categories for quarters in which the net patient service revenues were negative. Responsible Individuals: Patti Clavette, Chief Financial Officer; Jackie Lundblad, Chief Executive Officer Corrective Action Plan: Management will modify the lost revenue reported on future reports, if any, to reflect an accurate total lost revenue amount. In addition, a formal review and approval process will be implemented to ensure calculations are in accordance with applicable requirements and a member of management will be identified to review all reporting requirements for federal grants and awards to ensure the Hospital is in compliance with the requirements. Anticipated Completion Date: September 30, 2023

View Audit 21564

Finding 20391 (2022-006)

Significant Deficiency 2022

Wickenburg Community Hospital

AZ

Questioned Costs Allowable Costs / Cost Principles Cash Management

Finding 2022-006 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Compliance Requirement: Allowable Costs Finding Summary: Management calculated the applicant?s contribution as 25% of the funds requested ...

Finding 2022-006 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Compliance Requirement: Allowable Costs Finding Summary: Management calculated the applicant?s contribution as 25% of the funds requested for reimbursements instead of first applying the full contribution to the requested reimbursement. Responsible Individuals: Patti Clavette, Chief Financial Officer; Jackie Lundblad, Chief Executive Officer Corrective Action Plan: Management will properly adjust subsequent requests for reimbursement under the grant agreement for the remaining portion of the applicant?s contribution. In addition, management will evaluate controls in place to ensure conditions of future grants are met in order to prevent further noncompliance or question costs. Anticipated Completion Date: September 30, 2023

View Audit 21564 Questioned Costs: $1

Finding 20389 (2022-005)

Significant Deficiency 2022

Wickenburg Community Hospital

AZ

Student Financial Aid Subrecipient Monitoring Reporting

Finding 2022-005 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Compliance Requirement: Reporting Finding Summary: Management was unaware of the requirement to submit the annual proposed budget to the R...

Finding 2022-005 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Compliance Requirement: Reporting Finding Summary: Management was unaware of the requirement to submit the annual proposed budget to the Rural Development Area Office within 30 days of each year end. The Hospital approves the budget annually. However, the budget is not submitted to USDA. Responsible Individuals: Patti Clavette, Chief Financial Officer; Jackie Lundblad, Chief Executive Officer Corrective Action Plan: Management will put a process in place to ensure the approved budget is submitted to USDA within 30 days of year end. Anticipated Completion Date: December 31, 2023

View Audit 21564

Finding 20384 (2022-004)

Material Weakness 2022

Morris Area Public School 2769

MN

Allowable Costs / Cost Principles Material Weakness School Nutrition Programs

Finding Summary: During the course of our engagement, we noted instances where documentation was not retained supporting payroll expenditures and invoices were paid in an incorrect amount that was charged to the federal Child Nutrition Cluster program. Responsible Individuals: Shane Monson, Superint...

Finding Summary: During the course of our engagement, we noted instances where documentation was not retained supporting payroll expenditures and invoices were paid in an incorrect amount that was charged to the federal Child Nutrition Cluster program. Responsible Individuals: Shane Monson, Superintendent. Corrective Action Plan: The District will review and strengthen the controls surrounding the review and approval of allowable costs to ensure they are supported, approved of, and calculations are accurate. Anticipated Completion Date: June 30, 2023

View Audit 20655

Finding 20381 (2022-001)

Significant Deficiency 2022

Tri-County Community Health Council, Inc. (d/b/a Commwell Health)

NC

Special Tests & Provisions Subrecipient Monitoring Eligibility

CORRECTIVE ACTION PLAN November 4, 2022 Health Resources and Services Administration Tri-County Community Health Council, Inc. (d/b/a CommWell Health) respectfully submits the following corrective action plan for the year ended March 31, 2022. _______________________________________________________...

CORRECTIVE ACTION PLAN November 4, 2022 Health Resources and Services Administration Tri-County Community Health Council, Inc. (d/b/a CommWell Health) respectfully submits the following corrective action plan for the year ended March 31, 2022. ____________________________________________________________________________________ CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: March 31, 2022 The findings from the March 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS ? FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Centers Program Cluster (Assistance listing number 93.224/93.527) Finding 2022-001 - Special Tests and Provisions SIGNIFICANT DEFICIENCY Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken CommWell Health concurs with the recommendation and has designed a series of enhancements to existing registration orientation and ongoing training. Additional training time will be dedicated with current front desk registration colleagues to ensure that they can determine household income from the documentation given to them by patients. This education will be completed by December 31, 2022. New hire orientation training will include a thorough review of the Front Desk Handbook and slide fee procedures. Post-test will be given to each front desk colleague upon completion of education. Scores of at least 90% will required or training and testing will be repeated. In addition, CommWell Health is moving to a new electronic health record (EHR), EPIC, beginning November 7, 2022. This system has much better controls built in to help ensure that slide fee is documented correctly. EPIC also does not have many of the system limitations our previous EHR had. Audits of 100% of slide fee records will be done every day by designated colleagues to ensure slide fee documentation is correct. Supervisors will review daily audit findings and ensure additional training is given accordingly. Corrective action will be taken on any errors noted during audits. Finance staff will conduct random internal audits of slide fee records each month to evaluate for compliance with applicable requirements. Results of internal audits will be reviewed monthly in Utilization Review Committee. If the Health Resources and Services Administration has questions regarding this plan, please call Cheryl Stanley, Chief Financial Officer, at 910-567-7008.

View Audit 20022

Finding 20379 (2022-001)

Significant Deficiency 2022

Junior Achievement of Arizona, Inc.

AZ

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

Management has implemented procedures to verify that the expenditures that are requested for reimbursement are not duplicated and are allowable under the Uniform Guidance. Review procedures have been added to help ensure that only allowable salaries expenses are included in reimbursement requests an...

Management has implemented procedures to verify that the expenditures that are requested for reimbursement are not duplicated and are allowable under the Uniform Guidance. Review procedures have been added to help ensure that only allowable salaries expenses are included in reimbursement requests and that all voided checks are omitted.

View Audit 19855 Questioned Costs: $1

Finding 20378 (2022-002)

Significant Deficiency 2022

Housing Authority of the Township of Neptune

NJ

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.423 § 200.438 § 200.473

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Bart Cook,...

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Bart Cook, Executive Director, is responsible for implementing this corrective action by September 30, 2023.

View Audit 19315 Questioned Costs: $1

Finding 20377 (2022-001)

Significant Deficiency 2022

Peacehealth Networks

WA

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

As noted within the portal filing summary for the general reporting Period 1, the Corporation?s consolidated lost revenue totaled $141,363,926. Payments from the PRF for Period 1 totaled $53,982,121 for the consolidated parent and $14,810,675 for St. John?s Medical Center Period 2 targeted report. A...

As noted within the portal filing summary for the general reporting Period 1, the Corporation?s consolidated lost revenue totaled $141,363,926. Payments from the PRF for Period 1 totaled $53,982,121 for the consolidated parent and $14,810,675 for St. John?s Medical Center Period 2 targeted report. As a result, there were sufficient qualifying lost revenues to receive and earn all PRF funds received, regardless of the reporting error identified and described in the ?condition found? section above. Therefore, management believes no repayment of PRF funds received would be required. Management is implementing a process to add additional review steps prior to finalizing future reporting submissions.

View Audit 19419

Finding 20376 (2022-004)

Material Weakness 2022

The Be Kind People Project Foundation

AZ

Reporting Material Weakness Matching / Level of Effort / Earmarking

2022 ? 004 Material Weakness in Internal Control over Compliance with Preparation of Schedule of Expenditures of Federal Awards Condition: The Organization does not have an internal control system designed to provide for the preparation of the Schedule. The Schedule was not reviewed and required ad...

2022 ? 004 Material Weakness in Internal Control over Compliance with Preparation of Schedule of Expenditures of Federal Awards Condition: The Organization does not have an internal control system designed to provide for the preparation of the Schedule. The Schedule was not reviewed and required adjustments. Cause: The Organization had turnover and limited staffing available. Management?s Response and Corrective Action Plan: The organization was unprepared for the first time performing a single audit. Also, the information that was needed was issued later than optimal by the government for the reporting requirements. However, now that there is an understanding of the process, the schedule will be monitored monthly. The more consistent staffing will provide a better flow of communication with the approval process. The YTD schedules will be presented at quarterly Board Finance Committee meetings. Responsible Individuals: ? Accountability for understanding and management of the entire process ? Marcia Meyer, CEO ? Preparation of regular schedules during year ? Jennie Myers ? Preparation of quarterly schedule updates ? Jennie Myers ? Approval of quarterly schedules and presentation to Finance Committee ? Marcia Meyer (approval) and Jennie Myers ? Preparation of annual schedule in advance of the audit ? Jennie Myers ? Approval of annual schedule before submitting for audit ? Marcia Meyer Anticipated Completion Date: This will be implemented immediately and will be up to date by June 2023.

View Audit 19100

Finding 20375 (2022-003)

Material Weakness 2022

The Be Kind People Project Foundation

AZ

Allowable Costs / Cost Principles Material Weakness Matching / Level of Effort / Earmarking § 200.303

2022-003 Material Weakness in Internal Control over Compliance with Activities Allowed or Unallowed and Allowable Costs/ Cost Principles Condition: The Organization did not retain the required documentation to support the review of expenditures. Cause: The Organization had turnover and limited st...

2022-003 Material Weakness in Internal Control over Compliance with Activities Allowed or Unallowed and Allowable Costs/ Cost Principles Condition: The Organization did not retain the required documentation to support the review of expenditures. Cause: The Organization had turnover and limited staffing available. Management?s Response and Corrective Action Plan: Changing the personnel involved has solved much of the problem, also the full awareness of what needs to be retained has also been explained to management. If/ when funds from federal sources are used, those expenditures will be reviewed monthly. Specifically, this will mean: ? Maintain EIDL-sourced funds in separate bank/ account. ? Have single authorization for any movement/ usage of funds in EIDL account. ? If/when funds from EIDL are used, have a written statement for purpose and documentation produced for use at the time of request. Responsible Individuals: ? Maintain separate account ? Marcia Meyer, CEO, in conjunction with Board Finance Committee ? Authorization for use of funds ? Marcia Meyer ? Maintenance of records for use ? JC Thompson ? Confirmation with use of funds per allowable uses per national guidelines ? Jennie Myers ? Reporting on monthly finance report ? Jennie Myers Anticipated Completion Date: This process is underway and will be visible at the fiscal year-end audit in June 2023.

View Audit 19100

Finding 20360 (2022-004)

Significant Deficiency 2022

Joseph's House and Shelter, Inc.

NY

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Finding 2022-004 ? Allowable Costs/Cost Principles--Significant Deficiency Recommendation: The Organization should put in place policies and procedures necessary to maintain detailed contemporaneous documentation supporting the allocation of payroll and related expenses to individual programs in a...

Finding 2022-004 ? Allowable Costs/Cost Principles--Significant Deficiency Recommendation: The Organization should put in place policies and procedures necessary to maintain detailed contemporaneous documentation supporting the allocation of payroll and related expenses to individual programs in a manner that accurately reflects the work performed. Views of Responsible Officials and Planned Corrective Actions: The Executive Director worked with the Director of Grants and Finance to review and revise the agency?s accounting policies and procures. To ensure proper oversight, all procedures and reports will be reviewed by the Board?s Finance Committee, followed by a final review and approval of the Full Board of Directors of Joseph?s House & Shelter. One project of note was a collaborative effort undertaken by the Executive Director, a new Director of HR and Administration, the Human Resources Manager, and the Director of Grants and Finance to roll out a more detailed time keeping system that is used to track employee time spent per program. This data is then subsequently directly coded and uploaded into the accounting software. This process ensures on an ongoing basis that the allocation of payroll and related expenses will accurately reflect the work being performed and has significantly improved timely and precise grant claims. This was implemented in Q2 2023.

View Audit 18957

Finding 20359 (2022-003)

Material Weakness 2022

Joseph's House and Shelter, Inc.

NY

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness

Finding 2022-003 ? General Oversite ? Material Weakness Recommendation: We recommend that the Organization create policies and procedures to ensure proper oversight of the financial reporting function. In addition, we would recommend the Organization to consider the costs and benefits of restruct...

Finding 2022-003 ? General Oversite ? Material Weakness Recommendation: We recommend that the Organization create policies and procedures to ensure proper oversight of the financial reporting function. In addition, we would recommend the Organization to consider the costs and benefits of restructuring the finance department. This could include allocating additional resources to hire additional employees, reallocation of responsibilities within the organization and less reliance on the contracted accounting services. View of Responsible Officials and Planned Corrective Actions: The Executive Director has worked with the Director of Grants and Finance to review and revise the agency?s accounting policies and procures. To ensure proper oversight, all procedures and reports will be reviewed by the Board?s Finance Committee, followed by a final review and approval of the Full Board of Directors of Joseph?s House & Shelter. Beginning in Q1 2022, agency leadership took necessary action to begin restructuring the Finance Department following a change in staffing with the contracted accounting service. In Q2 2022, the agency promoted a long-tenured staff member to the newly-created Director of Grants and Finance position, which separated and removed all finance duties from the Director of Administration. To support the Director of Grants and Finance, a full time Grants and Finance Specialist staff position was created in Q3 of 2022. The organization has scaled back reliance on the contracted accounting service and has ensured that all claims, with the implementation of personnel time tracking systems, are submitted through our Finance Department. We continue to use a contracted accounting service for higher-level accounting duties and for on-going advisement that supplements, instead of replaces, the work of internal staff. We are confident these changes have improved the agency?s ability to provide adequate management oversight in the financial reporting process. This was completed in Q2 of 2023.

View Audit 18957

Finding 20323 (2022-003)

None 2022

City of Birmingham

AL

Reporting

Corrective Action Plan: Management's response: Management in the Finance and Community Development Departments will work together to ensure that appropriate training is provided to all individuals responsible for the preparation and approval of financial reporting information. The ERA program was ...

Corrective Action Plan: Management's response: Management in the Finance and Community Development Departments will work together to ensure that appropriate training is provided to all individuals responsible for the preparation and approval of financial reporting information. The ERA program was set up in a short period of time, which did not allow for the Community Development Department to set up appropriate intern controls. We acknowledge that there were mistakes made regarding financial documentation and reporting during the setup and implementation of the program. Some of those mistakes included: ? Required internal controls and reporting were not overseen by the department's accounting team. ? Reports were pulled from the software program (Neighborly) instead of the City of Birmingham New World system, which accurately reflected the funds deposited and expensed. ? Subrecipient financial management system reporting. We are currently working to place internal controls over the ERA program and correcting all reports previously submitted. Some of those controls are: ? Deputy Director has talked with the COB Grants team regarding reporting and which system to report from. During this meeting, it was identified that we were using the wrong financial program in reporting. Updated reports are being developed. ? The Deputy Director has planned to meet with the Department of Treasury, and Grants Department to discuss training and previous reports submitted. 2 ? The Community Development office will provide a workflow that allows for internal controls within the department and Grants department. ? All staff including our subrecipients will be trained on reporting and documentation. ? We will work with our financial subrecipient on providing monthly reconciliation of funds received (returned check) and funds paid out. This will include: ? Wire transfers with amounts and dates ? Case numbers ? Amounts paid ? Landlord or utility company paid ? Checks returned ? Balance of funding ? Dates of each transaction ? Quarterly reports Although mistakes were made in the startup and implantation of the ERA program, we have successfully aided thousands of citizens in the city of Birmingham. We strive to correct any mistakes and provide better internal controls and training. We appreciate the input and audit oversight that insures we are not only providing great services to the citizens, but we are also providing quality internal controls and reporting that substantiate the work. Person Responsible: Dr. Meghan V. Thomas, Director of Community Development Aaron L. Saxton, Acting Director of Finance Estimated Completion Date: June 2023 3

View Audit 28073

Finding 20322 (2022-002)

None 2022

City of Birmingham

AL

Special Tests & Provisions Subrecipient Monitoring Allowable Costs / Cost Principles

Corrective Action Plan: Management has arranged for grants training for relevant employees. Directors over the City's ESG federal program will develop procedures with the City's Finance Department in order to ensure that the City meets the award requirements for both ESG and ESG- CV funds. Perso...

Corrective Action Plan: Management has arranged for grants training for relevant employees. Directors over the City's ESG federal program will develop procedures with the City's Finance Department in order to ensure that the City meets the award requirements for both ESG and ESG- CV funds. Person Responsible: Dr. Meghan V. Thomas, Director of Community Development Aaron L. Saxton, Acting Director of Finance

View Audit 28073

Finding 20321 (2022-001)

None 2022

Chowan University

NC

Student Financial Aid Matching / Level of Effort / Earmarking Special Tests & Provisions

Name of Responsible Individual: Lori Jenkins & Ruth Casper Corrective Action: The University Financial Aid Office has restructured the disbursement notification schedule as noted below: ? Disbursement notification letters are to be printed every 21 days. The federal requirement for notificat...

Name of Responsible Individual: Lori Jenkins & Ruth Casper Corrective Action: The University Financial Aid Office has restructured the disbursement notification schedule as noted below: ? Disbursement notification letters are to be printed every 21 days. The federal requirement for notification is every 30 days. ? The Direct Loan Officer and Director of Financial Aid have access to create and print the letters. ? Electronic calendar notices for the disbursement notifications are sent to the Direct Loan Officer, Director of Financial Aid and the Asst. Vice President for Analytics & Audit. ? Task completion will be verified by the Asst. Vice President for Analytics & Audit on a monthly basis. Anticipated Completion Date: The disbursement notification schedule has been revised as of August 26, 2022.

View Audit 28034

Finding 20319 (2022-002)

Significant Deficiency 2022

Simpson Midtown INC

PA

Subrecipient Monitoring HUD Housing Programs Significant Deficiency

Views of Responsible Officials and Planned Corrective Actions: Management will ensure proper training is given to staff responsible for annual recertifications. Management will ensure monthly reconciliation of recertification is reviewed timely and all supporting documentation of the reconciliation ...

Views of Responsible Officials and Planned Corrective Actions: Management will ensure proper training is given to staff responsible for annual recertifications. Management will ensure monthly reconciliation of recertification is reviewed timely and all supporting documentation of the reconciliation is kept in the resident tenant files.

View Audit 28212

Finding 20318 (2022-001)

Material Weakness 2022

Advance Community Health

NC

Allowable Costs / Cost Principles HUD Housing Programs Reporting

Advance Community Health was inundated with HRSA reporting due to the multiple funding we received in response to the Covid-19 Pandemic. In an effort to help health centers deal expeditiously with the Covid crisis some of the funding was given in advance with reporting requirements to follow. The ...

Advance Community Health was inundated with HRSA reporting due to the multiple funding we received in response to the Covid-19 Pandemic. In an effort to help health centers deal expeditiously with the Covid crisis some of the funding was given in advance with reporting requirements to follow. The rush to get funding out to address the Covid-19 pandemic crisis resulted in reporting requirements that were developed and implemented very quickly, and the reporting requirements were confusing to many health centers. The Provider Relief Funding was one of the instances in which funding was given in advance with reporting requirements to follow. As a result of the confusion surrounding these last-minute reporting requirements, we believe that the former CFO inadvertently omitted certain revenue that perhaps should have been included in the Provider Relief Funding (PRF) report and there was no clear explanation in the narrative section as to why these revenues were omitted. We attempted to recall and amend the PRF report but were told by the PRF reporting team that we are unable to amend the report at this time. However, should the opportunity to amend the PRF Report occur, we will make the appropriate amendment to the PRF report with a reconciliation and narrative that will support the earning of the PRF funding. To prevent future occurrences of where it is not clear why revenue items are being omitted or included on a federal provider relief report, a reconciliation will be prepared that ties the revenue section of the PRF report with the revenue section of the internal financial statements. The reconciliation will clearly outline what is included in and what is omitted from the report and establish clear documentation to strongly support the amounts on the PRF report. A narrative documenting why certain revenue is omitted should be attached, which will clearly and concisely explain how the revenue amounts on the PRF report were derived. The reconciliation will be prepared by our senior accountant and reviewed by the CFO. Tiffany Robertson, the interim CFO and Rhonda Payne, our Chief Compliance Officer will be responsible for and will continue to assess our internal reporting processes. We will continue to conduct staff training as deemed necessary to ensure compliance with federal reporting requirements for PRF funding. The training and procedure should be implemented by December 2022.

View Audit 26499

Finding 20317 (2022-001)

Material Weakness 2022

Mid-Minnesota Legal Assistance

MN

Subrecipient Monitoring Internal Control / Segregation of Duties

Finding Number: 2022-001 Finding Title: Subrecipient Monitoring Program: COVID-19 21.027 Coronavirus State & Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Taofeek Ishola, Controller Corrective Action Planned: The Organization will ensure that the appropria...

Finding Number: 2022-001 Finding Title: Subrecipient Monitoring Program: COVID-19 21.027 Coronavirus State & Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Taofeek Ishola, Controller Corrective Action Planned: The Organization will ensure that the appropriate federal award information is included in all subrecipient agreements. The Organization has taken steps to immediately request supporting documentation for all invoices that have been paid and will take steps to ensure that payments for future invoices are not released until the required supporting documentation has been received and reviewed. In addition, the Organization will review all current and future subrecipient agreements to ensure that they understand all monitoring procedures that are required are understood and being performed. Anticipated Completion Date: These procedures will be implemented immediately.

View Audit 26520

Finding 20316 (2022-001)

Significant Deficiency 2022

The Guthrie Clinic

PA

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.303

The Guthrie Clinic and Affiliates Corrective Action Plan For the Year Ended June 30, 2022 Finding 2022-001: Significant Deficiency in Internal Control - Reporting Assistance Listing No.: 93.498 COVlD-19: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Condition/Context. In th...

The Guthrie Clinic and Affiliates Corrective Action Plan For the Year Ended June 30, 2022 Finding 2022-001: Significant Deficiency in Internal Control - Reporting Assistance Listing No.: 93.498 COVlD-19: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Condition/Context. In the Corporation's Period 2 submission, using the Lost Revenues Reporting Method: Alternative Reasonable Methodology (Option 3), the lost revenues for quarter 4 of 2020 were incorrectly reported as $0 (rather than $4,934,624) and the lost revenues for quarter 1 of 2021 were incorrectly reported as $4,934,624 (rather than $0). This is not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The Corporation has implemented additional internal controls through independent review and sign off of the draft PRF reporting, prior to final submission, to ensure completeness and accuracy. Name(s) of Contact Person(s) Responsible for Corrective Action: Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO -Guthrie Hospitals Anticipated Completion Date: This was corrected in the Period 3 submission filed on September 30, 2022

View Audit 26519

Finding 20315 (2022-004)

Significant Deficiency 2022

Straight and Narrow, Inc. Roman Catholic Diocese of Paterson

NJ

Reporting Internal Control / Segregation of Duties

Finding --- Internal controls should be strengthened to ensure proper preparation and reviews of the Schedules of Expenditures of Federal Awards and State Financial Assistance. Corrective action --- Subsequent to year end, management has hired new members of management and reorganized other roles a...

Finding --- Internal controls should be strengthened to ensure proper preparation and reviews of the Schedules of Expenditures of Federal Awards and State Financial Assistance. Corrective action --- Subsequent to year end, management has hired new members of management and reorganized other roles at the entity level to allow for reviews to occur. Training and education will occur at all supervisory levels to ensure that responsible parties to contracts report completely and accurately. Status --- Commenced Completion date --- by June 30, 2023 Contact --- Dimpal Patel, Controller Contact phone --- 973-737-2077 Contact address --- 777 Valley Road, Clifton, New Jersey 07013

View Audit 26249

Finding 20313 (2022-002)

Material Weakness 2022

Erie Elementary Charter School

IL

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.302 § 200.303 § 200.305 § 200.318 § 200.319

FINDING NUMBER: 2022-002 Condition: The Organization is either lacking or has non-conforming written policies and procedures for the following administrative functions, required by the Uniform Guidance: 1. Financial Management - 2 CFR 200.302(b)(6) 2. Allowable Costs - 2 CFR 200.302(b)(7) 3. Federal...

FINDING NUMBER: 2022-002 Condition: The Organization is either lacking or has non-conforming written policies and procedures for the following administrative functions, required by the Uniform Guidance: 1. Financial Management - 2 CFR 200.302(b)(6) 2. Allowable Costs - 2 CFR 200.302(b)(7) 3. Federal payment - 2 CFR 200.305(b)(1) 4. Procurement - 2 CFR 200.318(a) and 2 CFR 200.318(c)(1) 5. Competition - 2 CFR 200.319(d) 5. Competition ? 2 CFR 200.319(d) 6. Methods of procurement to be followed - 2 CFR 200.320 7. Compensation (Personal Services) - 2 CFR 200.430(a)(1) 8. Compensation (Fringe Benefits - Leave) - 2 CFR 200.431(b)(1) 9. Relocation costs of employees - 2 CFR 200.464(a)(2) 10. Travel costs - 2 CFR 200.474 Planned Corrective Action: Management agrees with the finding and plans to review Uniform Guidance, modify and create policies and procedures where necessary to meet administrative Uniform Guidance requirements. The adopted policies and procedures will be reviewed and approved by the School Board of Directors at the organization?s next scheduled Board meeting. School Representative Responsible for Corrective Action: Carlos Perez, Executive Director Anticipated Completion Date: June 14, 2023

View Audit 25279

Finding 20296 (2022-002)

Significant Deficiency 2022

Independent School District No. 273

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Significant Deficiency

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE ? U.S. DEPARTMENT OF EDUCATION, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, SPECIAL EDUCATION CLUSTER ? FEDERAL ALN 84.027 AND 84.173 2022-002 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Findi...

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE ? U.S. DEPARTMENT OF EDUCATION, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, SPECIAL EDUCATION CLUSTER ? FEDERAL ALN 84.027 AND 84.173 2022-002 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR ? 180 requires the District to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements. The District did not have sufficient controls in place within its special education cluster federal programs to assure that it was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned ? The District will review policies and procedures relating to suspension and debarment for its federal programs and will ensure that all parties with which it contracts for goods or services are eligible to participate in contracts involving the expenditures of federal program funding. Official Responsible ? Mert Woodard, Director of Business Services. Planned Completion Date ? June 30, 2023. Disagreement With or Explanation of Finding ? The District agrees with this finding. Plan to Monitor ? Mert Woodard, Director of Business Services, will assure appropriate controls are in place, and will review internal control procedures relating to suspension and debarment to ensure they are in line with the Uniform Guidance requirements.

View Audit 19273

Finding 20293 (2022-001)

Material Weakness 2022

MacCormac College Dba Generations College

IL

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking

2022-001 - Procurement Policy Recommendation: The auditors recommended that the College formally adopt a procurement procedures document to ensure the applicable procurement requirements are adhered to and supported. Actions Taken or Planned: A procurement policy was formally approved by the Boar...

2022-001 - Procurement Policy Recommendation: The auditors recommended that the College formally adopt a procurement procedures document to ensure the applicable procurement requirements are adhered to and supported. Actions Taken or Planned: A procurement policy was formally approved by the Board of Trustees of the College on February 23, 2023. Person Responsible: Matt Gawenda, Dean of Finance Estimated Date of Completion: February 23, 2023

View Audit 21161

Finding 20291 (2022-001)

None 2022

Northwest Mississippi Community College

MS

Reporting Internal Control / Segregation of Duties

Individuals Responsible for Corrective Action Plan: Management will submit a revised second quarter 2022 reports that includes all funds expended through June 30, 2022. Anticipated Completion Date: September 30, 2023

View Audit 19194

Finding 20290 (2022-001)

None 2022

Casa Bienvivir

TX

Special Tests & Provisions Cash Management HUD Housing Programs

November 17, 2022 HUD Service Office Director Mr. Donald R. Hogan U. S. Department of Housing and Urban Development Kansas City Multifamily Regional Center 400 State Avenue, Room 200 Kansas City, KS 66101-2406 Casa Bienvivir, respectfully submits the following corrective action plan for the year e...

November 17, 2022 HUD Service Office Director Mr. Donald R. Hogan U. S. Department of Housing and Urban Development Kansas City Multifamily Regional Center 400 State Avenue, Room 200 Kansas City, KS 66101-2406 Casa Bienvivir, respectfully submits the following corrective action plan for the year ended September 30, 2022. Strickler & Prieto, LLP 201 E. Main, Suite 1615, El Paso, TX 79912 Audit Period: Year Ended September 30, 2022 The findings from the September 30, 2022 schedule of findings and questions costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS-FINANCIAL STATEMENT AUDIT No matters were reported FINDINGS AND QUESTIONED COSTS-MAJOR FEDERAL AWARD PROGRAMS AUDIT 2022-001: FAILURE TO FUND THE RESIDUAL RECEIPTS RESERVE ACCOUNT WITHIN 60 DAYS OF FISCAL YEAR END a. Recommendation We agree the funding of the residual receipts reserve account was not made within the 60 day after fiscal year end per HUD regulations. b. Action Taken Funding of the residual receipts reserve account will be made in a timely manner. If HUD has questions regarding this plan, please call Luis Ortiz at (915) 562-3444. Sincerely yours, ______________________________ Luis Ortiz, Vice President of Finance

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