Corrective Action Plans

Finding 516933 (2023-003)

Significant Deficiency 2023

MI

Subrecipient Monitoring Period of Performance Significant Deficiency § 200.1 § 200.332 § 200.414

The Agency agrees with the finding. When granting funds as a subaward to a pass-through entity, the Agency will update its master templates for subawards to include the required information. In addition, when the sub agreements are routed for signature and reviewed by the Chief Financial Officer, ...

The Agency agrees with the finding. When granting funds as a subaward to a pass-through entity, the Agency will update its master templates for subawards to include the required information. In addition, when the sub agreements are routed for signature and reviewed by the Chief Financial Officer, they will be double-checked to ensure compliance with this requirement.

View Audit 334839

Finding 516920 (2023-001)

Material Weakness 2023

City of Tacoma

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Material Weakness

The City is fully committed to establishing and maintaining robust internal controls to ensure compliance with federal requirements, particularly in the administration of federal grant programs. Reporting: To meet Federal Funding and Transparency Act (FFATA) reporting requirements, the City will tak...

The City is fully committed to establishing and maintaining robust internal controls to ensure compliance with federal requirements, particularly in the administration of federal grant programs. Reporting: To meet Federal Funding and Transparency Act (FFATA) reporting requirements, the City will take the following actions: Update training material and implement annual training for all Accounting staff and City departments managing federal grants. Update and distribute monthly email to departments to clarify the required information for FFATA filing and require responses with supporting documentation for review. Periodically review federal reporting requirements for any updates and make adjustments as needed, utilizing resources such as the State Auditor’s Office (SAO) Newsletter, conferences, and trainings. Wage Rate Requirement: To meet Davis Bacon Act reporting requirements, the City will incorporate the verbiage from 29 CFR 5.5(a) in full into specifications, as applicable, which will be incorporated into the resulting contracts.

View Audit 334833

Finding 516917 (2023-002)

Significant Deficiency 2023

Centerplace Health, Inc.

FL

Finding 2023-02 - U.S. Department of Human Health and Services- The Organization placed one of its patients on a sliding fee for a different service than the one ultimately provided. Since this occurrence, a new position has been created and staffed-- ‘Patient Service Representative Team Lead’. This...

Finding 2023-02 - U.S. Department of Human Health and Services- The Organization placed one of its patients on a sliding fee for a different service than the one ultimately provided. Since this occurrence, a new position has been created and staffed-- ‘Patient Service Representative Team Lead’. This staff member will oversee and train the Patient Service Representatives in their responsibilities, including the sliding fee discount schedule application and compliance. A focus of this newly created position is training and compliance of the sliding fee schedule throughout all the clinics, is ongoing since Oct. 15. The Patient Service Team Lead will be supervised by the Revenue Cycle Manager as part of the Finance Department reporting to the Interim CEO Anna Ferguson, who will oversee this effort. The new position and implementation of training to correct the finding commenced Oct. 15 2024.

View Audit 334825

Finding 516916 (2023-001)

None 2023

Immigrant Social Services, Inc.

NY

§ 200.512

Federal Assistance Listing Number: 93.959 Block Grants for Prevention and Treatment of Substance Abuse Condition The Organization’s Data Collection Form submission to the Federal Audit Clearinghouse was not filed on time within nine months of the end of its fiscal year. Views of Responsible Official...

Federal Assistance Listing Number: 93.959 Block Grants for Prevention and Treatment of Substance Abuse Condition The Organization’s Data Collection Form submission to the Federal Audit Clearinghouse was not filed on time within nine months of the end of its fiscal year. Views of Responsible Officials and Corrective Action Although a new consulting firm was engaged to complete the June 30, 2023 financial statement audit and ensure filing of the June 30, 2023 Single Audit within nine months of the end of the fiscal year, additional time was needed to complete accurate fiscal records for the year ended June 30, 2023. Monthly closings and fiscal records reconciliations for the year ending June 30, 2024, are being conducted on a timely basis. As a result, we are expecting an on-time filing of the Data Collection form for the year ended June 30, 2024.

View Audit 334820

Finding 516915 (2023-002)

None 2023

The Durham Trinity Corporation

CT

2023-002 SECURITY DEPOSIT ACCOUNT FUNDING Criteria: Tenant security deposit bank accounts must be fully funded and maintained in a separate bank account. Condition: During our audit testing, we noted that while the Project maintained a separate bank account for tenant security deposit funds, it wa...

2023-002 SECURITY DEPOSIT ACCOUNT FUNDING Criteria: Tenant security deposit bank accounts must be fully funded and maintained in a separate bank account. Condition: During our audit testing, we noted that while the Project maintained a separate bank account for tenant security deposit funds, it was not fully funded. Cause: Tenant security deposits subledger is not reconciled with tenant security deposits bank account to ensure account is fully funded. Effect: Tenant security deposits bank account is underfunded. Questioned Costs: None noted. Recommendation: The Project should implement controls to ensure that the tenant security deposits bank account is fully funded. Management’s Views and Corrective Action Plan: Management will transfer funds to the tenant security deposits bank account to ensure it is fully funded.

View Audit 334819

Finding 516914 (2023-001)

None 2023

The Durham Trinity Corporation

CT

2023-001 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 ...

2023-001 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.

View Audit 334819

Finding 516900 (2023-002)

Material Weakness 2023

Grant County

WA

Subrecipient Monitoring

The County will ensure staff receives appropriate training and tools necessary to implement controls that address the finding, specifically identifying when sub-recipient monitoring is required and making sure that it happens.

View Audit 334797

Finding 516898 (2023-003)

Significant Deficiency 2023

Comprehensive Community Solutions, INC

IL

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

Finding Number: 2023-003 Finding Name: Data Collection Form Late Submission Finding Synopsis: The organization did not submit the December 31, 2023 data collection form and reporting package to the Federal Audit Clearinghouse in a timely matter. Action Steps: The late submission was due to switching...

Finding Number: 2023-003 Finding Name: Data Collection Form Late Submission Finding Synopsis: The organization did not submit the December 31, 2023 data collection form and reporting package to the Federal Audit Clearinghouse in a timely matter. Action Steps: The late submission was due to switching audit service providers. Systems and procedures are already in place to ensure timely completion of audit and submission of the audit package to the Federal Audit Clearinghouse. Management is now aware that when switching audit firms we will have to allocate more time for the new firm to get familiar with the agency. Contact Person(s): William Chatman, Executive Director/CEO, 815-963-6236 Claudia Seijas, Director of Finance, 815-963-6236 Anticipated Completion Date: Continues

View Audit 334793

Finding 516868 (2023-004)

Material Weakness 2023

Metropolitan Park District of the Toledo Area

OH

Reporting Allowable Costs / Cost Principles § 200.328

The position of Grants Coordinator has been created and filled to handle grants management functions which will ensure proper quarter end dates and expenditures appropriate for the period are reported. Under the new process, the Grant Coordinator collaborates with the Construction Financial Adminis...

The position of Grants Coordinator has been created and filled to handle grants management functions which will ensure proper quarter end dates and expenditures appropriate for the period are reported. Under the new process, the Grant Coordinator collaborates with the Construction Financial Administrator to complete forms which are then reviewed with the Director of Grants and CFO prior to submission.

View Audit 334765

Finding 516866 (2023-003)

Material Weakness 2023

Metropolitan Park District of the Toledo Area

OH

Procurement, Suspension & Debarment

Metroparks has internal controls in place to verify that all entities, with whom the District had entered into covered transactions, had not been suspended or debarred. These controls consist of verifying the vendor is not suspended or debarred by checking the Auditor of State’s site reporting find...

Metroparks has internal controls in place to verify that all entities, with whom the District had entered into covered transactions, had not been suspended or debarred. These controls consist of verifying the vendor is not suspended or debarred by checking the Auditor of State’s site reporting findings for recovery. Metroparks will continue to check the Auditor of State’s site and has now added the additional check at www.sam.gov.

View Audit 334765

Finding 516865 (2023-001)

Significant Deficiency 2023

Bancroft Global Development

DC

Subrecipient Monitoring Reporting

Views of Responsible Official and Corrective Action Plan: We concur with the finding that we did not file a FFATA subaward report at the required time. This oversight was in part because the awarding agency did not include the reporting requirement in the award documents. When we became aware of ove...

Views of Responsible Official and Corrective Action Plan: We concur with the finding that we did not file a FFATA subaward report at the required time. This oversight was in part because the awarding agency did not include the reporting requirement in the award documents. When we became aware of oversight, we were unable to comply by submitting the report to www.USASpending.gov because the awarding agency had not fulfilled its requirement under 2 CFR 170.200 to register the award. This State Department action is a necessary precondition to meeting our FFATA reporting requirement. Going forward, we will implement policies and procedures that ensure that (1) we file timely FFATA reports for applicable subawards or, in the case such a submission is again not possible, (2) document our requests to the awarding agency to register the award thereby enabling us to comply. Name and Title of Responsible Official: Greg Joachim, Executive Director Planned Completion Date: Immediately.

View Audit 334752

Finding 516861 (2023-003)

Material Weakness 2023

Frederiksted Health Care, Inc.

VI

Special Tests & Provisions

U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) AUDIT FINDING Finding 2023-003 Special Tests and Provisions - Sliding Fee Discounts Description of Finding: During the course of the audit, it was noted that the Center was unable to...

U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) AUDIT FINDING Finding 2023-003 Special Tests and Provisions - Sliding Fee Discounts Description of Finding: During the course of the audit, it was noted that the Center was unable to provide supporting documentation to verify that the visit occurred and that the proper amounts were billed and adjusted. We were also unable to obtain documentation to support the patient's income level and family size. As a result, we were unable to determine proper application of the sliding fee discount schedule. Statement of Concurrence: We concur with the finding above. Corrective Action: While Management is in agreement with this finding, we would like to state that during our 2023 HRSA site visit, our sliding fee discount program was found to be in compliance. Due to the cyber-attack, FHC was not able to access its practice management system for 2023. To reduce future breaches, FHC implemented the following changes: The virtual machine hosts were re-initialized, and the latest version of VMWare were installed. Advanced endpoint protection was also installed on all computers and servers; Multi-factor authentication (MFA) for email use was established; the remote workers access was changed to TruGrid, a platform that provides secure remote desktop protocol (RDP) connections. Backup redundancy was established, following the 3-2-1 method of three backups, two different locations, one copy always offline. Servers are constantly replicated in the Cloud, differential backups are run every two hours, and one copy is always kept offline. FHC is confident that these changes will greatly reduce the likelihood of another cyberattack. Frederiksted Health Care has arranged a cybersecurity partnership with High Tide Solutions, a technology firm. High Tide Solutions now provides a suite of services including server management, penetration testing, data backup management, network management, Ransomware protection, cybersecurity training and cloud platform support. As a result of the implementation of the above-mentioned changes, FHC is now confident that we will have the appropriate safeguards in place to protect pertinent data in the event of another cyberattack. Name of Contact Person: Jacquelynn Rhymer-George Chief Financial Officer Tel. No.: (340) 772-1992 E-mail: jrgeorge@fhc-inc .net Projected Completion Date: 12/31/24 If HRSA has questions regarding this Plan, please call Jacquelyn Rhymer-George at (340) 772-1992 or jrgeorge@fhc-inc net. Sincerely Yours, Jacquelynn Rhymer-George Chief Financial Officer

View Audit 334747

Finding 516766 (2023-004)

None 2023

Holy Names University

CA

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Given staff & contract staff turnover during the year, required financial aid reporting requirements were late, this will not be an issue moving forward as the University ceased participation in all federal financial aid programs and is expected to fully transition to a scholarship granting organi...

Given staff & contract staff turnover during the year, required financial aid reporting requirements were late, this will not be an issue moving forward as the University ceased participation in all federal financial aid programs and is expected to fully transition to a scholarship granting organization.

View Audit 334723

Finding 516758 (2023-002)

None 2023

Holy Names University

CA

Student Financial Aid Internal Control / Segregation of Duties

We agree with the recommendation. A full-time staff position "Student Scholarship Accounting & Compliance Officer" is filled and a component of this role is to disburse credit balances within 14 days, should there be a need. However no Federal financial assistance funds were awa...

We agree with the recommendation. A full-time staff position "Student Scholarship Accounting & Compliance Officer" is filled and a component of this role is to disburse credit balances within 14 days, should there be a need. However no Federal financial assistance funds were awarded after June 30, 2023 as the University ceased academic operations and degree granting in May 2023 upon completion of spring semester.

View Audit 334723

Finding 516750 (2023-003)

None 2023

Holy Names University

CA

Subrecipient Monitoring

Under the University’s Program Participation Agreement and the Gramm-Leach-Bliley Act (GLBA), schools must protect student financial aid information, with particular attention to information provided to institutions by the Department or otherwise obtained in support of the administration of the fede...

Under the University’s Program Participation Agreement and the Gramm-Leach-Bliley Act (GLBA), schools must protect student financial aid information, with particular attention to information provided to institutions by the Department or otherwise obtained in support of the administration of the federal student financial aid. According to 16 CFR 314.4(b), a school must identify reasonably foreseeable internal and external risks to the security, confidentiality, and integrity of customer information that could result in the unauthorized disclosure, misuse, alteration, destruction, or other compromise of such information, and assess the sufficiency of any safeguards in place to control these risks. At a minimum, such a risk assessment should include consideration of risks in each relevant area of your operations, including: Employee training and management; Information systems, including network and software design, as well as information processing, storage, transmission, and disposal; and Detecting, preventing, and responding to attacks, intrusions, or other systems failures. Condition Although the University has documented various IT policies around access, they are not comprehensive enough to cover the Gramm-Leach-Bliley Act requirements around the process of identifying the internal and external risks to data security. Cause The University has not conducted a formal risk assessment since January 2021. Effect Student information may be at risk of unauthorized disclosure, misuse, alteration, destruction, or other compromise of such information. Questioned Costs There were no questioned costs related to this finding. Context During our review of the University’s Information Technology system, we noted through inquiry that a formal risk assessment of the University’s documented safeguards had not been performed since January 2021. Recommendation We recommend that the University re-engage the outside resource to independently perform and develop a formal risk assessment, along with recommendations for remediation of any open items and/or deficiencies. Corrective Action Planned The organization has engaged an outside IT consultant to manage the organization’s IT needs moving forward. Responsible PersonnelDouglas Burnet Chief Financial OfficerPhone: 415-425-0666 Burnet@hnu.edu

View Audit 334723

Finding 516749 (2023-002)

Significant Deficiency 2023

Pennington County

MN

Reporting

Name of Contact Person Responsible for Corrective Action: County Board and Jennifer Herzberg, County Auditor/Treasurer Corrective Action Planned: Future annual county audits will be completed within nine months of the fiscal year end to allow for timely submission of the data collection form and re...

Name of Contact Person Responsible for Corrective Action: County Board and Jennifer Herzberg, County Auditor/Treasurer Corrective Action Planned: Future annual county audits will be completed within nine months of the fiscal year end to allow for timely submission of the data collection form and reporting package. Comments: The County Auditor/Treasurer will monitor the progress of the annual audit in the future so that the annual audit will be completed on a timely basis as described in our corrective action plan. Anticipated completion date: December 31, 2024

View Audit 334722

Finding 516739 (2023-003)

Material Weakness 2023

Hocking County

OH

Procurement, Suspension & Debarment Subrecipient Monitoring

The Auditor’s Office will work alongside the Commissioner’s Office to check vendors at the beginning of the year and recurring vendors will be checked.

View Audit 334701

Finding 516735 (2023-004)

Material Weakness 2023

Hocking County

OH

Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.302 § 200.318 § 200.319 § 200.320 § 200.430

The Auditor’s Office will work with the Commissioner’s Office and Prosecutor’s Office to implement the required policies.

View Audit 334701

Finding 516666 (2023-001)

Significant Deficiency 2023

Philip Health Services, Inc.

SD

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

RE: Audit Finding Corrective Action Plan Philip Health Services recognizes the need for an account to be designated for the loan reserve of $210,564. We will designate a CD in the CDARS Accounts in the amount of $250,000 that is insured by FDIC with a term of 2 years. When this CD is renewed, ...

RE: Audit Finding Corrective Action Plan Philip Health Services recognizes the need for an account to be designated for the loan reserve of $210,564. We will designate a CD in the CDARS Accounts in the amount of $250,000 that is insured by FDIC with a term of 2 years. When this CD is renewed, it will continue to be reserved until the loan reaches an amount that will no longer require the designation. Respectfully, Maureen Cadwell Chief Executive Officer Philip Health Services, Inc.

View Audit 334657

Finding 516660 (2023-004)

Significant Deficiency 2023

Shannon County, Missouri

MO

Reporting Internal Control / Segregation of Duties

The Treasurer is preparing and reporting COVID-19 funds and will work with the County Clerk to ensure correct reporting in the future. The expected implementation date will be in the next reporting cycle of April 2024.

View Audit 334643

Finding 516658 (2023-001)

Significant Deficiency 2023

Envision Community Services INC

IL

Reporting Internal Control / Segregation of Duties

We will have our current accountant set a schedule for performing monthly closes of the financial statements so they can be presented in summary format to management and the board of directors. We will require that the President/CEO and other key members of the management team and the board of direc...

We will have our current accountant set a schedule for performing monthly closes of the financial statements so they can be presented in summary format to management and the board of directors. We will require that the President/CEO and other key members of the management team and the board of directors review the monthly financial reports provided by the accountant so that all board members understand the financial position and results of activities of ECS on a regular and consistent basis. Finally, we will develop a transition plan with procedures requiring that whomever is responsible for the accounting and financial reporting function for ECS reconcile all financial accounts and close the financial records for the month prior to departure to ensure a smooth transition ECS’s accounting and financial reporting function to the next person responsible for its maintenance

View Audit 334636

Finding 516598 (2023-003)

Significant Deficiency 2023

Southwestern Wisconsin Community Action Program, Inc.

WI

Reporting

Auditor's Recommendation: We recommend Southwestern Wisconsin Community Action Program, Inc. and Subsidiaries implement additional controls over reporting including, but not limited to, training staff on the Head Start reporting deadlines, to be in compliance with reporting requirements and deadline...

Auditor's Recommendation: We recommend Southwestern Wisconsin Community Action Program, Inc. and Subsidiaries implement additional controls over reporting including, but not limited to, training staff on the Head Start reporting deadlines, to be in compliance with reporting requirements and deadlines. Corrective Action: SWCAP has discussed with their outsourced accounting firm who will be responsible for the filing. It was determined that management will submit the filing going forward and created calendar system with automated reminders to notify management and key team members of upcoming reporting deadlines to ensure they are completed and filed on time. Responsible for Corrective Action: Operations Manager and outsourced accounting firm Anticipated Completion Date: Completed as of December 2024.

View Audit 334558

Finding 516587 (2023-002)

Significant Deficiency 2023

Southwestern Wisconsin Community Action Program, Inc.

WI

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

2023-002: Late Audit Submission Auditor's Recommendation: SWCAP should take steps to ensure that its financial records are available in a timely manner to allow the audit to begin sufficiently before the audit due date. SWCAP also should work with their auditing firm to agree upon information that w...

2023-002: Late Audit Submission Auditor's Recommendation: SWCAP should take steps to ensure that its financial records are available in a timely manner to allow the audit to begin sufficiently before the audit due date. SWCAP also should work with their auditing firm to agree upon information that will and will not be prepared by SWCAP so that a proper audit plan can be developed for timely completion. Corrective Action: SWCAP acknowledges the delay in completing the 2023 audit. The unforeseen staffing challenges by our auditing firm in conjunction with our internal turnover significantly impacted our timeline. SWCAP has identified and implemented changes with its personnel and hired an outsourced accounting firm. SWCAP has implemented proactive measures to streamline its audit preparation and submission processes to prevent similar delays in the future. These include enhancing internal review procedures, ensuring clear communication with auditors, and allocating sufficient resources for timely compliance with reporting requirements, federal regulations, and guidelines. Responsible for Corrective Action: Finance Team (Outsourced accounting firm, Operations Manager, Executive Director). Anticipated Completion Date: Completed as of December 2024.

View Audit 334558

Finding 516586 (2023-001)

Material Weakness 2023

Southwestern Wisconsin Community Action Program, Inc.

WI

Reporting Material Weakness

2023-001: Internal Control Over Financial Reporting Auditor's Recommendation: We recommend SWCAP implement procedures to ensure accounts are adjusted and that provided supplementary audit information is accurately prepared. Corrective Action: SWCAP experienced significant turnover in its accounting ...

2023-001: Internal Control Over Financial Reporting Auditor's Recommendation: We recommend SWCAP implement procedures to ensure accounts are adjusted and that provided supplementary audit information is accurately prepared. Corrective Action: SWCAP experienced significant turnover in its accounting and finance team during the year. Immediate action has been taken and as of December 2024, SWCAP has identified and implemented changes with its personnel, hired an outsourced accounting firm, and implemented additional internal controls to include secondary level of review. SWCAP will make any additional changes necessary to complete the closing process and provide accurate financial information. Responsible for Corrective Action: Finance Team (Outsourced accounting firm, Operations Manager, Executive Director). Anticipated Completion Date: Completed as of December 2024.

View Audit 334558

Finding 516585 (2023-002)

Material Weakness 2023

Digital Harbor Foundation INC

MD

Procurement, Suspension & Debarment Material Weakness § 200.318 § 200.327

MATERIAL WEAKNESS 2023-002 Policies and Procedures Auditor’s Recommendation: We recommend that the Foundation adopt a formal written procurement policy in the format and with the elements required by 2 CFR Sections 200.318 to 200.327. Action Taken: • As a First Year Single Auditee, the management...

MATERIAL WEAKNESS 2023-002 Policies and Procedures Auditor’s Recommendation: We recommend that the Foundation adopt a formal written procurement policy in the format and with the elements required by 2 CFR Sections 200.318 to 200.327. Action Taken: • As a First Year Single Auditee, the management team will ensure that senior leadership team, finance and accounting team, as well as program manager/directors for federal awards receive some form of training and certify receipt of this training within six-months of these findings no later than December 31st, 2024. • As a First Year Single Auditee, the management team will ensure that specific policies are created to ensure a procurement process for goods and services expensed from federal funds is established and in alignment with UG (Uniform Guidance) standards for federal awards no later than December 31st, 2024. • As a First Year Single Auditee, the management team will have an independent audit firm review this policy to ensure they are in alignment and conformance with UG (Uniform Guidance) standards no later than December 31st, 2024.

View Audit 334550

Corrective Action Plans

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