Corrective Action Plans

Finding 20272 (2022-001)

Significant Deficiency 2022

KS

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2022 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 ? Audit Findings Follow-up requires the auditee t...

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2022 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 ? Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor?s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended December 31, 2022. Finding 2022-001 Responsible Party Name: Fred Arreguin Position: Chief Financial Officer ? Management Agent Telephone Number: 816-561-4240 Federal Agency U.S. Department of Housing and Urban Development Federal Program Supportive Housing for the Elderly ? Section 202 Compliance Requirements N ? Special Tests and Provisions Finding Type Compliance and Internal Control Auditee?s Comment on Finding We agree with the auditor?s finding Corrective Action We will submit a request for retroactive approval of the $10,724 withdrawal from the reserve for replacement account on June 23, 2022. Anticipated Completion Date April 30, 2023

View Audit 22368 Questioned Costs: $1

Finding 20271 (2022-002)

Significant Deficiency 2022

Healthwest

MI

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.309

Finding 2022-002 ? Considered a significant deficiency in internal control over compliance/immaterial non-compliance Federal Grant ? ALN 93.958 Condition ? During testing it was noted that FICA costs were overcharged by $14,047. Corrective Action ? HealthWest will review its methods for determini...

Finding 2022-002 ? Considered a significant deficiency in internal control over compliance/immaterial non-compliance Federal Grant ? ALN 93.958 Condition ? During testing it was noted that FICA costs were overcharged by $14,047. Corrective Action ? HealthWest will review its methods for determining allocations of fringe benefits to their grants. Review and, any necessary, updates to daily procedures and processes are occurring. All finance staff and any HealthWest staff assigned to grants will be required to obtain grants specific training annually. Finally, monthly monitoring of all expenses will be reviewed. Contract Person ? Brandy Carlson, Chief Financial Officer Anticipated Completion Date ? June 30, 2023

View Audit 21044 Questioned Costs: $1

Finding 20270 (2022-003)

Material Weakness 2022

City of Lakewood

WA

Procurement, Suspension & Debarment Subrecipient Monitoring

Corrective action the auditee plans to take in response to the finding: The City disagrees with the State Auditor?s Office in regards to inadequate internal controls, rather it is a matter of interpretation of the requirements as it relates to revenue loss (refer to City?s response to audit finding ...

Corrective action the auditee plans to take in response to the finding: The City disagrees with the State Auditor?s Office in regards to inadequate internal controls, rather it is a matter of interpretation of the requirements as it relates to revenue loss (refer to City?s response to audit finding in the audit report). Anticipated date to complete the corrective action: The is current on suspension and debarment requirements and will ensure federal contracts are compliant in the future.

View Audit 19184

Finding 20269 (2022-002)

Material Weakness 2022

City of Lakewood

WA

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking

Corrective action the auditee plans to take in response to the finding: The City will ensure SF-425 is completed timely. Anticipated date to complete the corrective action: The issue was resolved immediately.

View Audit 19184

Finding 20251 (2022-015)

Material Weakness 2022

Doral Academy of Nevada

NV

Allowable Costs / Cost Principles Questioned Costs Reporting § 200.303

Finding Number: 2022-015 ? Reporting Corrective Action Plan: A process has been put in place for the school principal to review all RFRs prior to submission to the grantor. Approval is evidenced by email sent by principal to the Director of Grant Management, which is saved with the RFR as support. R...

Finding Number: 2022-015 ? Reporting Corrective Action Plan: A process has been put in place for the school principal to review all RFRs prior to submission to the grantor. Approval is evidenced by email sent by principal to the Director of Grant Management, which is saved with the RFR as support. Responsible Individuals: Nachum Golodner, Director of Accounting Anticipated Completion Date: June 30, 2023

View Audit 20771

Finding 20243 (2022-013)

Material Weakness 2022

Doral Academy of Nevada

NV

Allowable Costs / Cost Principles School Nutrition Programs Internal Control / Segregation of Duties § 200.303

Finding Number: 2022-013 ? Activities Allowed or Unallowed and Allowable Costs/Cost Principles Corrective Action Plan: A process has been put in place for the school principal to review all RFRs prior to submission to the grantor. Approval is evidenced by email sent by principal to the Director of G...

Finding Number: 2022-013 ? Activities Allowed or Unallowed and Allowable Costs/Cost Principles Corrective Action Plan: A process has been put in place for the school principal to review all RFRs prior to submission to the grantor. Approval is evidenced by email sent by principal to the Director of Grant Management, which is saved with the RFR as support. Responsible Individuals: Nachum Golodner, Director of Accounting Anticipated Completion Date: June 30, 2023

View Audit 20771

Finding 20242 (2022-016)

Material Weakness 2022

Doral Academy of Nevada

NV

Reporting School Nutrition Programs Internal Control / Segregation of Duties § 200.303

Finding Number: 2022-016 ? SEFA Preparation Corrective Action Plan: In 2022, the office had downsized due to turnover in staff. While a process was in place for reconciling, a secondary review was not performed to verify accuracy of the residual value calculations. To strengthen the oversight of fin...

Finding Number: 2022-016 ? SEFA Preparation Corrective Action Plan: In 2022, the office had downsized due to turnover in staff. While a process was in place for reconciling, a secondary review was not performed to verify accuracy of the residual value calculations. To strengthen the oversight of financial management in the School, Academica Nevada, the School?s management company, has filled all the open positions and realigned staff responsibilities to reduce individual workloads and provide additional oversight and review. The grant manager will reconcile all grants to ensure proper cutoff, with a secondary review performed by a member of management. Responsible Individuals: Nachum Golodner, Director of Accounting Anticipated Completion Date: June 30, 2023

View Audit 20771

Finding 20241 (2022-014)

Material Weakness 2022

Doral Academy of Nevada

NV

Procurement, Suspension & Debarment School Nutrition Programs

Finding Number: 2022-014 ? Procurement, Suspension, and Debarment Corrective Action Plan: Academica Nevada, the School?s management company, and the School will complete an update of the procurement policies to ensure that federal law and standards are clearly detailed and defined. Responsible Indiv...

Finding Number: 2022-014 ? Procurement, Suspension, and Debarment Corrective Action Plan: Academica Nevada, the School?s management company, and the School will complete an update of the procurement policies to ensure that federal law and standards are clearly detailed and defined. Responsible Individuals: Nachum Golodner, Director of Accounting Anticipated Completion Date: June 30, 2023

View Audit 20771

Finding 20240 (2022-001)

None 2022

Fox Run Village, Inc.

MI

Reporting Questioned Costs

Finding 2022-001: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Reporting Cluster: Not applicable Federal Agency: Department of Health and Human Services (?HHS?) Award Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing #:...

Finding 2022-001: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Reporting Cluster: Not applicable Federal Agency: Department of Health and Human Services (?HHS?) Award Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing #: 93.498 Assistance Listing Title: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution ? Period 4 Award Year(s): January 1, 2020 ? December 31, 2022 Management acknowledges the identified issue and concurs with the suggested course of action. A comprehensive analysis of the inputs utilized in the computation of lost revenue will be undertaken by Management. This meticulous review aims to guarantee the precision and completeness of the calculation. A thorough documentation of this review process will be conducted, ensuring the establishment of a comprehensive audit trail and accuracy of the detailed computation. Furthermore, Management is actively pursuing the rectification of the previous submissions in the HRSA portal to accurately reflect the necessary corrections stemming from the clerical error. The anticipated timeline for the review and subsequent filing is set for completion by September 30, 2023.

View Audit 20921

Finding 20234 (2022-001)

Significant Deficiency 2022

Community Health Services, Inc.

CT

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN May 22, 2023 United States Department of Health and Human Services Community Health Services, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2022. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: December 31...

CORRECTIVE ACTION PLAN May 22, 2023 United States Department of Health and Human Services Community Health Services, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2022. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: December 31, 2022 The findings from the December 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCY 2021.001 ? Sliding Fee Scale Discount Recommendation The Center should implement controls to ensure proper slide fee discounts are provided. Action Taken The Center implemented internal controls to mitigate the risk of missing sliding fee discount documentation. The creation of this control consisted of designing a report that would identify all sliding fee discount applicants for the specified timeframe, as well as identify whether supporting documentation had been scanned into the patient?s electronic health record. As a result of the repeated finding, the Center added an additional layer of review. The Director of Development, Grants and Outreach reviews all slide applications before they are scanned and entered into the electronic health record and applied to the patient?s account. The Center will continue monthly internal auditing procedures where an Eligibility Specialist haphazardly selects slide applications from the previous month to ensure compliance. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Dianna Kulmacz, CFO at (860) 808-8765. Sincerely yours, Dianna Kulmacz Chief Financial Officer

View Audit 19676

Finding 20233 (2022-003)

Significant Deficiency 2022

Longmont Housing Authority

CO

HUD Housing Programs Special Tests & Provisions Significant Deficiency

Significant Deficiency in Internal Control 2022-003 Special Tests and Provisions ? Reasonable Rent Repeat finding from prior year: No Finding Summary: ? The Program requires the Authority to determine that rent to owners are reasonable in comparison to rent for other comparable unassisted units at t...

Significant Deficiency in Internal Control 2022-003 Special Tests and Provisions ? Reasonable Rent Repeat finding from prior year: No Finding Summary: ? The Program requires the Authority to determine that rent to owners are reasonable in comparison to rent for other comparable unassisted units at the time of an initial move-in to a unit or during the annual recertification if the rent is increased. During the testing of compliance for reasonable rent, auditors identified instances in which the reasonable rent form was not obtained timely. Responsible Individuals: Housing Compliance Manager Corrective Action Plan: Training was instituted for existing and new staff coming on board to know the correct rent reasonableness form to print and place in the file. Anticipated Completion Date: May 31, 2023

View Audit 18756

Finding 20232 (2022-002)

Significant Deficiency 2022

Longmont Housing Authority

CO

HUD Housing Programs Subrecipient Monitoring Significant Deficiency

Significant Deficiency in Internam Control 2022-002 Special Tests and Provisions ? HQS Enforcement Repeat finding from prior year: No Finding Summary: ? For units under a HAP contract that fail to meet HQS requirements, the Authority must require the owner to correct life threatening HQS deficiencie...

Significant Deficiency in Internam Control 2022-002 Special Tests and Provisions ? HQS Enforcement Repeat finding from prior year: No Finding Summary: ? For units under a HAP contract that fail to meet HQS requirements, the Authority must require the owner to correct life threatening HQS deficiencies within 24 hours after the inspection and all other HQS deficiencies within 30 calendar days or within a specified Authority-approved extension. Responsible Individuals: Housing Compliance Manager Corrective Action Plan: A change in the process for our third party inspection consultants was implemented. The 24 hour HQS confirmations were not being sent directly to the Housing Authority. The consultants are now required to send those confirmations (pictures, receipts, work order?etc.) so HCV Specialists can document the correction was completed within the 24 hour cycle. Anticipated Completion Date: May 31, 2023

View Audit 18756

Finding 20231 (2022-001)

Significant Deficiency 2022

Longmont Housing Authority

CO

HUD Housing Programs Internal Control / Segregation of Duties Special Tests & Provisions

Significant Deficiency in Internal Control 2022-001 Special Tests and Provisions ? HQS Inspections Repeat finding from prior year: No Finding Summary: The Program requires the Authority to complete an inspection at least biennially to determine if the unit meets HQS standards. We noted one of the te...

Significant Deficiency in Internal Control 2022-001 Special Tests and Provisions ? HQS Inspections Repeat finding from prior year: No Finding Summary: The Program requires the Authority to complete an inspection at least biennially to determine if the unit meets HQS standards. We noted one of the tenants tested for standard inspections did not have biennial HQS inspection scheduled or completed in 2022. Responsible Individuals: Housing Compliance Manager Corrective Action Plan: Our software system has the capability of not completing a re-certification without the proper biennial HQS Inpection, this feature is now activated so a re-certification cannot be completed without the biennial inspection. Anticipated Completion Date: April 30, 2023

View Audit 18756

Finding 20229 (2022-004)

None 2022

Longmont Housing Authority

CO

Questioned Costs Reporting Significant Deficiency

Significant Deficiency in Internal Control 2022-004 Reporting Repeat finding from prior year: No Finding Summary: ? The Program requires the Authority to prepare and provide quarterly financial status reports to the granting agency. During our testing over reporting, we noted that quarterly reports ...

Significant Deficiency in Internal Control 2022-004 Reporting Repeat finding from prior year: No Finding Summary: ? The Program requires the Authority to prepare and provide quarterly financial status reports to the granting agency. During our testing over reporting, we noted that quarterly reports were not prepared during 2022. Responsible Individuals: Housing and Community Investment Director, Housing Compliance Manager, Accounting Supervisor Corrective Action Plan: Quarterly reports were completed during the audit. We have setup calendar appointments and added this reporting to our compliance calendar. Anticipated Completion Date: May 31, 2023

View Audit 18756

Finding 20216 (2022-002)

None 2022

Interstate 35 Community School District

IA

We will update our written policies to include the required written policies under Uniform Guidance.

View Audit 19802

Finding 20215 (2022-005)

Significant Deficiency 2022

Municipality of Salinas

PR

HUD Housing Programs Reporting Matching / Level of Effort / Earmarking § 200.302

The Municipality will proceed to train the Section 8 program personnel so that they can record all the transactions through the system in order to maintain complete and accurate accounting record.

View Audit 19726

Finding 20214 (2022-001)

Significant Deficiency 2022

The Women's Home

TX

Eligibility Internal Control / Segregation of Duties Significant Deficiency

Dear Cognizant or Oversight Agency for Audit: The Women's Home respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Doeren Mayhew, 2600 North Loop West, Suite 600, Houston, TX 77092. The finding discus...

Dear Cognizant or Oversight Agency for Audit: The Women's Home respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Doeren Mayhew, 2600 North Loop West, Suite 600, Houston, TX 77092. The finding discussed below from the Schedule of Findings and Questioned Costs (the schedule) for the year ended December 31, 2022, is numbered consistently with the number assigned in the schedule. Federal Award Finding 2022-001. Corrective Action Plan: The initial chart creation checklist will be modified to include the TDHCA-Housing Stability Services Program Intake Form; TDHCA-Housing Stability Services Program Intake Form will be added to the intake paperwork packets to be completed upon client entry into the program; New staff will be trained on completion of intake paperwork including TDHCA-Housing Stability Services Program Intake Form as part of their orientation process; Regular chart audits will be conducted to review all documents and re-certify as necessary; A copy of each completed TDHCA-Housing Stability Services Program Intake Form will be submitted monthly to the Grant Compliance Specialist to review prior to monthly report submission to the state; Grant Compliance Specialist will send the Program Managers a list of clients in need of re-certification monthly; Compliance team to meet with program team twice a year to provide updates on compliance requirements. Corrective Action Steps Taken: The program team has received training on completion of the TDHCA-Housing Stability Services Program Intake Form; The program team has completed an audit of all open charts and are in the process of certifying or re-certifying all open clients to ensure compliance. Contact Person Responsible for Corrective Action: Ms. Anna Coffey, Chief Executive Officer. Anticipated Completion Date: It is expected that all processes listed above will be implemented by May 31, 2023. Many processes are ongoing and will be conducted throughout the length of grant. Respectfully submitted, Ms. Anna Coffey, Chief Executive Officer

View Audit 19675

Finding 20213 (2022-002)

Material Weakness 2022

West Central Nebraska Joint Housing Authority

NE

Internal Control / Segregation of Duties Special Tests & Provisions Eligibility

Finding 2022-002: We agree with the finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the inte...

Finding 2022-002: We agree with the finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the internal control deficiencies noted. The Board had reviewed the issue and determined that there are no additional procedures which can be reasonably done to eliminate the deficiencies and accepts them.

View Audit 19649

Finding 20201 (2022-002)

Material Weakness 2022

Icahn School of Medicine at Mount Sinai

NY

Procurement, Suspension & Debarment

Finding 2022-002 Procurement and Suspension and Debarment Information on the federal program: Grantor: Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agr...

Finding 2022-002 Procurement and Suspension and Debarment Information on the federal program: Grantor: Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding described above. The Mount Sinai Health System has implemented a corrective action that includes a monthly reconciliation to ensure that all vendors are screened against various state and federal lists/registries checking for excluded, debarred and/or restricted vendors. The monthly process includes the generation of a file of all paid vendors with the screening being conducted by Mount Sinai?s exclusion screening vendor OIG Compliance Now. Name of responsible official: Franco Sagliocca, Corporate Director, Supply Chain franco.sagliocca@mountsinai.org Projected completion date: December 31, 2023: Completed process for generating a monthly file of paid vendors to submit to OIG Compliance Now for monthly screening against various state and federal lists/registries checking for excluded, debarred and/or restricted vendors.

View Audit 28674

Finding 20198 (2022-002)

Material Weakness 2022

Aurora Charter School

MN

Equipment & Real Property Management Questioned Costs Procurement, Suspension & Debarment § 200.313

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE AND MATERIAL NONCOMPLIANCE ? U.S. DEPARTMENT OF EDUCATION ? PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, COVID-19 ? EDUCATION STABILIZATION FUND, FEDERAL ALN 84.425 2022-002 Internal Control Over Compliance and Material Noncompliance With E...

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE AND MATERIAL NONCOMPLIANCE ? U.S. DEPARTMENT OF EDUCATION ? PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, COVID-19 ? EDUCATION STABILIZATION FUND, FEDERAL ALN 84.425 2022-002 Internal Control Over Compliance and Material Noncompliance With Equipment and Real Property Management Requirements Finding Summary 2 CFR ? 200.313 (c)(1) and (d)(1) requires that Aurora Charter School (the School) obtain approval from the federal funding agency or pass-through agency prior to the purchase of equipment with federal funding. During our audit, we noted the School did not have sufficient controls in place within the COVID-19 ? Education Stabilization Fund federal program to assure compliance with federal equipment and real property management requirements, resulting in material noncompliance. Corrective Action Plan Actions Planned ? This condition and the resulting material noncompliance was caused by a misunderstanding of the cost threshold at which federal equipment and real property management compliance requirements must be applied, due to the School?s adopted internal capitalization threshold being lower than the federal threshold. The School intends to revise its internal capitalization threshold to align with the federal threshold, and to review its other control procedures relating to equipment and real property management requirements to ensure compliance for future federal awards expenditures. Official Responsible ? Matthew Cisewski, Executive Director. Planned Completion Date ? June 30, 2023. Disagreement With or Explanation of Finding ? The School agrees with this finding. Plan to Monitor ? The School?s Executive Director, Matthew Cisewski, will oversee the implementation of proposed corrective actions and verify that appropriate controls are in place and understood by individuals responsible for federal program oversite at the School to ensure future compliance with federal equipment and real property management requirements.

View Audit 28201

Finding 20195 (2022-002)

Material Weakness 2022

Bath Local School District

OH

Questioned Costs Internal Control / Segregation of Duties

The School District acknowledges this requirement and will make corrective procedures going forward to make sure the Davis-Bacon Act language will be included in any construction project contracts over $2,000.

View Audit 28419

Finding 20191 (2022-007)

Significant Deficiency 2022

Hartford Union High School District

WI

Questioned Costs Procurement, Suspension & Debarment Reporting

District Response and Corrective Action Plan: With the transition of the entire business office, it was discovered that grant budgets were not submitted and claims were not filed. The current business office updated the grant budgets and submitted claims to the best of their ability with the informa...

District Response and Corrective Action Plan: With the transition of the entire business office, it was discovered that grant budgets were not submitted and claims were not filed. The current business office updated the grant budgets and submitted claims to the best of their ability with the information that they had. Grants will be maintained by the business manager, the curriculum director, and the student services director. Weekly meetings are in place to review grant budgets and submit the appropriate claims quarterly after purchases have been made.

View Audit 28366

Finding 20181 (2022-010)

Material Weakness 2022

Hartford Union High School District

WI

Questioned Costs Allowable Costs / Cost Principles School Nutrition Programs

District Response and Corrective Action Plan: The Business Office has implemented new procedures requiring requisitions prior to every purchase. All purchases for the 2022-2023 school will have approval. Timecards are approved in Skyward via the Organizational Chart by each employee?s supervisor.

View Audit 28366

Finding 20180 (2022-009)

Significant Deficiency 2022

Hartford Union High School District

WI

School Nutrition Programs Questioned Costs Eligibility

District Response and Corrective Action Plan: The district will perform the sampling prior to November 15th to meet the reporting deadline.

View Audit 28366

Finding 20179 (2022-008)

Significant Deficiency 2022

Hartford Union High School District

WI

Procurement, Suspension & Debarment Questioned Costs School Nutrition Programs

District Response and Corrective Action Plan: The Business Office will monitor the list at SAM.gov monthly and will check new vendors against the suspendered and debarment list. The District will not work with debarred vendors.

View Audit 28366

Corrective Action Plans

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