Corrective Action Plans

Finding 33535 (2022-001)

Significant Deficiency 2022

NY

Cash Management Reporting

November 30, 2022 NYS Education Department Office of Audit Services 89 Washington Ave. Room 524 EB Albany, NY 12234 Dear Sir/Madame: The purpose of this correspondence is to provide your office with the Afton Central School District?s response to the management letter as written by district au...

November 30, 2022 NYS Education Department Office of Audit Services 89 Washington Ave. Room 524 EB Albany, NY 12234 Dear Sir/Madame: The purpose of this correspondence is to provide your office with the Afton Central School District?s response to the management letter as written by district auditors. D?Arcangelo & Cp, LLP. Po Box 4300 Rome, NY 13440 Federal fund single audit: 2022-001 -Inaccurate federal grant expenditure reimbursement The Auditor recommends FS-25?s be completed for expenditure reimbursement for items directly pertaining to the specific grant. Grant reimbursement should not be grouped, but rather individual FS-25?s completed for each grant containing only expenditures applicable to the grant. District Response: Planned Action: The district has corrected the accounting software account codes to separate out the 4 parts of the ARP ESSER 3 grant. This will allow the district to complete the FS-25?s accurately. Contact Person Responsible for corrective action: Kristyn DeGroat, Business Manager Date of Completion: April 1, 2022

View Audit 29766

Finding 33527 (2022-003)

Significant Deficiency 2022

Ouachita Parish School Board

LA

School Nutrition Programs Subrecipient Monitoring

Corrective Action Planned: Management will review the internal controls in place to ensure disbursements are properly approved. Person Responsible for Corrective Actions: Director of Business, Ouachita Parish School Board, 1600 North 7th Street, West Monroe, LA 71291. Phone: (318)432-5234 Fax: (...

Corrective Action Planned: Management will review the internal controls in place to ensure disbursements are properly approved. Person Responsible for Corrective Actions: Director of Business, Ouachita Parish School Board, 1600 North 7th Street, West Monroe, LA 71291. Phone: (318)432-5234 Fax: (318)432-5221.

View Audit 29702

Finding 33525 (2022-003)

Significant Deficiency 2022

Simpson University

CO

Reporting Significant Deficiency § 200.329

Education Stabilization Fund Reporting Planned Corrective Action: We are in process of updating the website. Person Responsible for Corrective Action Plan: Tim Dietz, CFO Anticipated Date of Completion: 4/30/2023

View Audit 35847

Finding 33520 (2022-002)

Significant Deficiency 2022

Simpson University

CO

Significant Deficiency

Gramm-Leach-Bliley Act Compliance Planned Corrective Action: The Director of Information Technology is in the process of creating the necessary security policies to further Simpson University?s compliance of the consumer financial information rule of the Gramm-Leach-Bliley Act. Completion of this p...

Gramm-Leach-Bliley Act Compliance Planned Corrective Action: The Director of Information Technology is in the process of creating the necessary security policies to further Simpson University?s compliance of the consumer financial information rule of the Gramm-Leach-Bliley Act. Completion of this project has a planned finalization date of 6/1/2023. The following security measures have been implemented since the audit findings of 2021. -Established a Zero Trust access control strategy -Created an Incident Response Policy and Cyber Security Plan -IT and HR departments have developed training materials and schedules for all employees pertaining to cyber security policies -Deployed encryption at-rest and immutable backups -Enforced Multi-factor authentication -Installed next-generation endpoint protection software: Crowdstrike Falcon Complete -Drafted a Written Information Security Program (WISP) Person Responsible for Corrective Action Plan: Ryan Opfer, IT Director Anticipated Date of Completion: 4/30/2024

View Audit 35847

Finding 33509 (2022-002)

Material Weakness 2022

Salvation Army of Greater St. Louis

MO

Questioned Costs Allowable Costs / Cost Principles § 200.430

Finding 2022-002 Allowable Costs/Cost Principles (Material Weakness) Condition: Compensation ? personal services: For this program, there was no evidence that actual employee time was tracked, reviewed and approved, or the actual time spent was used as a basis for allocating personnel charges to ...

Finding 2022-002 Allowable Costs/Cost Principles (Material Weakness) Condition: Compensation ? personal services: For this program, there was no evidence that actual employee time was tracked, reviewed and approved, or the actual time spent was used as a basis for allocating personnel charges to the grant. Correction Action Planned: ? Each location will use a time sheet for tracking actual hours worked on grants. This time sheet will include all grants that the employee worked on and non-grant time. The time sheet will be signed bythe employee and reviewed and approved by the employee?s supervisor ensuring time spent on grant is accurately recorded. ? The grant accountants will retain completed time sheets together with other expenditure support for grant reimbursement. The grant accountants will review the actual salary expense against initial budgeted grant expense and make necessary adjustments to charges to reflect accurate salary expense for each grant. The Grant Accounting Manager will review and approve grant accounting adjustments prior to completion of changes. Anticipated Completion Date: September 30, 2023 Name of Contact Person Responsible for the Plan: Kevin T. Hodges

View Audit 33712 Questioned Costs: $1

Finding 33502 (2022-001)

Material Weakness 2022

Okanogan School District No. 105

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Okanogan School District No. 105 September 1, 2021 through August 31, 2022 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Reg...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Okanogan School District No. 105 September 1, 2021 through August 31, 2022 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2022-001 Finding caption: The District did not have adequate controls for ensuring compliance with Davis-Bacon Act (prevailing wage rate) requirements. Name, address, and telephone of District contact person: Klancy Allen, Director of Finance P.O. Box 592 Okanogan, WA 98840 (509) 422-3629 Corrective action the auditee plans to take in response to the finding: The District administration will obtain and include required Davis-Bacon Act contract language to facilitate adequate internal controls for ensuring compliance with the federal wage rate requirements in future federally funded projects. Anticipated date to complete the corrective action: May 2023 Page

View Audit 33885

Finding 33500 (2022-002)

Significant Deficiency 2022

City of Calexico

CA

Subrecipient Monitoring Reporting Cash Management

Finding 2022-002 Reporting ? Internal Control and Compliance over Reporting (Significant Deficiency) Criteria: CODE OF FEDERAL REGULATIONS, Title 49 ? TRANSPORTATION, Part 18 ? UNIFORM ADMINISTRATIVE REQUIREMENTS FOR GRANTS AND COOPERATIVE AGREEMENTS TO STATE AND LOCAL GOVERNMENTS, Subpart C ? P...

Finding 2022-002 Reporting ? Internal Control and Compliance over Reporting (Significant Deficiency) Criteria: CODE OF FEDERAL REGULATIONS, Title 49 ? TRANSPORTATION, Part 18 ? UNIFORM ADMINISTRATIVE REQUIREMENTS FOR GRANTS AND COOPERATIVE AGREEMENTS TO STATE AND LOCAL GOVERNMENTS, Subpart C ? Post-Award Requirements: 18.41 Financial Report (a) General (4), Due date. When reports are required on a quarterly or semiannual basis, they will be due 30 days after the reporting period. When required on an annual basis, they will be due 90 days after the grant year. Final reports will be due 90 days after the expiration or termination of grant support. 18.58 (a) General. The Federal agency will close out the award when it determines that all applicable administrative actions and all required work of the grant has been completed. 18.50 (b) Reports. Within 90 days after the expiration or termination of the grant, the grantee must submit all financial, performance, and other reports required as a condition of the grant. Upon request by the grantee, Federal agencies may extend this time frame. These may include but are not limited to: (1) Final performance or progress report, (2) Financial Status Report (SF 269) or Outlay Report and Request for Reimbursement for Construction Programs (SF-271) (as applicable), (3) Final request for payment (SF-270) (if applicable), and (4) Invention disclosure (if applicable). U.S. OFFICE OF MANAGEMENT AND BUDGET CIRCULAR A-133?AUDITS OF STATES, LOCAL GOVERNMENTS, AND NON-PROFIT ORGANIZATIONS (OMB Circular A-133), Subpart C? Auditees, Section .300?Auditee Responsibilities (b) Maintain internal control over federal programs that provides reasonable assurance that the auditee is managing federal awards in compliance with laws, regulations, and the provisions of contracts or grant agreements that could have a material effect on each of its federal programs. Condition: For the Airport Improvement Program (AIP), the City did not submit the reports within the required deadline: Report Type Award Number Period Date Due Date Submitted SF-425 Financial 3-06-0034-018-2020 10/1/20 ? 9/30/21 12/31/2021 Not submitted SF-271 Financial 3-06-0034-018-2020 10/1/20 ? 9/30/21 12/31/2021 Not submitted SF-425 Financial 3-06-0034-021-2021 6/1/21 ? 9/30/21 12/31/2021 Not submitted SF-271 Financial 3-06-0034-021-2021 6/1/21 ? 9/30/21 12/31/2021 Not submitted Four (4) financial reports were tested and all reports were not submitted by the required deadline. City?s Corrective Action Plan: Finding Auditor Recommendation Action Plan Finding 2022-002: Internal Control and Compliance over Reporting (Grant Reports) ? We recommend that the City strengthen their report submission process and procedures to ensure all required (Grant) reports are properly review and approved and submitted timely. By August 1, 2023 ? The Finance Director will prepare an annual calendar with assembly and submission dates for each required monthly, quarterly, and annual grantee reports ? Staff members in both Program and Finance Departments will be assigned to prepare and cross-check required grant reports Contact person responsible for corrective action: Sandra Fonseca, Interim Finance Director Anticipated completion date: August 1, 2023

View Audit 31709

Finding 33499 (2022-002)

Significant Deficiency 2022

Southern Illinois Healthcare Foundation

IL

Procurement, Suspension & Debarment

U.S. Department of Health and Human Services Southern Illinois Healthcare Foundation (?SIHF?) 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 c...

U.S. Department of Health and Human Services Southern Illinois Healthcare Foundation (?SIHF?) 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?FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF HEALTH AND HUMAN SERVICES 2022 ? 002 PROCUREMENT Recommendation: Management should adhere to or revise the Organization?s existing procurement policy and implement a system of processes and internal controls to ensure that the appropriate level of documentation is maintained based on the procurement methodology selected for a transaction of contract. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: SIHF will ensure that controls are put into place to assure the organization?s policy around procurement is being followed. Name of the contact person responsible for corrective action: John Jeffries, CFO. Planned completion date for corrective action plan: June 30, 2023 If the Department of Health and Human Services has questions regarding this plan, please call John Jeffries at 618-332-5324.

View Audit 31112

Finding 33498 (2022-001)

Significant Deficiency 2022

Unified School District No. 428

KS

Cash Management School Nutrition Programs

Condition The District submitted inaccurate meal counts for reimbursement. Recommendation We recommend that the District review its controls related to monthly reimbursement requests for the Child Nutrition Cluster in order to ensure that accurate meal counts are submitted. Action Taken The School D...

Condition The District submitted inaccurate meal counts for reimbursement. Recommendation We recommend that the District review its controls related to monthly reimbursement requests for the Child Nutrition Cluster in order to ensure that accurate meal counts are submitted. Action Taken The School District has resubmitted the December 2021 meal count claims, which have been approved by KSDE. As of August 2022, paper meal count sheets are no longer being used to account for meals, and the Food Service Program is back to using their POS eTrition for meal counting, which will reduce the errors of meal claims. Steps when preparing to submit meal claims will be as follows: 1. Managers at each school will ensure meal counts on their 9-A & 9-B excel forms match their eTrition meal counts. 2. The Production Records Secretary will double check that the 9-A & 9-B excel forms that were turned in match the meal counts in eTrition. 3. The Director will input the claims based off of the 9-A & 9-B excel forms. 4. The Director will have the Office Manager double check that the claims were input into KN-Claim correctly before the Director will make the final submission.

View Audit 36146

Finding 33475 (2022-001)

None 2022

City of Bristol, Tn

TN

Finance Department THE CITY OF BRISTOL, TENNESSEE 801 Anderson Street P. 0 . Box 1189 Bristol, Tennessee 37621-1189 Telephone: (423) 989-5500 Facsimile: (423) 989-5719 Email: hverran@bristoltn.org MANAGEMENT'S CORRECTIVE ACTI ON PLAN For the Year Ended June 30, 2022 CORRECTION ACTION PLAN...

Finance Department THE CITY OF BRISTOL, TENNESSEE 801 Anderson Street P. 0 . Box 1189 Bristol, Tennessee 37621-1189 Telephone: (423) 989-5500 Facsimile: (423) 989-5719 Email: hverran@bristoltn.org MANAGEMENT'S CORRECTIVE ACTI ON PLAN For the Year Ended June 30, 2022 CORRECTION ACTION PLAN The City of Bristol, Tennessee respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Brown, Edwards & Company, LLP 433 E. Center Street, Suite 101 Kingsport, Tn 37660 Responsible officials for corrective action: NAME: Hollie Verran TITLE: Finance Director Signed: ------- -- --- The findings from the June 30, 2022, schedule of findings and questioned costs is discussed below. 2022-001: Elementary and Secondary School Emergency Relief Fund - AL# 84.425C, 84.425D, AL# 84.425U; Childhood Nutrition Cluster - AL# 10.553, 10.555; HOME Investment Partnership Program - AL# 14.239; Special Education Cluster - AL# 84.027, 84.027X, 84.173, 84.173X; Epidemiology and Lab Capacity for Infectious Diseases - AL# 93.323, Late Filing of Data Collection Form Recommendation: Management should take steps to ensure that the form is filed timely. Management's response: Management relied on prior auditor to guide the timeline of the filing requirement. Management concurs with the finding and will take steps to ensure that the data collection form is filed timely going forward. Anticipated completion date: December 31, 2022

View Audit 36144

Finding 33473 (2022-001)

Significant Deficiency 2022

Moore College of Art & Design

PA

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking

The College has created a selection set in its financial aid software to identify these students so they will be selected for verification.

View Audit 35306 Questioned Costs: $1

Finding 33472 (2022-003)

Significant Deficiency 2022

Moore College of Art & Design

PA

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking

The College will be providing additional consulting support going forward when a new Director of Financial Aid is hired.

View Audit 35306 Questioned Costs: $1

Finding 33471 (2022-002)

Significant Deficiency 2022

Moore College of Art & Design

PA

Student Financial Aid Reporting

The College will be providing additional consulting support going forward when a new Director of Financial Aid is hired.

View Audit 35306

Finding 33470 (2022-001)

Significant Deficiency 2022

Child & Adolescent Behavioral Health

OH

Internal Control / Segregation of Duties Reporting Significant Deficiency

Federal Audit Clearinghouse: Child and Adolescent Behavioral Health respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 through June 30, 2022. The findings from the schedule of findings and questioned costs are discussed below. The f...

Federal Audit Clearinghouse: Child and Adolescent Behavioral Health respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 through 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 2022-001 Provider Relief Funds ? Assistance Listing No. 93.498 Recommendation: Child and Adolescent Behavioral Health management request that HHS re-open the portal so as to resubmit based on the lost revenue calculation versus based on the original reporting method which used expenditures as a basis. If unable to re-open the portal, verify for next submission to HHS, if applicable, that the organization submits report based on the lost revenue calculation. It was also recommended that Child and Adolescent Behavioral Health management review this reporting submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agreed with the above finding and attempted to re-open the HHS portal to accurately report based on the lost revenue calculation, but given the timing of the request, were denied by HHS. Name(s) of the contact person(s) responsible for corrective action: Pam Lung, CFO Planned completion date for corrective action plan: December 2022 If the Federal Audit Clearinghouse or Department of Health and Human Services has questions regarding this plan, please call Pam Lung at 330-454-7917 ext. 163.

View Audit 32851

Finding 33467 (2022-002)

Significant Deficiency 2022

Unified School District #244

KS

School Nutrition Programs Cash Management Reporting

Corrective Action Plan - 55 - January 25, 2023 Cognizant or Oversight Agency for Audit Unified School District #244 respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Jarred, Gilmore & Phillips, PA, P.O....

Corrective Action Plan - 55 - January 25, 2023 Cognizant or Oversight Agency for Audit Unified School District #244 respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Jarred, Gilmore & Phillips, PA, P.O. Box 779, 1815 S Santa Fe, Chanute, Kansas 66720. Audit period: Year ended June 30, 2022. The findings from the January 25, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Finding 2022-001 ? Misreported Checks Condition: During our review of Accounts Payable, it was noted that the use of split checks led to a check number designated for supplies being used to pay a different vendor for payroll taxes. Recommendation: Procedures should be implemented the only allow for check numbers to be used for one vendor only and those encumbered funds that aren?t fully spent be credited back to the original funds. Action Taken: Split checks will no longer be used and all current outstanding split check numbers have been reviewed in the accounting software to ensure that the checks have only been written to the appropriate vendor and that those outstanding split checks were only used on the appropriate vendors as stated in the original purchase order. Anticipated Completion Date: February 2023 Finding: 2022-002 ? Meal Reporting Condition: During our testing of meal reporting, we tested two months of meal report claims submitted to the State and traced to individual count sheets per school. It was discovered in one month three meals were over reported and six meals the second month were over reported. Recommendation: Policies and procedures should be written to provide internal control over meal reporting. We recommend the District establish a review process, such as having another individual review count sheets and compare them to the number of meals submitted, to ensure all meals submitted for reimbursement are for the correct number of meals. - 56 - Action Taken: We are in agreement and since the 2022 fiscal audit took place, the District has updated their processes to include a review of all count sheets to ensure that the correct number of meals are being submitted for reimbursement. Anticipated Completion Date: October 24, 2022 Should the Oversight Agency for Audit have questions regarding this plan, please contact Christy Hess, Business Manager/Board Clerk, at (620) 364-8478. Sincerely Unified School District #244 Unified School District #244

View Audit 31822

Finding 33465 (2022-003)

Material Weakness 2022

Manhattan School District 114

IL

Equipment & Real Property Management

Corrective Action Plan Finding No.: 2022-_ 003__ Condition: No District employee was assigned the responsibility of maintaining all inclusive federally funded property records; consequently, the District only has incomplete lists. Plan: District administrativ...

Corrective Action Plan Finding No.: 2022-_ 003__ Condition: No District employee was assigned the responsibility of maintaining all inclusive federally funded property records; consequently, the District only has incomplete lists. Plan: District administrative personnel should maintain all inclusive federally funded property records by soliciting input from the employees previously maintaining incomplete lists. Anticipated Date of Completion: 6/30/2023 Name of Contact Person: Russell Ragon Management Response: Management will implement the auditor's recommendation for the year ended June 30, 2023.

View Audit 31821

Finding 33461 (2022-002)

Material Weakness 2022

Manhattan School District 114

IL

Matching / Level of Effort / Earmarking

Corrective Action Plan Finding No.: 2022-_ 002__ Condition: The District's Fiscal Year 2022 and 2021 Maintenance of Effort calculations were prepared by personnel at the Illinois State Board of Education and subsequent to the District personnel's review contained numerous errors. The calculations...

Corrective Action Plan Finding No.: 2022-_ 002__ Condition: The District's Fiscal Year 2022 and 2021 Maintenance of Effort calculations were prepared by personnel at the Illinois State Board of Education and subsequent to the District personnel's review contained numerous errors. The calculations were submitted including those errors. Plan: District personnel assigned to review the Maintenance of Effort calculation should be trained to properly complete the calculation. Anticipated Date of Completion: 1/30/2023 Name of Contact Person: Russell Ragon Management Response: Management will implement the auditor's recommendation in January 2023.

View Audit 31821

Finding 33460 (2022-001)

None 2022

Facts-Sunrise, Inc.

RI

HUD Housing Programs Internal Control / Segregation of Duties

D?Ambra CPA 531 Harris Avenue Woonsocket, RI 02895 Attn: Mr. Craig D?Ambra Dear Craig, Regarding Facts-Sunrise, Inc., Project NO. 016-HD-017, Audited Financial Statements for June 30, 2022. Schedule of Findings and Questioned Costs Part III findings and Questioned Costs for Federal Awards Current Fi...

D?Ambra CPA 531 Harris Avenue Woonsocket, RI 02895 Attn: Mr. Craig D?Ambra Dear Craig, Regarding Facts-Sunrise, Inc., Project NO. 016-HD-017, Audited Financial Statements for June 30, 2022. Schedule of Findings and Questioned Costs Part III findings and Questioned Costs for Federal Awards Current Findings: Finding 2022-001 Condition: (1) no application in file; (1) no citizenship status form. Recommendation: Management should correct the files in error. Response: Management has corrected the files in error. Thank you. Regards, Charles M. Lynch Finance Director and Responsible Party

View Audit 28758

Finding 33459 (2022-001)

Significant Deficiency 2022

Altcap

MO

Procurement, Suspension & Debarment

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2022 Name of Audit: AltCap Name of Audit Firm: Allen, Gibbs & Houlik L.C. Period Covered by Audit: Year Ending December 31, 2022 Corrective Action Plan Prepared by: Name: Richard Vohs Position: Vice Preside...

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2022 Name of Audit: AltCap Name of Audit Firm: Allen, Gibbs & Houlik L.C. Period Covered by Audit: Year Ending December 31, 2022 Corrective Action Plan Prepared by: Name: Richard Vohs Position: Vice President of Finance and Accounting Telephone Number: 816-216-1851 Findings-Financial Statement Audit None Findings-Uniform Guidance Audit Federal Agency: U.S. Department of Treasury Federal Program: Community Development Financial Institutions Program (CDFI) Finding 2022-001 Comments on Findings and Each Recommendation AltCap agrees with the auditors? finding and recommendation. Action(s) Taken or Planned on the Finding In August 2023, we retroactively checked all loan recipients during 2022 for suspension and debarment. No exceptions were found. We will implement a procedure, effective immediately, to check Sam.gov exclusions during the loan approval process and include a copy of our search results with the approved loan application. We will also require the loan applicant certify, by submission of a certificate, that neither it nor its principals are presently debarred, suspended, proposed for disbarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. Estimated completion date: September 2023.

View Audit 29222

Finding 33458 (2022-004)

Significant Deficiency 2022

Choice Regional Health Network

WA

Questioned Costs Allowable Costs / Cost Principles § 200.405

Significant deficiency in internal controls over compliance and instances of noncompliance related to allowable costs. Contact Person(s): Beth Mizushima, Chief Operating Officer, mizushimab@crhn.org; and Connie Sowa, Compliance, Governance and Contracts Officer, sowac@crhn.org. Explanation and ...

Significant deficiency in internal controls over compliance and instances of noncompliance related to allowable costs. Contact Person(s): Beth Mizushima, Chief Operating Officer, mizushimab@crhn.org; and Connie Sowa, Compliance, Governance and Contracts Officer, sowac@crhn.org. Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Not applicable. Corrective action planned: Paylocity, third party payroll processor, was implemented in October FY23. In FY23 we have reviewed payroll for each month to ensure the charge to the awards are the same as the actual allocation percentage to each grant, and have strengthened the internal controls over the complete, timely and accurate recording of payroll expenses for each payroll. The new internal controls include reconciling the Paylocity system reports to the bank reconciliations and the final journal entries to record the payroll expenses. Anticipated completion date: Completed September 2023.

View Audit 29220 Questioned Costs: $1

Finding 33457 (2022-003)

Significant Deficiency 2022

Choice Regional Health Network

WA

Subrecipient Monitoring § 200.332

Significant deficiency in internal controls over compliance and instances of noncompliance related to subrecipient monitoring. Contact Person(s): Beth Mizushima, Chief Operating Officer, mizushimab@crhn.org; and Connie Sowa, Compliance, Governance and Contracts Officer, sowac@crhn.org. Explanation...

Significant deficiency in internal controls over compliance and instances of noncompliance related to subrecipient monitoring. Contact Person(s): Beth Mizushima, Chief Operating Officer, mizushimab@crhn.org; and Connie Sowa, Compliance, Governance and Contracts Officer, sowac@crhn.org. Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Not applicable. Corrective action planned: In FY23 we have established a Compliance, Governance and Contracts Officer staff position (1.0 FTE) that provides compliance support. We have also developed and implemented training around our Ethics and Compliance Manual, which includes 14 new policies and procedures related to ensuring subrecipient compliance standards are met for all grant awards. Since July 1, 2023, we have completed assessments for the risk of noncompliance with all partner agencies before executing contracts. In FY23 we have also amended contracts to be on a reimbursement for allowable expenditures structure rather than fixed amount. We believe that the former leadership team who established the fixed fee award may have misinterpreted the guidance around providing flexibility to reduce burden for financial assistance during COVID response. Furthermore, it is our belief that the former program officer and staff discussed the details of their work and contracts, but we cannot find documentation of receiving prior approval. To address this issue, we have amended contracts in FY23 to include specific contract wording requiring prior approval to implement a fixed fee contract. Additionally, we are in the process of implementing a contract and portal partners management platform. The new contract management system and the improvements in compliance process will ensure that we adhere to the provisions as outlined in 2 CFR200.332. Anticipated completed process September 30, 2023

View Audit 29220

Finding 33456 (2022-002)

Material Weakness 2022

Choice Regional Health Network

WA

Cash Management Subrecipient Monitoring Allowable Costs / Cost Principles

Material weakness in internal controls over compliance and instances of noncompliance related to cash management. Contact Person(s): Beth Mizushima, Chief Operating Officer, mizushimab@crhn.org; and Connie Sowa, Compliance, Governance and Contracts Officer, sowac@crhn.org. Explanation and specific...

Material weakness in internal controls over compliance and instances of noncompliance related to cash management. Contact Person(s): Beth Mizushima, Chief Operating Officer, mizushimab@crhn.org; and Connie Sowa, Compliance, Governance and Contracts Officer, sowac@crhn.org. Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Not applicable. Corrective action planned: We agree that the one cash draw in FY22 was made without incurring sufficient expenditures towards the related award. In FY23 we have committed additional resources and staff to review expenditures from FY22 and FY23 to ensure that all project expenditures were allowable under each grant prior to drawing revenue in FY23. Additionally, in FY23 we have established a Compliance, Governance and Contracts Officer position, which provides increased oversight, approval to support drawdowns for Federal funds and to ensure compliance, adherence to requirements and improving overall internal controls and accounting processes. Anticipated completion date: We have ensured that FY23 draws are determined by the allowable expenditures for each grant. The improved accounting processes and internal controls will occur by September 30, 2023. The accounting process for Draws is included in the Accounting Manual.

View Audit 29220

Finding 33453 (2022-001)

Material Weakness 2022

Homes for McConnellsburg, Inc.

MD

HUD Housing Programs Special Tests & Provisions Eligibility

A. Current Findings on the Schedule of Findings and Questioned Costs 1. Finding 2022-001 a. Comments on the Finding and Each Recommendation We agree with the finding and the auditor's recommendation has been adopted. b. Action(s) Taken or Planned on the Finding Management agrees with the finding. In...

A. Current Findings on the Schedule of Findings and Questioned Costs 1. Finding 2022-001 a. Comments on the Finding and Each Recommendation We agree with the finding and the auditor's recommendation has been adopted. b. Action(s) Taken or Planned on the Finding Management agrees with the finding. In addition to hiring a new Director of Compliance and rebuilding the compliance team in 2021 to review and approve certifications, we have increased our corporate operations team and they are now responsible for reviewing all certification due dates weekly with the site teams to ensure timely completion of certifications.

View Audit 28755

Finding 33452 (2022-004)

Significant Deficiency 2022

Town of Dayton

WY

Procurement, Suspension & Debarment § 200.318

2022-004: Written Debarred, Suspended Vendors & Federal Standards of Conflict Finding Condition ? The Town of Dayton did not have written controls in place to ensure that vendors were not suspended or debarred or included on the list of vendors prior to entering into a contract with the Town. The wr...

2022-004: Written Debarred, Suspended Vendors & Federal Standards of Conflict Finding Condition ? The Town of Dayton did not have written controls in place to ensure that vendors were not suspended or debarred or included on the list of vendors prior to entering into a contract with the Town. The written standard of conduct covering conflicts of interest and governing the performance of its employees and contractors must be documented when engaged in the selection, award, and administration of Federal grants contracts. Corrective Action Plan ? Even though the Town didn?t have a formal written policy in place regarding the search for suspended or debarred vendors/contractors, the Town did do the SAM?s search before signing agreements with contractors on each of the Federal Grant projects that were engaged in during the year. That being said, the Town will develop a written internal control plan and a policy on procurement for debarment in the coming months.

View Audit 29219

Finding 33448 (2022-006)

Significant Deficiency 2022

Bethesda University

CA

Student Financial Aid Matching / Level of Effort / Earmarking

The University have reviewed and modified the Financial Aid (F/A) manual to make sure it is up-to-date. F/A manual will be reviewed annually to ensure that it reflects the recent changes, if any, as a part of the institutional practice. After the carefully reviewing our policy regarding the ?Exit...

The University have reviewed and modified the Financial Aid (F/A) manual to make sure it is up-to-date. F/A manual will be reviewed annually to ensure that it reflects the recent changes, if any, as a part of the institutional practice. After the carefully reviewing our policy regarding the ?Exit Interview?, we concluded that we have the policy and procedure in place. However, there was no consistency on following the written policy and procedures. We will implement the following changes to ensure that BU follows the policies and procedures: 1. Designate personnel in charge of informing Financial Aid department when student exits from the program 2. Designate personnel in Financial Aid department to inform the student and conduct the exit interview 3. Financial Aid department makes sure that the student completes the exit interview and the student?s graduation request won?t be approved until the student completes the exit interview. Financial Aid department will follow up the students who need to complete the exit counseling. Person Responsible for Corrective Action Plan: Sheng Wang, Chief Financial Officer Anticipated Date of Completion: June 30, 2023

View Audit 28952

Corrective Action Plans

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