Corrective Action Plans

Finding 513357 (2023-004)

Material Weakness 2023

Catholic Charities of the Diocese of Camden

NJ

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

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Veterans Affairs Direct Award: Grant No. 12 NJ...

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Veterans Affairs Direct Award: Grant No. 12 NJ 053 55 Grant No. 12 NJ 053 22 VA Homeless Providers Grant and Per Diem Program AL# 64.033 9/2021 9/2023 10/2021 3/2023 Grant No. 12 NJ 053 HL 9/2021 9/2023 Grant No. 12 NJ 053 LT 8/2022 9/2026 Grant No. 12 NJ 053 23 9/2021 9/2023 2023-004 - Activities Allowed and Allowable Costs (Significant Deficiency) Statement of Condition Supportive service expenditures were processed and paid for ineligible participants. Criteria The Homeless Veterans Comprehensive Service Programs Act of 1992 (Public Law 102 590) established the VA Homeless Providers Grant and Per Diem Program to fund the costs of creating or improving transitional supportive housing facilities or services centers, and grants to support case managers to assist Veterans in attaining or retaining permanent housing. Cause Due to lack of supervisory oversight, several employees falsified participant documents whereby ineligible individuals with personal relationships to these employees receive assistance payments. Effect Management became aware of the improprieties and hired an independent forensic investigator. The forensic investigator identified improper disbursements to ineligible participants along with other disbursements that required further research, inconclusive, insufficient, unverified, and LLC discrepancy disbursements. Management also notified the State of New Jersey Department of Community Affairs Office of Auditing. Recommendation Management should strengthen controls over documentation required for participants to receive' assistance payments along with controls over review of documentation in participant files and processing of these payments. View of Responsible Officials Management agrees with the recommendation and has begun implementing additional procedures to ensure that applicant files are complete and that case files and support are being reviewed by supervisory personnel. Corrective Action: Theim.proper activity was identified in October 2023 and the following actions were subsequently taken: • Two caseworks and a supervisor were terminated. • The agency's Executive Director retired. • The agency's Controller was temporarily elevated to Interim Administrator, overseeing day-to day operations and reviewing all agency disbursements. • The central accounting department revised the check processing procedures to ensure that the following documentation accompanied housing related check requests: o W-9 signed by the vendor o A signed Promissory Agreement from the client, landlord and caseworker if the agency is paying Rent/Sec Dep. o Proof of Ownership for the property (Deed, Tax bill, NJ Parcels website) documentation. The Proof of Ownership documentation must match the W-9. Management has taken steps to ensure that the rental properties for which assistance will be rendered are in fact owned by the landlord stated on the lease. o Copy of an executed rental lease. o Rent Ledger, or a letter from the Landlord on their letterhead detailing client past and overdue charges/payments. Should include dates, amounts, etc... o Proof of Hardship - case management notes detailing hardship are sufficient for the Accounting Dept, although not necessarily sufficient for the requirement of the grant. • Policy changes with regard to check distribution have been modified. All checks are mailed directly to the vendor/payee from the central accounting department. • Two supervisors replaced the one terminated supervisor in order to ease the amount of supervision duties tasked to one person. • A new Executive Director for the Organization was hired in Febr·uary 2024. • Created and filled the position of Grants Compliance Specialist. This position is responsible to: o Review, revise and create, where needed, policies/procedures to ensure that 0MB. Uniform Administrative Requirements are being considered and followed in the administering of all grant funding. o Responsible for regularly reviewing client files on a judgmental basis in order to ensure adherence to the agency's policies and procedures. Mandated the universal use of ETO Case Management Solution as the soul repository of client information, case notes with a link to electronic client documentation files on the agency network. This provides electronic access to client case files as well as an electronic audit trail. Projected Completion Date As mentioned, the actions note above have been implemented. Management and the Grant Compliance Specialist continue to review, modify and communicate policies/procedures with all case management staff. Contact Person Robert Waite, Controller 856-342-4186; robert.waite@camdendiocese.org If you have questions or concerns regarding this Plan, please reach out to Robert Waite, Controller using the phone number or email address above.

View Audit 331207

Finding 513355 (2023-007)

Significant Deficiency 2023

Catholic Charities of the Diocese of Camden

NJ

Reporting Significant Deficiency § 200.512

FEDERAL AWARD FINDING Federal Agency: Program Title: Assistance Listing Number: Award Number: Award Period: All Awards reported on the schedule of expenditures of federal awards. All Awards reported on the schedule of expenditures of federal awards. All Awards reported on the schedule of expendi...

FEDERAL AWARD FINDING Federal Agency: Program Title: Assistance Listing Number: Award Number: Award Period: All Awards reported on the schedule of expenditures of federal awards. All Awards reported on the schedule of expenditures of federal awards. All Awards reported on the schedule of expenditures of federal awards. All Awards reported on the schedule of expenditures of federal awards. All Awards reported on the schedule of expenditures of federal awards. 2023-007 - Late Submission of Single Audit Reporting Package (Significant Deficiency) Statement of Condition The Single Audit reporting package and related data collection form for the year ended June 30, 2023, was not submitted within nine months after the end of the audit period. Criteria In accordance with 2 CFR 200.512, the audit must be completed and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Internal control systems over financial reporting are to prevent late submission of the Single Audit reporting package, including the data collection form to the Federal Audit Clearinghouse. Cause The submission of the Single Audit reporting package was delayed due to a forensic audit needed to be completed before the single audit could be completed. Effect Management became aware of the improprieties and hired an independent forensic investigator. The forensic investigator identified improper disbursements to ineligible participants along with other disbursements that required further research, inconclusive, insufficient, unverified, and LLC discrepancy disbursements. Management also notified the State of New Jersey Department of Community Affairs Office of Auditing. Recommendation Management should review the internal controls in place over the filing of the data collection form and reporting package so it can be submitted timely to the Federal Audit Clearinghouse. View of Responsible Officials Management agrees with the finding and has provided the accompanying corrective action plan. Corrective Action: Management believes that the extraordinary circumstances that lead to the delayed submission of the 2023 fiscal audit reporting package are a one-time occurrence, future submission should not be affected. Management expects that the 2024 fiscal audit reporting package and data collection form will be submitted timely to the Federal Audit Clearinghouse. Projected Completion Date As mentioned, the actions note above have been implemented. Contact Person Robert Waite, Controller 856-342-4186; robert.waite@camdendiocese.org

View Audit 331207

Finding 513354 (2023-003)

Material Weakness 2023

Catholic Charities of the Diocese of Camden

NJ

Questioned Costs Internal Control / Segregation of Duties Eligibility

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Housing and Urban Development Emergency Solutio...

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Housing and Urban Development Emergency Solutions Grant Program AL# 14.231 Passed through State of New Jersey Department of Community Affairs: Grant No. 2019 02156 036106 8/2020 3/2023 Grant No. 2022 02156 0337 00 7/2021 7/2023 Grant No. 2022 02156 0339 00 4/2022 7/2023 Grant No. 2022 02156 0338 00 4/2022 9/2023 Grant No. 2022 02156 0052 08 12/2019 9/2023 Grant No. 2020 02156 0042 08 12/2019 9/2023 Grant No. 2020 02156 0042 04 12/2019 9/2023 Grant No. 2019 02156 0361OS 12/2018 9/2023 2023-003 - Activities Allowed and Allowable Costs (Significant Deficiency) Statement of Condition Supportive service expenditures were processed and paid for ineligible participants. Criteria ESG funds may be used for five program components: street outreach, emergency shelter, homelessness prevention, rapid re-housing assistance, and HMIS; as well as administrative activities. The five program components and the eligible activities that may be funded under each are set forth in 24 CFR 576.101 through 576.107. Cause Due to lack of supervisory oversight, several employees falsified participant documents whereby ineligible individuals with personal relationships to these employees receive assistance payments. Effect Management became aware of the improprieties and hired an independent forensic investigator. The forensic investigator identified improper disbursements to ineligible participants along with other disbursements that required further research, inconclusive, insufficient, unverified, and LLC discrepancy disbursements. Management also notified the State of New Jersey Department of Community Affairs Office of Auditing. Recommendation Management should strengthen controls over documentation required for participants to receive assistance payments along with controls over review of documentation in participant files and processing of these payments. www.catholiccharitiessouthjersey.org 1845 Haddon A\-enue, Camden, NJ 08103 I Tel: 856•342-4100 I Fu: 856---3424180 Serving si.,;: counties of Southern Nev,1Jersey: Atlantic, Camden, Cape May; Cumbedand, Gloucester & Salem View of Responsible Officials Management agrees with the recommendation and has begun implementing additional procedures to ensure that applicant files are complete and that case files and support are being reviewed by supervisory personnel. Corrective Action: The improper activity was identified in October 2023 and the following actions were subsequently taken: • Two caseworks and a supervisor were terminated. • The agency's Executive Director retired. • The agency's Controller was temporarily elevated to Interim Administrator, overseeing day-to-day operations and reviewing all agency disbursements. • The central accounting department revised the check processing procedures to ensure that the following documentation accompanied housing related check requests: o W-9 signed by the vendor o A signed Promissory Agreement from the client, landlord and caseworker if the agency is paying Rent/Sec Dep. o Proof of Ownership for the property (Deed, Tax bill, NJ Parcels website) documentation. The Proof of Ownership documentation must match the W-9. Management has taken steps to ensure that the rental properties for which assistance will be rendered are in fact owned by the landlord stated on the lease. o Copy of an executed rental lease. o Rent Ledger, or a letter from the Landlord on their letterhead detailing client past and overdue charges/payments. Should include dates, amounts, etc... o Proof of Hardship - case management notes detailing hardship are sufficient for the Accounting Dept, although not necessarily sufficient for the requirement of the grant. • Policy changes with regard to check distribution have been modified. All checks are mailed directly to the vendor/payee from the central accounting department. • Two supervisors replaced the one terminated supervisor in order to ease the amount of supervision duties tasked to one person. • A new Executive Director for the Organization was hired in February 2024. • Created and filled the position of Grants Compliance Specialist. This position is responsible to: o Review, revise and create, where needed, policies/procedures to ensure that 0MB Uniform Administrative Requirements are being considered and followed in the administering of all grant funding. o Responsible for regularly reviewing client files on a judgmental basis in order to ensure adherence to the agency's policies and procedures. Mandated the universal use of ETD Case Management Solution as the soul repository of client information, case notes with a link to electronic client documentation files on the agency network. This provides electronic access to client case files as well as an electronic audit trail. Projected Completion Date As mentioned, the actions note above have been implemented. Management and the Grant Compliance Specialist continue to review, modify and communicate policies/procedures with all case management staff. Contact Person Robert Waite, Controller 856-342-4186; robert.waite@camdendiocese.org If you have questions or concerns regarding this Plan, please reach out to Robert Waite, Controller using the phone number or email address above. Robert T Waite, Controller

View Audit 331207 Questioned Costs: $1

Finding 513339 (2023-002)

Material Weakness 2023

School Administrative Unit No. 16

NH

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.430

The SAU Grant's Coordinator will be responsible for ensuring the annual grant certification form for salary employees is completed and maintained.

View Audit 331205

Finding 513261 (2023-003)

Significant Deficiency 2023

School Administrative Unit No. 16

NH

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles

SAU16 has policy DAF in all the school districts, expect the SAU. We will ask the joint board to adopt policy DAF.

View Audit 331205

Finding 513249 (2023-003)

Material Weakness 2023

County of Dauphin

PA

Matching / Level of Effort / Earmarking Reporting

Finding 2023-003 Matching, Level of Effort, Earmarking, Program Income and Reporting Aging Cluster (ALN 93.044/93.045/93.053) Corrective Action: Management is in agreement with the finding. Management will ensure the necessary reports are filed with the granting agency in a timely fashion and amoun...

Finding 2023-003 Matching, Level of Effort, Earmarking, Program Income and Reporting Aging Cluster (ALN 93.044/93.045/93.053) Corrective Action: Management is in agreement with the finding. Management will ensure the necessary reports are filed with the granting agency in a timely fashion and amounts reported are accurate. Management anticipates corrective action to be in place by 01/01/2025. Responsible party: Mary Bateman, Controller.

View Audit 331199

Finding 513243 (2023-001)

Significant Deficiency 2023

Boys and Girls Clubs of Toledo and the Toledo Newsboys Association

OH

Cash Management Internal Control / Segregation of Duties

Auditor Description of Condition and Effect. We selected a sample of disbursements that were charged to the grant. Of this sample, 5 out of 40 disbursements had questioned costs. Two disbursements had amounts submitted for reimbursement but no actual costs were incurred by the Organization. Another ...

Auditor Description of Condition and Effect. We selected a sample of disbursements that were charged to the grant. Of this sample, 5 out of 40 disbursements had questioned costs. Two disbursements had amounts submitted for reimbursement but no actual costs were incurred by the Organization. Another two disbursements included expenses for other clubs outside the grant agreement that was charged to the grant. The last disbursement was missing supporting documentation for the costs charged to the grant. As a result of this condition, the Organization did not fully comply with the requirements of the Uniform Guidance. Auditor Recommendation. We recommend that the Organization verify that costs submitted for reimbursement are valid and allowable expenses. Additionally, the Organization needs to properly allocate costs in accordance with the grant agreements. Corrective Action. Management concurs with the finding. The Organization will ensure valid and allowable expenses, including proper allocation of costs, are remitted through enhancement of the current review processes. Responsible Person. Stacy Holman, Chief Financial Officer. Anticipated Completion Date. December 31, 2024.

View Audit 331186

Finding 513235 (2023-003)

Significant Deficiency 2023

Conservation Science Partners, Inc.

CA

Subrecipient Monitoring Reporting Significant Deficiency

Finding 2023-003: Finding Type: Major Federal Award Program Audit, Significant Deficiency Response: 1. Name of person responsible for the corrective action: Deborah Burr, Programs Manager, or Mary Forsyth, Business Manager 2. Corrective Action Planned: The Business Manager has established a FSRS...

Finding 2023-003: Finding Type: Major Federal Award Program Audit, Significant Deficiency Response: 1. Name of person responsible for the corrective action: Deborah Burr, Programs Manager, or Mary Forsyth, Business Manager 2. Corrective Action Planned: The Business Manager has established a FSRS.gov account and uploaded 2023 subaward information in 2024. Going forward, the Programs Manager will report subaward data through FSRS.gov to ensure compliance with FFATA for 2024 and going forward for any new subawards. 3. Anticipated Completion Date: December 31, 2024

View Audit 331178

Finding 513234 (2023-002)

Significant Deficiency 2023

Conservation Science Partners, Inc.

CA

Procurement, Suspension & Debarment

Finding 2023-002: Finding Type: Major Federal Award Program Audit, Significant Deficiency Response: 1. Name of person responsible for the corrective action: Deborah Burr, Programs Manager 2. Corrective Action Planned: In 2024, we have already taken corrective action to look up and save date-stam...

Finding 2023-002: Finding Type: Major Federal Award Program Audit, Significant Deficiency Response: 1. Name of person responsible for the corrective action: Deborah Burr, Programs Manager 2. Corrective Action Planned: In 2024, we have already taken corrective action to look up and save date-stamped documentation for our subawardees and contractors for the 2023 audit year, ensuring no entities are disbarred, suspended, or otherwise excluded from working with us on a federal award. Going forward, our Programs Manager will ensure subawardees and contractors in 2024 and beyond are verified through SAM.gov as stated in our 2024 Fiscal Policies. 3. Anticipated Completion Date: December 31, 2024

View Audit 331178

Finding 513233 (2023-001)

Material Weakness 2023

Aha Punana Leo, Inc.

HI

Reporting Matching / Level of Effort / Earmarking

ʻAha Pūnana Leo is reviewing grants and awards from federal and nonfederal sources and identifies and tracks all federal funds. We will strengthen our internal controls over reviewing the accuracy and completeness of the SEFA for financial reporting purposes. We have since implemented an additional ...

ʻAha Pūnana Leo is reviewing grants and awards from federal and nonfederal sources and identifies and tracks all federal funds. We will strengthen our internal controls over reviewing the accuracy and completeness of the SEFA for financial reporting purposes. We have since implemented an additional review step in the grant set-up process to specifically address the proper classification of revenue for each new funding source.

View Audit 331177

Finding 513135 (2023-003)

Significant Deficiency 2023

Metropolitan College of New York

NY

Beginning in April 2023, the College began ongoing conversations with its bondholders for relief of aniticipated Bond covenant defaults. Initials communications informed bondholders of the need for their support to implement strategic changes to the College's business model and to hence address and ...

Beginning in April 2023, the College began ongoing conversations with its bondholders for relief of aniticipated Bond covenant defaults. Initials communications informed bondholders of the need for their support to implement strategic changes to the College's business model and to hence address and avoid covenant defaults. The College's independent auditors required an executed forbearance agreement to be in place prior to issuing the financial statements for the 2023 fiscal year. The terms and scope of the Forbearance Agreement have been negotiated with the bondholders, and as of October 17, 2024 a final version of the Agreement has been fully executed. As the agreement was executed and shared with the auditors, the Colleges 2023 audited financial statements were prepared for issuance. The college administration believes that this is a one-time event and does not anticipate a similar situation in upcoming years.

View Audit 331122

Finding 513132 (2023-002)

None 2023

Metropolitan College of New York

NY

Cash Management

Upon discovery (during 2023) of the failure of the College to determine the amount of excess cash it had retained, and to timely return it ot the Secretary of Education, the College immediately implemented a corrective action plan that included a strengthening of procedures with corresponding intern...

Upon discovery (during 2023) of the failure of the College to determine the amount of excess cash it had retained, and to timely return it ot the Secretary of Education, the College immediately implemented a corrective action plan that included a strengthening of procedures with corresponding internal controls, and the immediate return of any excess cash. The Correction Action Plan included Student Financial Aid training sessions for Business Office Staff responsible for Title IV cash management oversight. To further address this situation, the College engaged an independent consultant to assist in the review and revisiion of existing Business Office Title IV policies and procedures, which were immediately adopted and implemented.

View Audit 331122

Finding 513131 (2023-001)

None 2023

Metropolitan College of New York

NY

Upon discovery (during 2023) of the failure of the College to perform monthly reconciliations, the College immediately implemented a corrective action plan that included a strengthening of procedures with corresponding internal controls, with immediate return of any excess cash. The Corrective Actio...

Upon discovery (during 2023) of the failure of the College to perform monthly reconciliations, the College immediately implemented a corrective action plan that included a strengthening of procedures with corresponding internal controls, with immediate return of any excess cash. The Corrective Action Plan included Student Financial Aid training sessions for Business Office Staff responsible for Title IV cash management oversight. To further address this situation, the College engaged an independent consultant to assist in the review and revision of existing Business Office Title IV policies and procedures, which were immediately adopted and implemented

View Audit 331122

Finding 513122 (2023-001)

None 2023

Firefighter Cancer Support Network, Inc.

CA

The Organization is working diligently to complete annual audits in a timely manner.

View Audit 331087

Finding 513100 (2023-001)

None 2023

Northern Kentucky Presbyterian Housing Corporation

IN

w management has taken over and will ensure that the auditors receive audit documentation in a timely manner.

View Audit 331064

Finding 513098 (2023-003)

Significant Deficiency 2023

Arirang Housing,inc.

CA

Subrecipient Monitoring Reporting § 200.512

Finding 2023-003: For the year ended June 30, 2022, the Corporation did not submit audited financial statements to the Federal Audit Clearinghouse within 30 days after receipt of the auditor's report on October 6, 2022. The audited financial statements were submitted to the Federal Audit Clearinghou...

Finding 2023-003: For the year ended June 30, 2022, the Corporation did not submit audited financial statements to the Federal Audit Clearinghouse within 30 days after receipt of the auditor's report on October 6, 2022. The audited financial statements were submitted to the Federal Audit Clearinghouse on July 5, 2024. Comments on the Finding and Each Recommendation: The Corporation should submit audited financial statements to the Federal Audit Clearinghouse within the time frames required. Action(s) taken or planned on the finding: The audited financial statements have been submitted to the Federal Audit Clearinghouse.

View Audit 331057

Finding 513096 (2023-002)

Significant Deficiency 2023

Arirang Housing,inc.

CA

Subrecipient Monitoring HUD Housing Programs

Finding 2023-002: The Corporation did not furnish HUD with a complete annual financial report within 90 days following the year ended June 30, 2023. Comments on the Finding and Each Recommendation: The Corporation should ensure the annual financial report is filed within 90 days of year end. Action(...

Finding 2023-002: The Corporation did not furnish HUD with a complete annual financial report within 90 days following the year ended June 30, 2023. Comments on the Finding and Each Recommendation: The Corporation should ensure the annual financial report is filed within 90 days of year end. Action(s) taken or planned on the finding: The audited financial statements have been submitted to HUD.

View Audit 331057

Finding 513094 (2023-001)

Significant Deficiency 2023

Arirang Housing,inc.

CA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

Finding 2023-001: During the year ended June 30, 2023, the Corporation did not make the require deposits to the reserve for replacements. Comments on the Finding and Each Recommendation: Management should make a deposit to the reserve for replacements for $4,846 for the delinquent deposits. In futur...

Finding 2023-001: During the year ended June 30, 2023, the Corporation did not make the require deposits to the reserve for replacements. Comments on the Finding and Each Recommendation: Management should make a deposit to the reserve for replacements for $4,846 for the delinquent deposits. In future periods, management should fund the reserve for replacements on an annual basis as required by the HUD regulatory agreement or request HUD approval for a suspension of deposits. Action(s) taken or planned on the finding: Management made a deposit of $4,846 on July 20, 2023 for the delinquent deposits.

View Audit 331057 Questioned Costs: $1

Finding 513085 (2023-004)

Material Weakness 2023

Allen County

IN

Procurement, Suspension & Debarment § 200.1 § 200.303 § 200.317 § 200.318 § 200.319

FINDING 2023-004 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: Suspension and Debarment – Allen County did not have documentation that vendors’ suspension and debarment status were verified through either ...

FINDING 2023-004 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: Suspension and Debarment – Allen County did not have documentation that vendors’ suspension and debarment status were verified through either a) checking the Excluded Parties List System (EPLS), b) collecting a certification, or c) adding a clause or condition to the covered transaction agreement. Procurement – Allen County did not ensure purchases between $10,000 and $150,000 had received the adequate number of quotes or documented why an adequate number of quotes was not received. Contact Person Responsible for Corrective Action: Chris Cloud, Chief of Staff Contact Phone Number and Email Address: 260-449-4752 / chris.cloud@allencounty.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct Finding 2023-004 for Suspension and Debarment, the Chief of Staff to the Board of Commissioners will check the EPLS on SAM.gov every time a contract is placed before the Board of Commissioners for signature not containing the appropriate suspension and debarment language or a county department starts a project with a vendor using State and Local Fiscal Recovery Funds (SLFRF). If a vendor is not found in EPLS, a certification will be solicited from the vendor prior to contract signing or purchase of goods or services verifying that they have not been suspended or disbarred. A new verification must be sought for every contract or purchase. Documentation will be kept on file by the Controller to the Board of Commissioners who is responsible for reviewing claims submitted for payment utilizing SLFRF. To correct Finding 2023-004 for Procurement, the Chief of Staff to the Board of Commissioners will instruct departments who may be spending between $10,000-$150,000 of SLFRF that price or rate quotations must be obtained from an adequate number of qualified sources. When departments submit a claim to the Controller of the Board of Commissioners for payment, they must also provide a cover sheet outlining a) rationale for the method of procurement, b) copies of quotes received, and c) a justification for the selected vendor. This information will be reviewed and if everything is in order, the cover sheet will be uploaded, along with the accompanying invoices, in the Workflow payment system as part of the record. Anticipated Completion Date: This CAP will be completed by December 31, 2024

View Audit 331014

Finding 513084 (2023-003)

Material Weakness 2023

Allen County

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.303

FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The County submitted the four required quarterly P&E reports and the annual Recovery Plan Performance Report during the audit period; however, a single employee prepared and...

FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The County submitted the four required quarterly P&E reports and the annual Recovery Plan Performance Report during the audit period; however, a single employee prepared and submitted each report without a review or oversight process in place to prevent, or detect and correct, errors. Contact Person Responsible for Corrective Action: Chris Cloud, Chief of Staff Contact Phone Number and Email Address: 260-449-4752 / chris.cloud@allencounty.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct Finding 2023-003, the Chief of Staff to the Board of Commissioners will have the Controller to the Board of Commissioners review the P&E Reports and the Recovery Plan Performance Report prior to being electronically submitted to the Department of Treasury via its State and Local Fiscal Recovery Funds portal. If errors are discovered by the Controller, the Chief of Staff will correct the electronic entry prior to submission. Anticipated Completion Date: This CAP will be completed by October 31, 2024, the deadline for submitting the third quarter 2024 P&E Report.

View Audit 331014

Finding 513083 (2023-002)

Material Weakness 2023

Allen County

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Cash Management § 200.303

FINDING 2023-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Federal Agency: Department of the Treasury Summary of Finding: (copied from SBOA Findings document provided) The Allen County Department of Health (Department of Health), a department within Allen County,...

FINDING 2023-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Federal Agency: Department of the Treasury Summary of Finding: (copied from SBOA Findings document provided) The Allen County Department of Health (Department of Health), a department within Allen County, was awarded the Health Issues and Challenges grant through the Indiana Department of Health financed through the American Rescue Plan Act (ARPA) for the purposes of funding programs that focus on the improvement of chronic disease, specifically, elevated blood lead level reduction. As part of sound management of the Federal award, the Department of Health was responsible for implementing a system of internal control that would ensure compliance with the applicable requirements. The Department of Health did not properly design or implement such a system. The Department of Health was required to submit data through the online portal, National Electronic Disease Surveillance System (NEDSS) Base System (NBS), monthly beginning in October 2022. The submitted data included program specific metrics relating to patient case management of certified Elevated Blood Lead Levels (EBLLs). The Department of Health was also required to ensure environmental investigation activities completed, including risk assessments and environmental inspections, were documented in the Indiana I-LEAD database monthly by a licensed Lead Risk Assessor. Environmental investigation activities performed by the Department of Health were documented in the Indiana I-LEAD database by a licensed Lead Risk Assessor who was an employee of the Department of Health. Similarly, case management activities performed were documented in the NEDSS Base System (NBS). Once activities were documented in the I-LEAD and NBS systems, the activities were further documented in a spreadsheet by the Lead Risk Assessor (for I-LEAD activities) and the Case Management Coordinator (for NBS activities). The spreadsheet was reviewed by the Director of the Environmental Services Division and the Finance Director monthly. The Finance Director then used the spreadsheet to prepare the monthly reimbursement requests and sent the monthly reimbursement requests to the Indiana Department of Health. We determined through inquiry with the Director of the Environmental Services Division and the Finance Director that while there was a review of the monthly spreadsheet, there was not a second review of the spreadsheet back to the activities reported in I-LEAD and NBS for accuracy. Additionally, the Finance Director prepared and submitted the reimbursement requests to the State without a second review or oversight process in place to prevent, or detect and correct, errors prior to submission. The lack of internal controls was a systemic issue throughout the audit period. Recommendation We recommend that management of the Health Department design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place to ensure reports are complete and accurate. ………………………… Contact Person Responsible for Corrective Action: JENNIFER MILLER (Finance Director) Contact Phone Number and Email Address: 260-449-7358 (Jennifer.miller@allencounty.us) Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: We were unaware of a requirement for a secondary review of each document/spreadsheet/database input/task that was conducted prior to submission to the Finance Director (defining the completed cases for which to invoice the State), and a requirement for a secondary review of the invoice/billing documents prior to submission to the State. We were informed that the State review process (as was described to SBOA staff) was the check and balance needed which ensured we had appropriately entered the data into the required database(s) and that we had then subsequently billed for those very same appropriately completed and entered cases. However, when we were informed of the outcomes of the SBOA audit and the subsequent need for a corrective action plan (CAP) relative to their findings, we moved quickly to begin the development of the CAP -- as we do now understand that despite the inaccurate instructions we were given, we did not appropriately do what the law requires locally relative to ensuring accurate completion of duties under grant contracts before submission for reimbursement. THE PLAN (which will be added as a new “Grants” section in our existing Finance Internal Controls policies): For all grants (reimbursable or deliverables-based), once a contract is near completion or upon execution, a primary and secondary staff member will be identified for each step of the database entry (as an example, and this will follow whatever the duties are defined by the grant and a primary responsible staff member will be defined per grant duty needs) as well as for the invoicing/billing documentation process. The primary staff member(s) will be responsible for doing what is defined in the grant contract (a duty, task, data entry, invoice creation, etc.) and the secondary staff member will be responsible for verifying the work of the primary staff member(s). (In some cases, when there are diverse duties and more than one primary staff member is needed to do the duties of the grant, there may be several primary staff members assigned to various duties as needed) If disparities are encountered (such as errors or omissions) in any step related to the above duties, they will first be reported the primary staff member for likely easy correction or resolution. If a pattern exists or repetitive errors are identified through the review and verification process, the secondary reviewer will report the issue(s) to the Department Administrator to make a determination as to whether the primary staff member’s duties are transferred to another staff member, or if the person is simply re-educated. The goal will be to ensure there is an appropriate check and balance step (as well as remediation/correction step if warranted) in place for all tasks and documentation completion as it relates to grant-funded duties and invoicing. Anticipated Completion Date: We will follow this practice for any new grants accepted by the Allen County Department of Health effective 9/17/2024.

View Audit 331014

Finding 513082 (2023-001)

Material Weakness 2023

Allen County

IN

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.300 § 200.302 § 200.303 § 200.328 § 200.329

FINDING 2023-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, and Procurement and Suspension and Debarment Summary of Finding: (copied from SBOA Findings document provided) The...

FINDING 2023-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, and Procurement and Suspension and Debarment Summary of Finding: (copied from SBOA Findings document provided) The Allen County Department of Health (Department of Health), a department within Allen County, was awarded the Health Issues and Challenges grant through the Indiana Department of Health financed through the American Rescue Plan Act (ARPA) for the purpose of funding programs that focus on the improvement of chronic disease, specifically, elevated blood lead level reduction. The Health Issues and Challenges grant is a reimbursable grant, whereby the County received reimbursement on a percase basis at a stated rate for Case Management and Environmental Investigation activities performed. The Department of Health received federal receipts related to the grant in the amount of $130,479 during 2023. As part of sound management of the Federal award, the Department of Health was responsible for implementing a system of internal control that would ensure compliance with the applicable requirements. The Department of Health did not properly design or implement such a system. Receipts of the program were adequately identified through the use of an account number within the County Health Fund (285) in the Allen County's ledger (ledger) which was unique to the Health Issues and Challenges grant receipts. However, the ledger did not adequately identify the expenditures of the grant program within the County Health Fund. Through inquiry with the Department of Health employees and review of unitprepared support of grant expenditures, we determined expenditures were made with grant funds during the audit period, however, we were unable to distinguish between the expenditures of the Health Issues and Challenges grant and all other activities of the Department of Health in the County Health Fund. Due to the lack of separate identification of expenditures in the financial records, we were not able to establish a population from which to audit the Health Issues and Challenges grant for compliance with the following compliance requirements of the program: 􀁸 Activities Allowed or Unallowed 􀁸 Allowable Costs/Cost Principles 􀁸 Period of Performance 􀁸 Procurement and Suspension and Debarment As such, the full award amount of $130,479, as reported on the Schedule of Expenditures of Federal Awards, was determined to be questioned costs. The lack of internal controls and noncompliance were systemic issues throughout the audit period. Recommendation: We recommend that management of the Health Department establish a system of internal controls to ensure that grant award funds are adequately accounted for and tracked in such a manner as to determine the activity, receipts and disbursement, associated with the grant. ………………………… Contact Person Responsible for Corrective Action: JENNIFER MILLER (Finance Director) Contact Phone Number and Email Address: 260-449-7358 (Jennifer.miller@allencounty.us) Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: When we were informed of the outcomes of the SBOA audit and the subsequent needs for a corrective action plan (CAP) relative to their findings, we moved quickly to begin the development of the CAP. We feel this finding/issue could be easily remedied by following our normal procedure for grants, whereby we develop a new fund, craft a Fund Ordinance for approval by the Allen County Commissioners to establish said new fund, and then subsequently track all expenditures and reimbursements in the separate fund vs. utilizing a line item for deposits in the main Health Fund as was done with this grant (which lacked the ability to denote exact salary expenditures and such next to each payment as it was all done within the larger fund for all staff and expenses. We were not aware of this need. THE PLAN (which will be added as a new “Grants” section in our existing Finance Internal Controls policies): For all grants (reimbursable or deliverables-based), once a contract is near completion or upon execution, a separate fund will be created through development and approval of a local fund ordinance. All expenditures allowed by said grant and all reimbursements received by the grant funder will be tracked solely and only within the separate grant fund that is tied to the signed contract from the funder. If there are staff payments for salaries or benefits being reimbursed by a grant, we will ensure that: (1) the hours/minutes per staff member per pay period for all work associated with these grant duties are tracked appropriately so as to ensure we are invoicing the grant funder for the exact and accurate work hours (regardless of whether or not the grant contract specifies this be tracked or reimbursed per minute/hour, as most do not require this); and (2) these amounts will be noted alongside the expenditures in the grant fund for clarity upon invoicing or auditing. Anticipated Completion Date: We will follow this practice for any new grants accepted by the Allen County Department of Health effective 9/17/2024. This is the standard practice for most grants we have accepted, and therefore, we will not vary from this practice in the future even if given permission to do so.

View Audit 331014 Questioned Costs: $1

Finding 513064 (2023-001)

Material Weakness 2023

Chugach Regional Resource Commission

AK

Reporting § 200.512

Due to turnover of the Commission's accounting staff, the Commission was unable to have the annual audit completed within the required timeframe, and subsequently was also late in submission of the FAC report. The Commission has hired internal staff to help with the audit preparation and contracted ...

Due to turnover of the Commission's accounting staff, the Commission was unable to have the annual audit completed within the required timeframe, and subsequently was also late in submission of the FAC report. The Commission has hired internal staff to help with the audit preparation and contracted with an accounting firm that has provided the Commission a CPA to conduct audit preparation and other financial services as requested. The Commission will work on getting financial information in a timely fashion and submit the reporting package in accordance with the guidelines. Anticipated completion date: November 30, 2024.

View Audit 330982

Finding 513062 (2023-003)

Significant Deficiency 2023

Southside Community Health Services, INC

MN

Allowable Costs / Cost Principles § 200.400

Finding 2023-003 Condition: The organization did not properly maintain documentation to support the pay rate authorization. Corrective Action Plan: Management will conduct internal audits to randomly select pay statements and verify there are pay rate authorization documents to support the pay r...

Finding 2023-003 Condition: The organization did not properly maintain documentation to support the pay rate authorization. Corrective Action Plan: Management will conduct internal audits to randomly select pay statements and verify there are pay rate authorization documents to support the pay rate in the pay statements. Person responsible: Finance Director and Human Resources Manager Completion date: Starting 4th quarter of 2024 and through 2025 until management is satisfied the problem is resolved.

View Audit 330957

Finding 513061 (2023-002)

Significant Deficiency 2023

Southside Community Health Services, INC

MN

Special Tests & Provisions

Finding 2023-002 Condition: The organization did not properly maintain documentation to support the qualification and sliding fee discount received. Corrective Action Plan: Management will conduct internal audits to randomly select encounters with a sliding fee discount and will verify the slidi...

Finding 2023-002 Condition: The organization did not properly maintain documentation to support the qualification and sliding fee discount received. Corrective Action Plan: Management will conduct internal audits to randomly select encounters with a sliding fee discount and will verify the sliding fee documentation is on file and properly completed. Person responsible: Finance Director and Revenue Cycle Manager Completion date: Starting 4th quarter of 2024 and through 2025 until management is satisfied the problem is resolved.

View Audit 330957

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