Corrective Action Plans

Finding 22748 (2022-001)

Significant Deficiency 2022

AZ

Allowable Costs / Cost Principles Questioned Costs School Nutrition Programs § 200.430

Findings and Questioned Costs Related to Federal Awards Finding Number: 2022-001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.559 Contact Person: Venessa Beecroft, Business Manager Anticipated Completion Date: June 30, 2023 Planned Corrective Action: ...

Findings and Questioned Costs Related to Federal Awards Finding Number: 2022-001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.559 Contact Person: Venessa Beecroft, Business Manager Anticipated Completion Date: June 30, 2023 Planned Corrective Action: The District will implement a tracking tool to ensure that all new hires return their work agreements as they are hired on throughout the year.

View Audit 22800 Questioned Costs: $1

Finding 22747 (2022-002)

None 2022

Community Action Organization of Western New York, Inc. and Subsidiaries

CO

Subrecipient Monitoring Reporting

Federal Financial Accountability and Transparency Act (FFATA) Reporting Planned Corrective Action: Previous management was unaware of the requirement to file the above-mentioned report. As of August 31, 2021, CAO no longer has a subrecipients. Current management within CAO Fiscal Department will fil...

Federal Financial Accountability and Transparency Act (FFATA) Reporting Planned Corrective Action: Previous management was unaware of the requirement to file the above-mentioned report. As of August 31, 2021, CAO no longer has a subrecipients. Current management within CAO Fiscal Department will file the above-mentioned report by December 31, 2022 Person Responsible for Corrective Action Plan: Sharada Briggs, Chief Financial Officer Anticipated Date of Completion: December 2022

View Audit 22723

Finding 22746 (2022-006)

Material Weakness 2022

Safenet, Inc.

PA

Allowable Costs / Cost Principles § 200.430

FINDING 2022-006: CRIME VICTIM ASSISTANCE (16.575) ? ALLOWABLE COSTS AND COST PRINCIPLES ? PAYROLL CHARGES AND COST ALLOCATION CONTACT PERSON: Robyn Young, Executive Director CORRECTIVE ACTION: Safenet, Inc. has implemented procedures to ensure that reimbursement requests for wages are supported b...

FINDING 2022-006: CRIME VICTIM ASSISTANCE (16.575) ? ALLOWABLE COSTS AND COST PRINCIPLES ? PAYROLL CHARGES AND COST ALLOCATION CONTACT PERSON: Robyn Young, Executive Director CORRECTIVE ACTION: Safenet, Inc. has implemented procedures to ensure that reimbursement requests for wages are supported by documentation that supports the amounts requested. Backup for payroll requests will be based off time and effort spent on each award using a new time keeping system that records time spent on each award. Management will routinely review payroll reports for accuracy and adjust when necessary. The Board of Directors for Safenet, Inc. approved a revised cost allocation plan on August 18, 2022 and a revised version on January 30, 2023 that have been reviewed by the auditor. This plan will support equitable allocation of costs across all sources. PROPOSED COMPLETION DATE: Immediately

View Audit 22633

Finding 22745 (2022-005)

Material Weakness 2022

Safenet, Inc.

PA

Cash Management § 200.305

FINDING 2022-005: CRIME VICTIM ASSISTANCE (16.575) ? CASH MANAGEMENT ? REIMBURSEMENT REQUESTS AND SUPPORTING DOCUMENTATION CONTACT PERSON: Robyn Young, Executive Director CORRECTIVE ACTION: Safenet, Inc. has implemented procedures to ensure that reimbursement requests are first agreed to underlyin...

FINDING 2022-005: CRIME VICTIM ASSISTANCE (16.575) ? CASH MANAGEMENT ? REIMBURSEMENT REQUESTS AND SUPPORTING DOCUMENTATION CONTACT PERSON: Robyn Young, Executive Director CORRECTIVE ACTION: Safenet, Inc. has implemented procedures to ensure that reimbursement requests are first agreed to underlying accounting records and amounts are substantiated with backup. Costs will also be reviewed for availability by someone with suitable knowledge of the particular award. This reviewer will check the accuracy of the request prior to submission. PROPOSED COMPLETION DATE: Immediately

View Audit 22633

Finding 22744 (2022-004)

Significant Deficiency 2022

City of Westminster, Maryland

MD

HUD Housing Programs Internal Control / Segregation of Duties Eligibility

The City?s Housing department will review the current filing system in place, and by using a checklist, will make sure to implement procedures that will ensure all proper documentation is filed and available for review.

View Audit 18365

Finding 22743 (2022-003)

Material Weakness 2022

City of Westminster, Maryland

MD

HUD Housing Programs Material Weakness Reporting

The City?s Housing and Finance departments will work together to make sure all parties understand what monthly reconciliations are required and the responsibility of each department to ensure proper action is taken. Procedures will be updated, as necessary, documented and evaluated at least annually...

The City?s Housing and Finance departments will work together to make sure all parties understand what monthly reconciliations are required and the responsibility of each department to ensure proper action is taken. Procedures will be updated, as necessary, documented and evaluated at least annually.

View Audit 18365

Finding 22742 (2022-002)

Significant Deficiency 2022

City of Westminster, Maryland

MD

Allowable Costs / Cost Principles HUD Housing Programs

The City?s Housing and Finance departments will work together to make sure all parties understand what administrative costs should be charged and how they should be appropriately charged across the various funding sources. Procedures will be updated, as necessary, documented and evaluated at least a...

The City?s Housing and Finance departments will work together to make sure all parties understand what administrative costs should be charged and how they should be appropriately charged across the various funding sources. Procedures will be updated, as necessary, documented and evaluated at least annually.

View Audit 18365

Finding 22741 (2022-001)

Material Weakness 2022

Christus Health

TX

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

CHRISTUS Health Corrective Action Plan Year Ended June 30, 2022 Finding 2022-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American R...

CHRISTUS Health Corrective Action Plan Year Ended June 30, 2022 Finding 2022-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: July 1, 2020 to June 30, 2022 Corrective Action Planned: Management agrees that certain expenses to the COVID department were not reviewed and approved at the order entry level in specific cases. Although evidence of review was not retained for every charge to the COVID department, we believe the appropriateness of the charge was reasonable. Additionally, based on monthly review of departmental expenses and full-time equivalent (FTE) analysis at the facility level, we believe that these expenditures are subject to the appropriate level of review to identify unexpected variances. We plan to review our processes related to the retention of expense documentation to improve audit evidence. Responsible party: Lee Sonne, Vice President of Finance and Controller Implementation Date: September 2023 with the filing of the 5th portal filing.

View Audit 18976

Finding 22738 (2022-001)

None 2022

Bedford Stuyvesant Restoration Corporation and Affiliates

NY

Questioned Costs HUD Housing Programs Reporting

Reporting Finding: We noted that seven out of twelve monthly reports for the year ended June 30, 2022 were not submitted on time. Monthly reports ending 08/31/2021, 11/30/2021, 12/31/2021, 01/31/2022, 02/28/2022, 03/31/2022 and 06/30/2022 which are due on the 20th day of the following month were sub...

Reporting Finding: We noted that seven out of twelve monthly reports for the year ended June 30, 2022 were not submitted on time. Monthly reports ending 08/31/2021, 11/30/2021, 12/31/2021, 01/31/2022, 02/28/2022, 03/31/2022 and 06/30/2022 which are due on the 20th day of the following month were submitted on 09/22/2021, 12/21/2021, 01/21/2022, 02/22/2022, 03/22/2022, 04/21/2022 and 11/03/2022 respectively. Contact Person: Thelma Arceo ? WAP Director Corrective Actions Taken or Planned: With WAP work schedules back to normal and the field work also operating more normally the program has been able to move back to normal reporting processing. Anticipated completion date: Start of program year 2023.

View Audit 19053

Finding 22737 (2022-222)

Significant Deficiency 2022

Nachlas Bais Yaakov INC

NJ

Significant Deficiency

Finding 22-2: The audit report was due to be received by the State of New Jersey no later than May 31, 2023. As a result, the audit was not submitted timely. Recommendation: The School should alert the auditor about new funding received during the year to give ample time to research and prepare. Act...

Finding 22-2: The audit report was due to be received by the State of New Jersey no later than May 31, 2023. As a result, the audit was not submitted timely. Recommendation: The School should alert the auditor about new funding received during the year to give ample time to research and prepare. Action Taken: The administrator will monitor the School?s funding that they receive throughout the year and will alert the auditor as soon as they receive funding from a new program. As such, the required corrective actions have been implemented. Implementation Date: Corrective Action Plan has been implemented as of July 10, 2023. Person Responsible for Implementation: Chaya Apter, Food Service Director, is the responsible party for implementation of the CAP. Telephone Number: (732)994-3935.

View Audit 19742

Finding 22736 (2022-221)

Significant Deficiency 2022

Nachlas Bais Yaakov INC

NJ

Procurement, Suspension & Debarment Significant Deficiency

Finding 22-2: The audit report was due to be received by the State of New Jersey no later than May 31, 2023. As a result, the audit was not submitted timely. Recommendation: The School should alert the auditor about new funding received during the year to give ample time to research and prepare. Act...

Finding 22-2: The audit report was due to be received by the State of New Jersey no later than May 31, 2023. As a result, the audit was not submitted timely. Recommendation: The School should alert the auditor about new funding received during the year to give ample time to research and prepare. Action Taken: The administrator will monitor the School?s funding that they receive throughout the year and will alert the auditor as soon as they receive funding from a new program. As such, the required corrective actions have been implemented. Implementation Date: Corrective Action Plan has been implemented as of July 10, 2023. Person Responsible for Implementation: Chaya Apter, Food Service Director, is the responsible party for implementation of the CAP. Telephone Number: (732)994-3935.

View Audit 19742

Finding 22735 (2022-001)

Significant Deficiency 2022

University of Colorado Health

CO

Questioned Costs Cash Management Eligibility

Condition: During testing of CFDA 93.461 HRSA COVID-19 Uninsured Program the auditor identified one eligibility finding related to a patient selected for testing who was uninsured at the time of service, but the patient subsequently applied for and received coverage under Medicaid with a retroactive...

Condition: During testing of CFDA 93.461 HRSA COVID-19 Uninsured Program the auditor identified one eligibility finding related to a patient selected for testing who was uninsured at the time of service, but the patient subsequently applied for and received coverage under Medicaid with a retroactive coverage effective date prior to the date of service. UCHealth should have controls and processes in place to identify retroactive insurance coverage for patients treated under the program to ensure HRSA reimbursement is not received for patients with insurance coverage. Planned Corrective Action: This account was reviewed. Emergency Medicaid was found and attached to the account and a full refund to HRSA COVID-19 was processed on 2/1/2023 in the amount of $50,808.16 on check #431627. Review of the account demonstrated that system actions identified the correct Medicaid coverage and flagged for manual review. User error was made on consecutive days where Medicaid was not properly added to the account. Financial Counseling and Business Services leadership have reinforced coverage attachment protocols with staff 2/24/2023. Contact person responsible for corrective action: Michael Bishop Anticipated Completion Date: 2/1/2023

View Audit 19423 Questioned Costs: $1

Finding 22734 (2022-001)

Significant Deficiency 2022

Village Cooperative of Cedar Rapids

IA

Internal Control / Segregation of Duties Questioned Costs Significant Deficiency

Department of Housing and Urban Development: HUD project FHA #074-23009 Village Cooperative of Cedar Rapids Federal ID# 45-3763469 The FASS system generated the following findings from its review of the August 31, 2022 financial statements. The results of the assessment are summarized below. The ...

Department of Housing and Urban Development: HUD project FHA #074-23009 Village Cooperative of Cedar Rapids Federal ID# 45-3763469 The FASS system generated the following findings from its review of the August 31, 2022 financial statements. The results of the assessment are summarized below. The project owner should provide their assigned HUD Project Manager a written response addressing each of the findings, and appropriate documentation (e.g. copies of cancelled checks, bank statements, etc.) to prove the finding has been resolved. Project Auditor Findings: The auditor reported the following findings: Compliance Oriented Findings. The Schedule of Findings and Questioned Costs by the auditor contained findings related to the following Auditor Indicator Codes: Finding Reference No. / Code - Finding Condition 2022-001 / S - Internal Control Deficiencies Corrective Action(s). For all audit findings that were unresolved as of the date of the audit report, the owner must provide their HUD Project Manager a written response and supporting documentation indicating the finding has been resolved. Corrective Action Plan: The Board of Directors is and will remain involved in the financial affairs of the Cooperative.

View Audit 19654

Finding 22733 (2022-002)

Significant Deficiency 2022

Rochester Housing Authority

NY

Questioned Costs Matching / Level of Effort / Earmarking

Name of Auditee: Rochester Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: September 30, 2022 CAP Prepared by: Shawn Burr, Executive Director Phone: (585) 697-6184 (A) Current Findings on the Schedule of Findings and Questioned Costs (2) Finding 2022-002 (a)...

Name of Auditee: Rochester Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: September 30, 2022 CAP Prepared by: Shawn Burr, Executive Director Phone: (585) 697-6184 (A) Current Findings on the Schedule of Findings and Questioned Costs (2) Finding 2022-002 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendation, please see below for action taken. (b) Action taken - HQS inspections of Shelter Plus Care properties will be performed on an annual basis. (c) Planned implementation date of corrective action - Completed by September 30, 2023.

View Audit 19130

Finding 22732 (2022-005)

Significant Deficiency 2022

Baraga County Memorial Hospital

MI

HUD Housing Programs Reporting Significant Deficiency

Finding # 2022-005 (Internal Controls over Reporting). Response: Management will implement controls around HUD-related reporting requirements to ensure all quarterly interim financials are submitted within 40 days following close of the reporting period. Responsible Party: Gail Jestila, CFO at Ba...

Finding # 2022-005 (Internal Controls over Reporting). Response: Management will implement controls around HUD-related reporting requirements to ensure all quarterly interim financials are submitted within 40 days following close of the reporting period. Responsible Party: Gail Jestila, CFO at Baraga County Memorial Hospital. Estimated Completion: 05/20/2023.

View Audit 18363

Finding 22731 (2022-004)

Significant Deficiency 2022

Baraga County Memorial Hospital

MI

HUD Housing Programs Significant Deficiency

Finding # 2022-004 (Internal Controls over Cash Disbursements). Response: Management will implement controls and process to ensure that payments for any services provided to an affiliate are reimbursed within 90 days going forward. Responsible Party: Gail Jestila, CFO at Baraga County Memorial Ho...

Finding # 2022-004 (Internal Controls over Cash Disbursements). Response: Management will implement controls and process to ensure that payments for any services provided to an affiliate are reimbursed within 90 days going forward. Responsible Party: Gail Jestila, CFO at Baraga County Memorial Hospital. Estimated Completion: 09/30/2023

View Audit 18363

Finding 22730 (2022-002)

Significant Deficiency 2022

Victory One Housing Development Fund Corporation

NY

HUD Housing Programs Reporting

Planned Corrective Action: Management acknowledges that the HUD financial information was not submitted timely and has implemented controls to ensure timely filings. Anticipated Completion Date: The financial statements will be submitted by July 31, 2023.

View Audit 19318

Finding 22729 (2022-001)

Significant Deficiency 2022

Victory One Housing Development Fund Corporation

NY

HUD Housing Programs

Planned Corrective Action: Management acknowledges that the required deposits to the replacement reserve account were not made. Management will transfer the funds as soon as cash flow permits. Anticipated Completion Date: Upon availability of cash flows.

View Audit 19318

Finding 22728 (2022-002)

None 2022

Foresthill Union School District

CA

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring

Views of Responsible Officials and Planned Corrective Actions: The District will implement a new process for calculating and accumulating total meal counts using Excel. The new meal count process will include the Cafeteria Lead and Business Manager doing comparison checks to ensure monthly totals ar...

Views of Responsible Officials and Planned Corrective Actions: The District will implement a new process for calculating and accumulating total meal counts using Excel. The new meal count process will include the Cafeteria Lead and Business Manager doing comparison checks to ensure monthly totals are accurately reported.

View Audit 18362 Questioned Costs: $1

Finding 22726 (2022-001)

Significant Deficiency 2022

Nehalem Bay Health Center and Pharmacy

OR

Eligibility Special Tests & Provisions Subrecipient Monitoring

Finding: 2022-001 Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Through testing a statistically valid sample of transactions for the appropriate application of the Organization's sliding fee discount prog...

Finding: 2022-001 Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Through testing a statistically valid sample of transactions for the appropriate application of the Organization's sliding fee discount program to 25 individual patient balances, two patients did not have a valid application in effect for the date of service tested, resulting in the ineligible patients receiving discounts of approximately $275 and $168. Individual(s) Responsible for Corrective Action: Primary: Nicole Townsend Treber, Front Desk Supervisor Support: Brendan Johnson, Director of Quality Support: Lora Ressler, Executive Administrative Assistant Planned Corrective Action: ? Front Desk Supervisor will provide on-going training to individuals involved in the patient intake and billing processes specific to the patient income and family size entry process; ? Monthly: Director of Quality will provide reports that show SFS adjustments vs completed SFS applications; ? Monthly: Designated employee will be responsible for audit sampling; ? Monthly: Results of audit sampling will be forwarded to Front Desk Supervisor and if needed, will provide additional training. Anticipated Completion Date: January 1, 2024

View Audit 18116

Finding 22725 (2022-002)

Significant Deficiency 2022

Guam Community College

GU

Subrecipient Monitoring Allowable Costs / Cost Principles Period of Performance

Views of responsible officials and planned corrective actions: The College has taken steps to charge the cost to the appropriate grant award number. The College will ensure that future costs are properly charged to the correct grant award number and that costs are within the appropriate period of pe...

Views of responsible officials and planned corrective actions: The College has taken steps to charge the cost to the appropriate grant award number. The College will ensure that future costs are properly charged to the correct grant award number and that costs are within the appropriate period of performance. In addition, finance and program staff will be trained on period of performance requirements, as well as other aspects of grant management. Contact Person: Rodalyn Gerardo, Vice President for Finance & Administration Expected Completion Date: September 30, 2023

View Audit 17796

Finding 22724 (2022-001)

Material Weakness 2022

Guam Community College

GU

Questioned Costs

Views of responsible officials and planned corrective actions: The College will ensure that new program courses and other areas not addressed in the state plan are reviewed and approved by the grantor to verify compliance with grant requirements. In addition, finance and program staff will be traine...

Views of responsible officials and planned corrective actions: The College will ensure that new program courses and other areas not addressed in the state plan are reviewed and approved by the grantor to verify compliance with grant requirements. In addition, finance and program staff will be trained on allowable costs and activities, as well as other aspects of grant management. Contact Person: Rodalyn Gerardo, Vice President for Finance & Administration Expected Completion Date: September 30, 2023

View Audit 17796

Finding 22714 (2022-004)

Significant Deficiency 2022

Art Academy of Cincinnati

OH

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

Findings 2022-004 and 2021-001 Direct Loan Reconciliations Condition: For the fiscal year ending May 31, 2022, monthly Direct Loan Reconciliations were not performed for the months of June 2021 through September 2021. Views of Responsible Officials: The Academy does not disagree with this audit fi...

Findings 2022-004 and 2021-001 Direct Loan Reconciliations Condition: For the fiscal year ending May 31, 2022, monthly Direct Loan Reconciliations were not performed for the months of June 2021 through September 2021. Views of Responsible Officials: The Academy does not disagree with this audit finding. Corrective Action Plan: Direct Loan reconciliations a performed on a monthly basis by the Director of Financial Aid and a report is provided to the VP of Administration of Finance showing the tie out between G5 and COD. Responsible Party: Frances Hutchinson, Director of Financial Aid Anticipated Completion Date: This process was implemented in October 2021.

View Audit 17960

Finding 22713 (2022-003)

Significant Deficiency 2022

Art Academy of Cincinnati

OH

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding 2022-003 Disbursements to or on Behalf of Students Condition: During testing of disbursements to or on behalf of students, 16 out of the 25 students selected for testing did not receive a written notification from the institution for the Fall of 2021 semester. Views of Responsible Official...

Finding 2022-003 Disbursements to or on Behalf of Students Condition: During testing of disbursements to or on behalf of students, 16 out of the 25 students selected for testing did not receive a written notification from the institution for the Fall of 2021 semester. Views of Responsible Officials: The Academy does not disagree with this audit finding. Corrective Action Plan: The Academy's student information system, Campus Cafe, provides online award letter notification to all students for review to approve and/or decline. Responsible Party: Frances Hutchinson, Director of Financial Aid Anticipated Completion Date: This process was implemented in Fall 2022.

View Audit 17960

Finding 22712 (2022-002)

Significant Deficiency 2022

Art Academy of Cincinnati

OH

Student Financial Aid Matching / Level of Effort / Earmarking Eligibility

Finding 2022-002 Internal Controls Condition: During testing of compliance requirements such as eligibility and verification testing, there was not documentation of a level of review to ensure the requirements were met and accurate. Views of Responsible Officials: The Academy does not disagree wit...

Finding 2022-002 Internal Controls Condition: During testing of compliance requirements such as eligibility and verification testing, there was not documentation of a level of review to ensure the requirements were met and accurate. Views of Responsible Officials: The Academy does not disagree with this audit finding. Corrective Action Plan: The Academy's Financial Aid Counselor will complete a checklist for eligibility and verification and the Director of Financial Aid will provide documented signoff once the checklist is reviewed for completeness and accuracy. Responsible Party: Frances Hutchinson, Director of Financial Aid Anticipated Completion Date: This process was implemented in November 2021 once Clifton Larson Allen started assisting the Academy.

View Audit 17960

Corrective Action Plans

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