Corrective Action Plans

Finding 4310 (2022-002)

None 2022

NC

Reporting § 200.328 § 200.329

The College has implemented procedures in which the Manager, Business Operations will work with the Director of Financial Aid to ensure that all HEERF quarterly reports depict accurate data. The Dean, Student Affairs and Enrollment will verify the accuracy of these reports prior to submission.

View Audit 6679

Finding 4262 (2022-004)

Significant Deficiency 2022

Asian and Pacific Islander Wellness Center, Inc. D/b/a San Francisco Community Health Center

CA

Cash Management Matching / Level of Effort / Earmarking

2022-003 Compliance Over Reporting Name of Contact Person: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with this finding which is directly related to the transitions in financial leadership and the need for a more robust finance team. The Center’s full-time pe...

2022-003 Compliance Over Reporting Name of Contact Person: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with this finding which is directly related to the transitions in financial leadership and the need for a more robust finance team. The Center’s full-time permanent CFO was hired in January 2022 who then immediately increased the team by two new members (1.0 FTE Controller hired in July 2022 and 1.0 FTE Staff Accountant hired in January 2023) and overhauled the Center’s financial policies and procedures manual. With the five-member finance team currently in place, we are on track to complete our FY2022-23 audit process by December 31, 2023. It is also relevant to note that San Francisco community health clinics migrated en masse to OCHIN Epic in 2022 with the overarching goal of our safety net hospitals and all community clinics being on the same EHR system to strengthen patient health outcomes for our city. The Center’s go-live date for this was June 2022 and required extensive time from all executive management, with our newly hired CFO being a key leader in this migration. This one-time, significant event had a direct impact on our ability to complete our audit in a timely manner. Proposed Completion Date: June 30, 2023

View Audit 6569

Finding 4261 (2022-003)

Significant Deficiency 2022

Asian and Pacific Islander Wellness Center, Inc. D/b/a San Francisco Community Health Center

CA

Cash Management Reporting

2022-002 Sliding Fee Discount Determination Name of Contact Persons: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with the recommendation and is taking steps to correct the errors of ensuring all sliding fee patient applications are maintained within the patient f...

2022-002 Sliding Fee Discount Determination Name of Contact Persons: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with the recommendation and is taking steps to correct the errors of ensuring all sliding fee patient applications are maintained within the patient files; and, ensuring all patients who apply for the sliding fee scale program receive the correct discount based upon income and family size. During the Center’s HRSA three-day operational site visit in July 2022, the Center made revisions to its Sliding Fee Application form to make space for our eligibility team members to clearly present their mathematical calculations to determine our patients’ annual incomes. This revision contributed to our 100% score that we received after the HRSA operational site visit. In order to further ensure we are in full compliance, the Center has contracted with an external consultant who is aware of HRSA standards and requirements and will thoroughly review current processes, procedures, and systems, and then will provide recommendations to the Center to implement and adopt. The Center will seek additional training and technical assistance to provide specific sliding fee scale training for all employees involved in our Sliding Fee program. Additionally, the Center will continue to implement quarterly audits of all sliding fee scale patients to ensure all sliding fee scale applications are complete and patients receive the correct discount. Proposed Completion Date: October 31, 2023

View Audit 6569

Finding 4260 (2022-002)

Significant Deficiency 2022

Asian and Pacific Islander Wellness Center, Inc. D/b/a San Francisco Community Health Center

CA

Special Tests & Provisions Eligibility

2022-001 Internal Control Over Financial Close Process Name of Contact Person: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with this finding and recommendations. The Center went through a change in CFO leadership throughout this fiscal year and our full-time p...

2022-001 Internal Control Over Financial Close Process Name of Contact Person: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with this finding and recommendations. The Center went through a change in CFO leadership throughout this fiscal year and our full-time permanent CFO started in January 2022, who then immediately expanded the Center’s finance department and implemented corrective procedures and greatly improved accounting processes and accounting operations, including all balance sheet accounts being reviewed and reconciled in a timely manner. In order to ensure we are fully compliant, two new positions were created and filled – a 1.0 FTE Controller hired in July 2022 and a 1.0 FTE Staff Accountant hired in January 2023. Additionally, our CFO overhauled our financial policies and procedures manual which was approved by the Center’s Board of Directors in July 2022. These policies and procedures were also reviewed by our HRSA consultants during our three-day operational site visit which took place in July 2022. Specific process improvements were made and included more specific segregation of duties, enhanced communication across all departments to address program items around budgetary and resource planning, transactional accuracy, and transparency. Moreover, the five-member finance department is working collaboratively with program management to advise and support the finance department on continued process improvements and maintaining open communication with program staff for effective feedback on program monitoring systems essential to strengthening internal control over financial close and reporting process. Proposed Completion Date: June 30, 2023

View Audit 6569

Finding 4194 (2022-001)

None 2022

The Durham Trinity Corporation

CT

Federal Audit Clearinghouse 1201 East 10th Street Jefferson, Indiana 47132 The Durham Trinity Corporation d/b/a Mauro Meadow (the Project) respectfully submits the following Corrective Action Plan for the year ended December 31, 2022. Hoyt, Filippetti & Malaghan, LLC 1041 Poquonnock Road Groton, C...

Federal Audit Clearinghouse 1201 East 10th Street Jefferson, Indiana 47132 The Durham Trinity Corporation d/b/a Mauro Meadow (the Project) respectfully submits the following Corrective Action Plan for the year ended December 31, 2022. Hoyt, Filippetti & Malaghan, LLC 1041 Poquonnock Road Groton, Connecticut 06340 Audit Period: Year ended December 31, 2022 The finding from the December 31, 2022 Schedule of Federal Findings and Questioned Costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. 2022-001 RESERVE ACCOUNT FUNDING Criteria: The Project’s reserve account must be fully funded in accordance with the budget as approved by USDA-RD and maintained in a separate bank account. Condition: During our audit testing, we noted that while the Project maintained a separate bank account for reserve funds, it was not funded in accordance with the budget. Cause: Budgeted transfers were not made before yearend to ensure the account is fully funded. Effect: Reserve bank account is underfunded. Questioned Costs: None noted. Recommendation: The Project should implement controls to ensure that the reserve bank account is fully funded. Management’s Views and Corrective Action Plan: Management will correct this when sufficient funds are able to be transferred into the reserve account. If you have any questions regarding this plan, please contact Matthew Scibek at 860-398-5425, or matt@westfordmgt.com.

View Audit 6512

Finding 4162 (2022-004)

Significant Deficiency 2022

Township of Bloomfield

NJ

Reporting Internal Control / Segregation of Duties

Description: The Township’s IDISC04PR29 Cash on Hand quarterly reports did not agree to the reconciled cash balance in the Community Development Trust bank account. Analysis: Policies and procedures be implemented to ensure the CDBG IDISC04PR29 cash on hand quarterly reports are prepared correctly ...

Description: The Township’s IDISC04PR29 Cash on Hand quarterly reports did not agree to the reconciled cash balance in the Community Development Trust bank account. Analysis: Policies and procedures be implemented to ensure the CDBG IDISC04PR29 cash on hand quarterly reports are prepared correctly and in agreement with the reconciled cash balances on hand. Corrective Action: Policies and procedures will be implemented to ensure the CDBG IDISC04PR29 cash on hand quarterly reports are prepared correctly and in agreement with the reconciled cash balances on hand. Implementation Date: Ongoing

View Audit 6483

Finding 4161 (2022-003)

Significant Deficiency 2022

Township of Bloomfield

NJ

Reporting Internal Control / Segregation of Duties

Description: The Township did not file the Community Development Block Grant program Annual Performance and Evaluation Report within 90 days after the end of the program year. Analysis: The Township implement policies and procedures to ensure all required reporting under the Community Development ...

Description: The Township did not file the Community Development Block Grant program Annual Performance and Evaluation Report within 90 days after the end of the program year. Analysis: The Township implement policies and procedures to ensure all required reporting under the Community Development Block Grant program is completed. Corrective Action: Township is working towards implementing reporting process to meet the 90 day filing deadline for CDGB Annual Performance and Evaluation Report. Implementation Date: Ongoing

View Audit 6483

Finding 4160 (2022-002)

Significant Deficiency 2022

Township of Bloomfield

NJ

Allowable Costs / Cost Principles Cash Management Equipment & Real Property Management

Description: Administrative charges to Community Development Block Grant program, are in some instances, not supported by detailed documentation nor are they charged to the correct program year in budgetary records Analysis: All administrative salary and wage and other administrative expenses be ch...

Description: Administrative charges to Community Development Block Grant program, are in some instances, not supported by detailed documentation nor are they charged to the correct program year in budgetary records Analysis: All administrative salary and wage and other administrative expenses be charged to the proper program year and be supported by detail documentation Corrective Action: Finance and Planning departments will coordinate to ensure administrative costs are charged to proper program year, and proper supporting documentation is maintained. Implementation Date: Ongoing

View Audit 6483

Finding 4159 (2022-001)

Significant Deficiency 2022

Township of Bloomfield

NJ

Cash Management

Description: The Township has excess cash proceeds in its Community Development Block Grant Program as a result of drawing down funds in excess of expenditures incurred. Analysis: The Township’s drawdown policies be enhanced; that only actual supported expenditures be drawn down against Community ...

Description: The Township has excess cash proceeds in its Community Development Block Grant Program as a result of drawing down funds in excess of expenditures incurred. Analysis: The Township’s drawdown policies be enhanced; that only actual supported expenditures be drawn down against Community Development Block Grant award allocations in IDIS. Corrective Action: IDIS drawdowns will be made based on the actual expenditures on the Township’s semi-monthly Bill list. Implementation Date: Ongoing

View Audit 6483

Finding 4155 (2022-004)

None 2022

International Service Center

PA

Cash Management

The Program Manager, alongside the Executive Director, will work on updating the ISC's Government Contracts Management Procedures. It will include detailed written procedures that encompass key areas of federal grants. We will develop a reimbursement policy consistent with federal guidelines for our...

The Program Manager, alongside the Executive Director, will work on updating the ISC's Government Contracts Management Procedures. It will include detailed written procedures that encompass key areas of federal grants. We will develop a reimbursement policy consistent with federal guidelines for our staff and volunteers. We aim to finalize this by 12/31/23. Starting the new year, we will also train all staff and volunteers involved with federal grants to ensure compliance.

View Audit 6460

Finding 4154 (2022-003)

Material Weakness 2022

International Service Center

PA

Questioned Costs Cash Management

We are exploring software alternatives to QuickBooks to improve our record-keeping for research expenditures. We target to complete this analysis by 12/31/23 and will share the results with you thereafter. We are exploring software alternatives to QuickBooks to improve our record-keeping for resear...

We are exploring software alternatives to QuickBooks to improve our record-keeping for research expenditures. We target to complete this analysis by 12/31/23 and will share the results with you thereafter. We are exploring software alternatives to QuickBooks to improve our record-keeping for research expenditures. We target to complete this analysis by 12/31/23 and will share the results with you thereafter. The Program Manager will train the Administrative Assistant and Fiscal Assistant on proper accounting procedures adhering to accounting standards.

View Audit 6460 Questioned Costs: $1

Finding 4153 (2022-002)

Material Weakness 2022

International Service Center

PA

Questioned Costs

The following measures will be implemented: 1. Enhanced Documentation Process: Starting immediately, every grant expenditure will be accompanied by detailed documentation that clearly identifies its relation to a particular program. This will ensure transparency and ease of traceability. 2. Trainin...

The following measures will be implemented: 1. Enhanced Documentation Process: Starting immediately, every grant expenditure will be accompanied by detailed documentation that clearly identifies its relation to a particular program. This will ensure transparency and ease of traceability. 2. Training & Awareness: We will provide additional training to our accounting and program teams to ensure that they are fully aware of the new documentation requirements and understand their importance. 3. Regular Review: We will conduct periodic internal reviews of our grant expenditure records to ensure that the new procedures are being consistently followed and that there are no gaps in documentation.

View Audit 6460 Questioned Costs: $1

Finding 4127 (2022-004)

None 2022

The Bridge Over Troubled Waters, Inc.

TX

Reporting § 200.302 § 200.328 § 200.329 § 200.502 § 200.510

Finding 2022-004: Internal Control over Compliance and Compliance with Reporting (Preparation of Schedule of Expenditures of Federal Awards) Finding: The SEFA as prepared by management did not originally include one federal grant with federal expenditures during the year and one grant for which the ...

Finding 2022-004: Internal Control over Compliance and Compliance with Reporting (Preparation of Schedule of Expenditures of Federal Awards) Finding: The SEFA as prepared by management did not originally include one federal grant with federal expenditures during the year and one grant for which the Assistance Listing Number (ALN) did not match the grant documents. Corrective Action: Compare all contract or award letters for accurate information reported on the SEFA prior to submission. Contact: Carmen Stevens, Finance Director Expected Completion Date: 11/30/2023 If you have any questions, please contact Carmen Stevens at 713-472-0753 or by email at cstevens@tbotw.org.

View Audit 6440

Finding 4121 (2022-003)

None 2022

The Bridge Over Troubled Waters, Inc.

TX

Internal Control / Segregation of Duties Reporting § 200.512

Finding 2022-003: Data Collection Form and Single Audit Reporting Package Finding: The Organization did not comply with the required submission date of the data collection form and reporting package to the FAC for the fiscal year ended December 31, 2022. Corrective Action: Prepare reports prior to d...

Finding 2022-003: Data Collection Form and Single Audit Reporting Package Finding: The Organization did not comply with the required submission date of the data collection form and reporting package to the FAC for the fiscal year ended December 31, 2022. Corrective Action: Prepare reports prior to due dates in case there is a computer issue. If a report is late, request an exception/extension in writing to file with report. Contact: Evelyn Vargas, Grants Compliance Manager Expected Completion Date: 11/30/2023 If you have any questions, please contact Evelyn Vargas at 713-472-0753 or by email at evargas@tbotw.org.

View Audit 6440

Finding 4041 (2022-001)

Significant Deficiency 2022

L.b.s.h. Housing Corporation

NY

Reporting

Management will work with their independent auditor to ensure that a proper data collection form will be submitted on a timely basis for the 2022 audit.

View Audit 6360

Finding 4038 (2022-002)

Significant Deficiency 2022

Granville Health System

NC

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System ensure that remaining statement balance for uninsured testing is not balance billed to the patient. Explanation of disagreement with audit finding: There is no di...

Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System ensure that remaining statement balance for uninsured testing is not balance billed to the patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We understand the finding. All balances remaining after HRSA payments will be reviewed and adjusted to zero. Name(s) of the contact person(s) responsible for corrective action: Adam McConnell, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2023

View Audit 6359 Questioned Costs: $1

Finding 4037 (2022-001)

Significant Deficiency 2022

Granville Health System

NC

Questioned Costs Cash Management Significant Deficiency

Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System review the submissions to HRSA to ensure that the patients they requested reimbursement for were in fact uninsured. Explanation of disagreement with audit finding...

Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System review the submissions to HRSA to ensure that the patients they requested reimbursement for were in fact uninsured. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We understand the finding. In future submissions, the System will review all patients to ensure that are uninsured. Name(s) of the contact person(s) responsible for corrective action: Adam McConnell, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2023

View Audit 6359 Questioned Costs: $1

Finding 4015 (2022-003)

Significant Deficiency 2022

Young Women's Christian Association of Metropoliatan St. Louis

MO

Procurement, Suspension & Debarment Reporting § 200.512

Management has historically submitted their financial statements to the federal audit clearinghouse in a timely fashion. Unfortunately, due to new reporting requirements such as the lease accounting standards we were not successful in achieving timely submission for the annual audit report. Manageme...

Management has historically submitted their financial statements to the federal audit clearinghouse in a timely fashion. Unfortunately, due to new reporting requirements such as the lease accounting standards we were not successful in achieving timely submission for the annual audit report. Management and their audit firm are currently adjusting planning procedures and strategy to ensure timely submission of the annual audit report in the future.

View Audit 6330

Finding 4011 (2022-002)

Material Weakness 2022

Young Women's Christian Association of Metropoliatan St. Louis

MO

Reporting Subrecipient Monitoring Material Weakness

Management is committed to ensuring we are in compliance with all Head Start Reporting required by the Department of Health and Human Services and other regulatory bodies. Management will thoroughly review all the terms and conditions of its grant awards with internal management and externally with ...

Management is committed to ensuring we are in compliance with all Head Start Reporting required by the Department of Health and Human Services and other regulatory bodies. Management will thoroughly review all the terms and conditions of its grant awards with internal management and externally with the Department of Health and Human Services and other regulatory bodies to ensure the proper completion of subaward reports in FSRS, the SF429 and other required reporting.

View Audit 6330

Finding 3995 (2022-003)

Material Weakness 2022

Brenda Thibeault

CT

Questioned Costs Subrecipient Monitoring Procurement, Suspension & Debarment

Agree with the finding. A system of internal control policies has been implemented where there is a preparer and reviewer for all transactions. All transactions are allocated according to the cost allocation plan. The Internal Controls Policy details specific roles and responsibilities of managem...

Agree with the finding. A system of internal control policies has been implemented where there is a preparer and reviewer for all transactions. All transactions are allocated according to the cost allocation plan. The Internal Controls Policy details specific roles and responsibilities of management. Material compliance knowledge requirements are being met by compliance training provided by state and federal funding entities alongside review of the guidance and contract manuals. Additional documentation such as expense justification forms and vendor approval lists have been implemented.

View Audit 6303 Questioned Costs: $1

Finding 3994 (2022-002)

Material Weakness 2022

Brenda Thibeault

CT

Questioned Costs Allowable Costs / Cost Principles

Agree with the finding. The Organization met the requirement for a cost allocation plan in the single audit year for 2020-2021. There was no written cost allocation plan submitted for the 2022 audit year. A cost allocation plan has been updated, approved by the board, and implemented to ensure ma...

Agree with the finding. The Organization met the requirement for a cost allocation plan in the single audit year for 2020-2021. There was no written cost allocation plan submitted for the 2022 audit year. A cost allocation plan has been updated, approved by the board, and implemented to ensure material compliance requirements are being met.

View Audit 6303 Questioned Costs: $1

Finding 3993 (2022-003)

Material Weakness 2022

Resource One Credit Union

TX

Reporting § 200.328 § 200.329

The input error was corrected prior to end of the audit. The credit union's CDFI analyst was contacted by the Chief Strategic Officer and the analyst opened the data field for editing in the AMIS system. The Chief Strategic Officer made the correction in the AMIS system and submitted the corrected i...

The input error was corrected prior to end of the audit. The credit union's CDFI analyst was contacted by the Chief Strategic Officer and the analyst opened the data field for editing in the AMIS system. The Chief Strategic Officer made the correction in the AMIS system and submitted the corrected information. The Chief Strategic Officer has assigned CDFI reporting responsibiities to the Director of Strategy. Future submissions will be performed by the Director of Strategy and reviewed by the Chief Strategic Officer prior to submission. Executive Responsible - Brady Popp, Chief Strategy Officer Projected Completion Date - Completed prior to the close of the audit

View Audit 6300

Finding 3992 (2022-004)

Significant Deficiency 2022

City of Depere

WI

Reporting Significant Deficiency Internal Control / Segregation of Duties

Management has taken sufficient corrective action to resolve and does not believe this will be an issue in the future.

View Audit 6296

Finding 3979 (2022-001)

Significant Deficiency 2022

Hodgeman County, Kansas

KS

Subrecipient Monitoring Cash Management Significant Deficiency § 200.305

U.S. DEPARTMENT OF HOMELAND SECURITY KANSAS ADJUANT GENERAL 2022-001: Disaster Grants – Public Assistance CFDA No. 97.036 Grant period: Year Ended December 31, 2022 Condition and Context: The County does not have a complete set of written cash management policies and procedures as required by the U...

U.S. DEPARTMENT OF HOMELAND SECURITY KANSAS ADJUANT GENERAL 2022-001: Disaster Grants – Public Assistance CFDA No. 97.036 Grant period: Year Ended December 31, 2022 Condition and Context: The County does not have a complete set of written cash management policies and procedures as required by the Uniform Guidance. The lack of written procedures did not result in any material noncompliance, fraud or abuse with respect to the major program. Criteria: The Uniform Guidance requires Non-Federal entities other than States, including those operating Federal programs as subrecipients of States, to follow the cash management standards set out at 2 CFR section 200.305. The County must have a complete set of written cash management policies, which conform to applicable Federal statutes and the cash management requirements identified in 2 CFR part 200. Cause: The County was unaware of the written cash management policy requirements required by the Uniform Guidance. Effect: An important component of internal controls is the existence of operating policies and procedures and that they are clearly understood and communicated. Without clear written policies and procedures, there is a higher risk of noncompliance with program requirements. Recommendation: Management should determine the scope of written policies needed for compliance with all federal programs and develop policies and procedures to comply with the Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and recommendation. The County’s existing policies are currently under review by management and staff to determine what updates/changes are necessary in order to meet the Uniform Guidance requirements. Once any updates/changes are drafted, the policy will be presented to the Governing Body for review and approval.

View Audit 6270

Finding 3960 (2022-002)

Material Weakness 2022

Municipality of Delmont

SD

Material Weakness

The City of Delmont Governing Board is the contact for the corrective action plan for this finding. Because of a large amount of turnover in staff at the City, the accounting records were not properly maintained. The City has recently hired a finance officer and is providing the training to proper...

The City of Delmont Governing Board is the contact for the corrective action plan for this finding. Because of a large amount of turnover in staff at the City, the accounting records were not properly maintained. The City has recently hired a finance officer and is providing the training to properly maintain appropriate records.

View Audit 6229

Corrective Action Plans

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