Corrective Action Plans

Finding 1874 (2022-008)

Material Weakness 2022

Itasca County

MN

Internal Control / Segregation of Duties Eligibility Material Weakness

ELIGIBILITY Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.558 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federa...

ELIGIBILITY Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.558 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2201MNTANF Compliance Requirement Affected: Eligibility Award Period: Year Ended December 31, 2022 Type of Finding: Material Weakness in Internal Control over Compliance, Other Matters Recommendation: We recommend the County review case files on a periodic basis throughout the year and document the review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will begin reviewing case files and documenting their review. Name(s) of the contact person(s) responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2023

View Audit 3268

Finding 1872 (2022-009)

Significant Deficiency 2022

Itasca County

MN

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

INACCURATE LISTING OF EMPLOYEES FOR RANDOM MOMENT STUDIES Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) and Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.778 & 93.558 Pass-Through Agenc...

INACCURATE LISTING OF EMPLOYEES FOR RANDOM MOMENT STUDIES Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) and Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.778 & 93.558 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2205MN5ADM, 2205MN5MAP, 2201MNTANF Compliance Requirement Affected: Activities Allowed or Unallowed/Allowable Cost/Cost Principles Award Period: Year Ended December 31, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: We recommend the County review the listing of employees working on certain programs on a periodic basis throughout the year and document the review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will begin reviewing the random moment studies and documenting their review. Name(s) of the contact person(s) responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2023

View Audit 3268

Finding 1870 (2022-007)

Material Weakness 2022

Itasca County

MN

Internal Control / Segregation of Duties Eligibility Material Weakness

CASEFILE REVIEW Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) – Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board F...

CASEFILE REVIEW Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) – Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2205MN5ADM, 2205MN5MAP Compliance Requirement Affected: Eligibility Award Period: Year Ended December 31, 2022 Type of Finding: Material Weakness in Internal Control over Compliance, Other Matters Recommendation: We recommend the County review case files on a periodic basis throughout the year and document the review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will begin reviewing case files and documenting their review. Name(s) of the contact person(s) responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2023

View Audit 3268

Finding 1868 (2022-006)

Material Weakness 2022

Itasca County

MN

Internal Control / Segregation of Duties Material Weakness Reporting

CONTROLS OVER REPORTING (PRIOR YEAR 2021-006) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) – Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochi...

CONTROLS OVER REPORTING (PRIOR YEAR 2021-006) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) – Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2205MN5ADM, 2205MN5MAP Compliance Requirement Affected: Reporting Award Period: Year Ended December 31, 2022 Type of Finding: Material Weakness in Internal Control over Compliance Recommendation: We recommend the County review the quarterly reports before submission and document their review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will begin documenting the review of their quarterly reports. Name(s) of the contact person(s) responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2023

View Audit 3268

Finding 1855 (2022-015)

Material Weakness 2022

Canadian County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring

The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.

View Audit 3224

Finding 1854 (2022-012)

Material Weakness 2022

Canadian County

OK

Procurement, Suspension & Debarment Allowable Costs / Cost Principles

The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.

View Audit 3224

Finding 1853 (2022-010)

Material Weakness 2022

Canadian County

OK

Subrecipient Monitoring Internal Control / Segregation of Duties

We will work to implement a Risk Assessment plan. We will implement controls to help make sure we are in compliance with all grant requirements and federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance ...

We will work to implement a Risk Assessment plan. We will implement controls to help make sure we are in compliance with all grant requirements and federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance supplement to work from.

View Audit 3224

Finding 1848 (2022-006)

Significant Deficiency 2022

Jackson City School District

OH

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Salaries and benefits for the Fiscal Year in the audit were approved by a prior interim treasurer. New procedures have been put in place the prevent this from happening with the current Treasurer. Anticipated Completion Date: 6/30/2023 Responsible Contact Person: Jared M. Bunting, Treasurer/CFO

View Audit 3216

Finding 1830 (2022-003)

Material Weakness 2022

The Experimental Station: 6100 Blackstone

IL

Questioned Costs Allowable Costs / Cost Principles

Action Taken - We concur with the recommendation. In 2023, Experimental Station adopted new written policies and procedures for tracking employee hours related to the program, including time and effort spent on multiple programs. Employee timesheets to provide the basis for allocating ...

Action Taken - We concur with the recommendation. In 2023, Experimental Station adopted new written policies and procedures for tracking employee hours related to the program, including time and effort spent on multiple programs. Employee timesheets to provide the basis for allocating salaries to the various funding sources under the program with quarterly review during the year.

View Audit 3200 Questioned Costs: $1

Finding 1829 (2022-002)

Significant Deficiency 2022

The Experimental Station: 6100 Blackstone

IL

Allowable Costs / Cost Principles

Action Taken - We concur with the recommendation. Experimental Station finance staff received guidance in 2023 regardingindirect cost allocation and ongoing monitoring of indirect costs. We have engaged an outside accounting firm with government grant expertise to provide bookkeeping services go...

Action Taken - We concur with the recommendation. Experimental Station finance staff received guidance in 2023 regardingindirect cost allocation and ongoing monitoring of indirect costs. We have engaged an outside accounting firm with government grant expertise to provide bookkeeping services going forward, which will include allocating and monitoring indirect costs.

View Audit 3200

Finding 1828 (2022-011)

Significant Deficiency 2022

Hertford County

NC

Eligibility

Finding 2022-011 Inadequate Request for Information Name of contact person: "Brenda Brown, Director and Kimberly Ward, F & C Medicaid Supervisor" Corrective Action: "Trainings have been conducted and continually emphasized to staff the importance of following pol...

Finding 2022-011 Inadequate Request for Information Name of contact person: "Brenda Brown, Director and Kimberly Ward, F & C Medicaid Supervisor" Corrective Action: "Trainings have been conducted and continually emphasized to staff the importance of following policy, procedures and guidelines that have been established. Staff reminded TWN must be requested for cases and income should be input correctly. Mailing appropriate forms and 5097s when necessary was also reiterated." Proposed completion date: Trainings will continue to be conducted with staff throughout the year.

View Audit 3186

Finding 1827 (2022-010)

Significant Deficiency 2022

Hertford County

NC

Eligibility

Finding 2022-010 Inaccurate Resources Entry Name of contact person: "Brenda Brown, Director and Satonya Gonzales, Adult Medicaid Supervisor" Corrective Action: "Adult Medicaid unit will participate in future trainings monthly, to review policies as outlined in t...

Finding 2022-010 Inaccurate Resources Entry Name of contact person: "Brenda Brown, Director and Satonya Gonzales, Adult Medicaid Supervisor" Corrective Action: "Adult Medicaid unit will participate in future trainings monthly, to review policies as outlined in the ABD Manual 2300. Staffed will review webinars in the Learning Gateway. Second Party Reviews will be conducted by staff and the supervisor. OST guidance will be requested as needed to ensure policy is adhered to. Our goal is to elevate \minimize repeat errors as listed in the audit findings." Proposed completion date: Management will continue to monitor the progress of this issue and modify the controls as needed.

View Audit 3186

Finding 1826 (2022-009)

Significant Deficiency 2022

Hertford County

NC

Eligibility Internal Control / Segregation of Duties

Finding 2022-009 Inaccurate Information Entry Name of contact person: "Brenda Brown, Director and Kimberly Ward, F & C Medicaid Supervisor" Corrective Action: "Trainings have been conducted and continually emphasized to staff the importance of followin...

Finding 2022-009 Inaccurate Information Entry Name of contact person: "Brenda Brown, Director and Kimberly Ward, F & C Medicaid Supervisor" Corrective Action: "Trainings have been conducted and continually emphasized to staff the importance of following policy, procedures and guidelines that have been established. Staff reminded of MAGI rules and how it affects the determination size of a household and the factors that affect the number." Proposed completion date: Trainings will continue to be conducted with staff throughout the year.

View Audit 3186

Finding 1825 (2022-008)

Significant Deficiency 2022

Hertford County

NC

Eligibility Reporting

Finding 2022-008 Untimely Review of SSI Termination Name of contact person: "Brenda Brown, Director and Satonya Gonzales, Adult Medicaid Supervisor" Corrective Action: SSI\SDX Policy reviewed with staff. Proposed completion date: Training on-...

Finding 2022-008 Untimely Review of SSI Termination Name of contact person: "Brenda Brown, Director and Satonya Gonzales, Adult Medicaid Supervisor" Corrective Action: SSI\SDX Policy reviewed with staff. Proposed completion date: Training on-going.

View Audit 3186

Finding 1824 (2022-007)

Significant Deficiency 2022

Hertford County

NC

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Finding 2022-007 Untimely Adoption of Policy Name of contact person: "Leslie Edwards, Finance Director" Corrective Action: "The Finance Office is currently fully staffed, the Finance Director and the County Manager will work together to ensure proper policies are...

Finding 2022-007 Untimely Adoption of Policy Name of contact person: "Leslie Edwards, Finance Director" Corrective Action: "The Finance Office is currently fully staffed, the Finance Director and the County Manager will work together to ensure proper policies are completed and up to date for federal awards. The fiance director will ensure that policies needed for federal grant awards are in place. " Proposed completion date: "December 31, 2023."

View Audit 3186

Finding 1815 (2022-001)

Material Weakness 2022

Kenneth Young Center

IL

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties

Audit Recommendation: Procedures should be implemented requiring the ocmpletion of timesheets for all employees. Planned Corrective Actions: Kenneth Young Center has implemented timesheet reporting and will require the submission of timesheets for its employees and make applicable necessary adjustme...

Audit Recommendation: Procedures should be implemented requiring the ocmpletion of timesheets for all employees. Planned Corrective Actions: Kenneth Young Center has implemented timesheet reporting and will require the submission of timesheets for its employees and make applicable necessary adjustments to ensure the payroll cost allocation is reflective of submitted timesheets. Anticipated Completion Date: Complete. Contact Person: Rachel Zavala, Controller.

View Audit 3175

Finding 1813 (2022-002)

Material Weakness 2022

Oficina De Proteccion Y Defensa De Las Personas Con Impedimentos

PR

Reporting

the Agency has already taken steps to submit SF-270 forms for the total amount of $232,725.42. These forms are currently awaiting grantor approval. We will closely monitor the progress of these submissions and ensure they are processed in a timely manner. Enhanced Monitoring: To prevent such discrep...

the Agency has already taken steps to submit SF-270 forms for the total amount of $232,725.42. These forms are currently awaiting grantor approval. We will closely monitor the progress of these submissions and ensure they are processed in a timely manner. Enhanced Monitoring: To prevent such discrepancies in the future, we will strengthen our monitoring processes. While we have established a Status Report to track the filing status of SF-270 forms, we will also implement measures to ensure that these forms are submitted as required. Proposed Completion Date: March 30, 2024

View Audit 3152

Finding 1811 (2022-001)

Material Weakness 2022

Oficina De Proteccion Y Defensa De Las Personas Con Impedimentos

PR

The agency has already taken significant strides in response to the auditor's recommendations. The finalization of our time distribution structure implementation is well underway, with a focus on aligning costs with the relative benefits received. Concurrently, formal procedures for payroll cost all...

The agency has already taken significant strides in response to the auditor's recommendations. The finalization of our time distribution structure implementation is well underway, with a focus on aligning costs with the relative benefits received. Concurrently, formal procedures for payroll cost allocation have been in development, nearing completion to ensure accurate and compliant allocation. A comprehensive training program for our finance personnel will be develop, equipping them with the skills needed for effective implementation. To uphold the integrity of these measures, a robust monitoring system will be implemented to oversee adherence. Proposed Completion Date: March 30, 2024

View Audit 3152

Finding 1810 (2022-001)

Significant Deficiency 2022

Healthy Relationships California

CA

Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking § 200.303

The bookkeeper and external accountant of Healthy Relationships California will collaborate to produce accurate reliable accounting records and financial reports.

View Audit 3151

Finding 1799 (2022-001)

None 2022

Boise County, Idaho

ID

Procurement, Suspension & Debarment

Effective January 3, 2023, Boise County Resolution 2023-01, the Boise County Procurement Policy & Procedure Manual, was adopted by the Board of County Commissioners.

View Audit 3143

Finding 1798 (2022-002)

Material Weakness 2022

National Alliance Against Disparities in Patient Health

VA

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303 § 200.68

Timesheets are reviewed by project managers before they are submitted to payroll processing. Additionally, a reconciliation of actual to budgeted hours will be performed on a monthly basis. Documentation of the timesheet reviews will be maintained electronically. Staff time for federal grants will b...

Timesheets are reviewed by project managers before they are submitted to payroll processing. Additionally, a reconciliation of actual to budgeted hours will be performed on a monthly basis. Documentation of the timesheet reviews will be maintained electronically. Staff time for federal grants will be supported by a completed timesheet signed by a project manager. The National Alliance Against Disparities in Patient Health does acknowledge that an additional level of review is justified as our grant volume continues to expand. The verification of work performed on a monthly basis will ensure accuracy. Project managers will meet weekly with the executive team to address any transitional issues. Evidence of this allocation review will be maintained electronically for future inspection and/or presentation to grantors or others with a need to know.

View Audit 3140

Finding 1797 (2022-001)

Material Weakness 2022

National Alliance Against Disparities in Patient Health

VA

Allowable Costs / Cost Principles HUD Housing Programs Matching / Level of Effort / Earmarking § 200.303 § 200.431

Timesheets are reviewed by project managers before they are submitted to payroll processing. Additionally, a reconciliation of actual to budgeted hours will be performed on a monthly basis. Documentation of the timesheet reviews will be maintained electronically. Staff time for federal grants will b...

Timesheets are reviewed by project managers before they are submitted to payroll processing. Additionally, a reconciliation of actual to budgeted hours will be performed on a monthly basis. Documentation of the timesheet reviews will be maintained electronically. Staff time for federal grants will be supported by a completed timesheet signed by a project manager. The National Alliance Against Disparities in Patient Health does acknowledge that an additional level of review is justified as our grant volume continues to expand. The verification of work performed on a monthly basis will ensure accuracy. Project managers will meet weekly with the executive team to address any transitional issues. Evidence of this allocation review will be maintained electronically for future inspection and / or presentation to grantors or others with a need to know.

View Audit 3140

Finding 1787 (2022-003)

Significant Deficiency 2022

Rescue Fire Protection District

CA

Procurement, Suspension & Debarment

Assistance Listing No: 97.044, Assistance to Firefighters Grant Federal Grantor: U.S. Department of Homeland Security - Direct Award Compliance Requirement: Procurement and Suspension and Debarment Condition: The District piggybacked on a procurement with Los Angeles County to procure program equipm...

Assistance Listing No: 97.044, Assistance to Firefighters Grant Federal Grantor: U.S. Department of Homeland Security - Direct Award Compliance Requirement: Procurement and Suspension and Debarment Condition: The District piggybacked on a procurement with Los Angeles County to procure program equipment, but the District did not have a procurement policy that meets the requirements of Uniform Guidance and did not adopt a compliant procurement policy for the program by, for example, adopting the Los Angeles County procurement policy for purposes of the procurement. In addition, the District did not obtain enough procurement documentation from Los Angeles County prior to approving the procurement to ensure the procurement was in accordance with Uniform Guidance and the District was not able to obtain enough information from Los Angeles County to confirm the procurement was in accordance with the requirements of Uniform Guidance during the single audit. Specifically, the District did not obtain evidence that Los Angeles County publicized the procurement, received an adequate number of bids and adequately evaluated the bids to select the lowest responsible bidder, ensuring full and open competition occurred. Management Response and Corrective Action Plan: We will add language to Section 100¬014, Bids and Contracts, of the District's Policies and Procedures indicating the District will follow 2 CFR Sections 200.318 to 200.327, including all applicable Appendixes, for procurements financed with federal funds. We believe the procurement of equipment under the program by Los Angeles County was in accordance with Uniform Guidance, but we were unable to obtain supporting documentation at the date the financial statements were issued. We will contact Los Angeles County for information indicating the procurement was properly publicized and Los Angeles County evaluated the bids obtained to select the lowest responsible bidder. District Personnel Responsible for Corrective Action: Joel Warman, Fire Captain; joel@rescuefiredepartment.org. Date Corrective Action will Occur: December 1, 2023.

View Audit 3106

Finding 1786 (2022-002)

Significant Deficiency 2022

Rescue Fire Protection District

CA

Allowable Costs / Cost Principles Reporting Equipment & Real Property Management

Assistance Listing No: 97.044, Assistance to Firefighters Grant Federal Grantor: U.S. Department of Homeland Security - Direct Award Compliance Requirement: Allowable Costs/Costs Principals Condition: The District's internal control over compliance procedures did not ensure the appropriate amount wa...

Assistance Listing No: 97.044, Assistance to Firefighters Grant Federal Grantor: U.S. Department of Homeland Security - Direct Award Compliance Requirement: Allowable Costs/Costs Principals Condition: The District's internal control over compliance procedures did not ensure the appropriate amount was claimed on the grant and did not ensure the appropriate local match amount was billed to five other local fire districts participating in the grant program (participating agencies). The District overclaimed federal grant funds by $6,399 and overcharged local matching fund amounts to the participating agencies by $6,557. Management Response and Corrective Action Plan: We will work with FEMA and the participating agencies to return the amounts overclaimed. District Personnel Responsible for Corrective Action: Joel Warman, Fire Captain; joel@rescuefiredepartmentorg. Date Corrective Action will Occur: December 1, 2023.

View Audit 3106

Finding 1785 (2022-001)

Significant Deficiency 2022

Rescue Fire Protection District

CA

Reporting

Assistance Listing No: 97.044, Assistance to Firefighters Grant Federal Grantor: U.S. Department of Homeland Security - Direct Award Compliance Requirement: Other Condition: The District submitted its audited financial statements and single audit report to the federal clearinghouse in October 2023, ...

Assistance Listing No: 97.044, Assistance to Firefighters Grant Federal Grantor: U.S. Department of Homeland Security - Direct Award Compliance Requirement: Other Condition: The District submitted its audited financial statements and single audit report to the federal clearinghouse in October 2023, more than 6 months after it was due on March 31, 2023. Recommendation: The District should consider contracting with an external accounting firm with significant knowledge in governmental and single audit accounting and reporting standards so that it can close its books and submit its audited financial statements and single audit report to the federal audit clearinghouse no later than the statutory deadline. Management Response and Corrective Action Plan: The District will consider hiring a bookkeeper that is knowledgeable in governmental accounting and reporting to assist the District with accounting and reporting and grant management, including federal grants. District Personnel Responsible for Corrective Action: Joel Warman, Fire Captain; joel@rescuefiredepartment.org. Date Corrective Action will Occur: December 1, 2023

View Audit 3106

Corrective Action Plans

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