Corrective Action Plans

Finding 500122 (2023-002)

Material Weakness 2023

PA

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

The County Human Services department has requested approval from PA DHS of its 2021-2022 fiscal year re-submission in September 2024. Following approval of the 2021-2022 submission and re-investment the County Human Services department will complete the submission of the 2022-2023 fiscal year report...

The County Human Services department has requested approval from PA DHS of its 2021-2022 fiscal year re-submission in September 2024. Following approval of the 2021-2022 submission and re-investment the County Human Services department will complete the submission of the 2022-2023 fiscal year report. The County Human Services department will reconcile the underlying expenditure detail in the accounting system to the expenditures reported. Internal approvals prior to submission and underlying records for reports will be maintained by the County Human Services department.

View Audit 322974

Finding 500117 (2023-003)

Material Weakness 2023

Charter Township of Commerce

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.302

Condition: The Township's March 31, 2024 report overstated expenses incurred for the reporting period by approximately $600,000. Planned Corrective Action: Molly Phillips and Katelyn Massey are working together to ensure that the expenses will be reported within the year they are incurring, and allo...

Condition: The Township's March 31, 2024 report overstated expenses incurred for the reporting period by approximately $600,000. Planned Corrective Action: Molly Phillips and Katelyn Massey are working together to ensure that the expenses will be reported within the year they are incurring, and allocated into the correct funds as approved by the Township Board. Contact person responsible for corrective action: Molly Phillips and Katelyn Massey Anticipated Completion Date: 12/31/2024

View Audit 322964

Finding 500100 (2023-003)

Material Weakness 2023

City of Wausau

WI

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

Federal Funding Accountability and Transparency Act- CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various grant requirements and laws surrounding the CDBG grant program and ensure that any written internal...

Federal Funding Accountability and Transparency Act- CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various grant requirements and laws surrounding the CDBG grant program and ensure that any written internal control or procedure manuals include all of the required compliance requirements. We also recommend that the City ensure multiple individuals are trained on the administration of the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This process will be added to the CDBG Policy and Procedure Manual to address the audit findings and improve reporting oversight. Name(s) of the contact person(s) responsible for corrective action: Tammy Stratz Planned completion date for corrective action plan: 10/14/2024

View Audit 322932

Finding 500098 (2023-001)

Significant Deficiency 2023

City of Wausau

WI

Allowable Costs / Cost Principles Reporting Significant Deficiency

Reporting and Environmental Reviews – CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various requirements of the CDBG grant program and identify individuals who can act as a reviewer and approver of the repo...

Reporting and Environmental Reviews – CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various requirements of the CDBG grant program and identify individuals who can act as a reviewer and approver of the reporting process. We also recommend the City document these procedures and internal controls as required by Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Community Development Manager and/or Community Development Specialist will prepare all Draw Requests and complete CDBG reports, including, but not limited to, the Annual Action Plan, CAPER, 5-Year Consolidated Plan, Labor Standards Report, and Minority/Women-Owned Business Reports. All Draw Requests will be reviewed by the Finance Director or Assistant Director, while other reports will be reviewed by the Development Director prior to submission to ensure accuracy and compliance. This process will be added to the CDBG Policy and Procedure Manual to address the audit findings and improve reporting oversight. Name(s) of the contact person(s) responsible for corrective action: Tammy Stratz, Randy Fifrick Planned completion date for corrective action plan: 9/30/2024

View Audit 322932

Finding 500059 (2023-003)

Material Weakness 2023

Northshore University Healthsystem

IL

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

Finding 2023-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple Workday allows costing allocations, which automatically split salaries above and below the cap. This process ensures that only appropriate salaries are charged to the grant. Management...

Finding 2023-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple Workday allows costing allocations, which automatically split salaries above and below the cap. This process ensures that only appropriate salaries are charged to the grant. Management will update the salary cap in the system in a timely manner and validate that the system is calculating correctly. Going forward, management will do a quarterly review of the effort distributions, and make adjustments when needed in a timely manner. Responsible Official: Robert Stanton, Assistant Vice President, Research and Financial Operations, NSH Research Central Office

View Audit 322924 Questioned Costs: $1

Finding 500004 (2023-005)

Significant Deficiency 2023

Northshore University Healthsystem

IL

Allowable Costs / Cost Principles

Finding 2023-005 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple As soon as the annual rate is calculated and reviewed after the annual audit is complete, Research will provide the approved fringe rate to accounting. Accounting will use the approved...

Finding 2023-005 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple As soon as the annual rate is calculated and reviewed after the annual audit is complete, Research will provide the approved fringe rate to accounting. Accounting will use the approved rate prospectively. Accounting will assess the variance between the new approved rate and the prior rate used. Research will approve the adjustment based on materiality and document the adjustment process. Management will develop a policy around the fringe allocation and adjustment Responsible Official: Robert Stanton, Assistant Vice President, Research and Financial Operations, NSH Research Central Office and Annaliza Villamin, System Director of Accounting, Endeavor Health

View Audit 322924

Finding 500000 (2023-002)

Material Weakness 2023

Northshore University Healthsystem

IL

Allowable Costs / Cost Principles Reporting

Finding 2023-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple The new Workday time and effort certification is now operational. Each individual is able to certify their own time and effort in the system, which eliminates manual tracking and paper...

Finding 2023-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple The new Workday time and effort certification is now operational. Each individual is able to certify their own time and effort in the system, which eliminates manual tracking and paperwork. Management will follow up and validate the effort certification is occurring in a timely manner. Management is currently drafting the policy to align with the new process. There will be continuous staff training and monitoring in this area. Responsible Official: Robert Stanton, Assistant Vice President, Research and Financial Operations, NSH Research Central Office

View Audit 322924

Finding 499998 (2023-003)

Material Weakness 2023

Wayne Township

IN

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

FINDING 2023-003 (Medicaid Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number: 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The...

FINDING 2023-003 (Medicaid Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number: 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Federal Cost report beginning 2022 will be done by a new firm. The firm is Blue & Co. They are a wellestablished CPA. The information that is supplied to the CPA firm will be maintained by Wayne Township and will be put the finished cost report. This is for the financial and other metrics that are needed for the report. The cost report will be reviewed for accuracy by the Township Office. The Ambulance payment adjustment is received about two- and one-half years in arrears. This comment would be repeated until we receive the funds for ambulance activity completed in 2023, which will occur in 2026. The payments received by the Medicaid program will be reviewed by the Township Accounting Specialist. After the person agrees it is then inputted into the accounting software and coded to the proper account. Before the Cost report is signed and submitted it will be reviewed by the Township and will ask questions as needed. Anticipated Completion Date: 12/31/24

View Audit 322923

Finding 499961 (2023-010)

Significant Deficiency 2023

Kandiyohi County

MN

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.403

SOCIAL SERVICES ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the County continue to be diligent in their review of what is allowable when coding to certain account codes that flow into the DHS reports. Explanation of disagreement with audit finding: There is no disagreem...

SOCIAL SERVICES ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the County continue to be diligent in their review of what is allowable when coding to certain account codes that flow into the DHS reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to better capture disallowed costs getting reported. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

View Audit 322900 Questioned Costs: $1

Finding 499960 (2023-009)

Significant Deficiency 2023

Kandiyohi County

MN

Student Financial Aid Allowable Costs / Cost Principles Significant Deficiency § 200.303

SSIS ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the County implement procedures to document review of disbursements when not able to show an electronic approval in the SSIS system. Explanation of disagreement with audit finding: There is no disagreement with the audit ...

SSIS ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the County implement procedures to document review of disbursements when not able to show an electronic approval in the SSIS system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to document review for all SSIS disbursements. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

View Audit 322900

Finding 499956 (2023-006)

Significant Deficiency 2023

Kandiyohi County

MN

Student Financial Aid Allowable Costs / Cost Principles Eligibility

TIME STUDY – ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the county streamline the payroll change process between the payroll department and human services department. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Acti...

TIME STUDY – ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the county streamline the payroll change process between the payroll department and human services department. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

View Audit 322900

Finding 499951 (2023-002)

None 2023

International Service Center

PA

Allowable Costs / Cost Principles

Management will develop a more comprehensive detailed written procedures related to federal award requirement by 12/31/2024

View Audit 322898

Finding 499949 (2023-001)

Material Weakness 2023

International Service Center

PA

Questioned Costs Allowable Costs / Cost Principles Cash Management

We will provide additional training to our fiscal staff to ensure that complete accounting records are maintained. We will conduct periodic internal reviews of our records to ensure that those records support the grant expenditures claimed during the year.

View Audit 322898 Questioned Costs: $1

Finding 499948 (2023-003)

Material Weakness 2023

Town of Whitestown

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.1 § 200.303

FINDING 2023-003 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Town submitted one P&E report during the audit period timely; however, a single employee prepared and submitted the P&E report withou...

FINDING 2023-003 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Town submitted one P&E report during the audit period timely; however, a single employee prepared and submitted the P&E report without a review or oversight process in place to prevent or detect and correct errors. Only one annual report was required to be submitted by the Town. For the report tested, all activity for the reporting period was not included, information submitted was not supported by the Town's records, and the reports were not fairly presented. Contact Person Responsible for Corrective Action: Matt Sumner Contact Phone Number and Email Address: 317-732-4532, msumner@whitestown.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: For applicable reports that are to be submitted for federal grants, we will implement a control/review and ensure the information being reported is correct prior to submission. Anticipated Completion Date: November 1, 2024

View Audit 322895

Finding 499945 (2023-003)

Significant Deficiency 2023

Community Development Corporation of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.430

We now have a dedicated grants reviewer in finance to support project management's reporting since January 2024 with cross training in the finance team. We will update our practices guide to include the documentation process for compliance by October 2024. Lynn Ketch, Executive Director, is the pers...

We now have a dedicated grants reviewer in finance to support project management's reporting since January 2024 with cross training in the finance team. We will update our practices guide to include the documentation process for compliance by October 2024. Lynn Ketch, Executive Director, is the person responsible for the plan.

View Audit 322891 Questioned Costs: $1

Finding 499935 (2023-002)

Significant Deficiency 2023

Episcopal Homes of Minnesota and Affiliates

MN

Allowable Costs / Cost Principles Reporting Significant Deficiency

View of Responsible Officials: Management agrees with the finding and recommendation and will review procedures to ensure future reporting submissions are detail reviewed. Responsible Party Sherri Friedrich Estimated Completion December 31, 2024

View Audit 322883

Finding 499932 (2023-001)

None 2023

Care Plus Bergen, Inc.

NJ

Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking

Planned Corrective Action: Management is reviewing current policies and procedures. Management will make proper adjustments to the policies to ensure that awards are accounted for in the proper performance period. Further education will be done with staff and there will be mid mid-year internal au...

Planned Corrective Action: Management is reviewing current policies and procedures. Management will make proper adjustments to the policies to ensure that awards are accounted for in the proper performance period. Further education will be done with staff and there will be mid mid-year internal audits. Person(s) Responsible: Sandi Weiss, AVP Finance Expected Completion Date: November 15, 2024

View Audit 322865 Questioned Costs: $1

Finding 499928 (2023-003)

Material Weakness 2023

Chris Properties Graham Circle, Inc.

GA

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

To address the deficiencies identified in the audit regarding allowable costs, the Organization has implemented the following procedures: 1. Procurement • A Procurement Manager was hired to lead the process for sourcing, negotiating terms and conditions, and purchasing items for the organization. • ...

To address the deficiencies identified in the audit regarding allowable costs, the Organization has implemented the following procedures: 1. Procurement • A Procurement Manager was hired to lead the process for sourcing, negotiating terms and conditions, and purchasing items for the organization. • The Procurement Manager is responsible for inspecting goods as necessary and keeping records of all steps in the process. 2. Accounts Payable • Manual check request forms have been implemented; however, the Finance Department is exploring an electronic approval process through a third-party system that interfaces with Sage Intacct. • Invoices are approved by the appropriate program or administrative leader prior to submitting to Accounts Payable. • The appropriate program or administrative leader is responsible for ensuring the correct department, project, and general ledger codes are included on the check request. • The Sr. Accounts Payable Analyst is responsible for ensuring the check requests are completed with the pertinent information, entering invoices that have been approved and uploading the invoices and any additional supporting documentation into the Sage Intacct accounting system as an attachment.

View Audit 322863 Questioned Costs: $1

Finding 499914 (2023-001)

None 2023

Oregon Child Development Coalition, Inc.

OR

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Significant Deficiency § 200.406

FINDING - FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2023-001 Head Start – Assistance Listing #93.600 Recommendation: The Organization should establish more defined written policies and procedures regarding credit card rebates that are in line with Uniform Guidance re...

FINDING - FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2023-001 Head Start – Assistance Listing #93.600 Recommendation: The Organization should establish more defined written policies and procedures regarding credit card rebates that are in line with Uniform Guidance requirements, as well as establish organizational controls to ensure that such policies and procedures are being followed. Explanation of disagreement with audit findings: There is no disagreement with the audit finding. Action taken in response to finding: The issue was recognized by management shortly after the close of the fiscal year. The entire balance of accumulated points was converted to gift cards. A historical analysis of the coding for all purchases charged to the credit card during the year under audit is being performed. A proportional amount of the total value of the gift cards will be credited to each federal award as a reduction of costs. This process will continue to be performed on a regular basis for the duration of the use of the credit card in question. Action Plan: OCDC will move to utilizing credit cards that do not have a rewards program. Inquiries have been made with OCDC’s banking institution regarding the available options. The policies and procedures surrounding the use of credit cards will be documented in writing, and anyone who is entrusted to use an agency credit card will be required to sign a document acknowledging their understanding of those policies and procedures. Name(s) of the contact people responsible for correction action: Tong Lee, Chief Financial Officer Plan completion date for corrective action plan: November 30, 2024

View Audit 322843

Finding 499913 (2023-002)

Significant Deficiency 2023

Alabama Nursing Home Association Education Foundation

AL

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303 § 200.403 § 200.405

Planned Corrective Action: Management contact the facility receiving the overpayment to recoup the funds or ask the facility to provide proof the funds were used for qualifying purposes under the program. If funds are returned, they will be redistributed to other facilities or returned to the Granto...

Planned Corrective Action: Management contact the facility receiving the overpayment to recoup the funds or ask the facility to provide proof the funds were used for qualifying purposes under the program. If funds are returned, they will be redistributed to other facilities or returned to the Grantor no later than December 31, 2024. Person(s) Responsible: John Matson, Executive Director

View Audit 322841 Questioned Costs: $1

Finding 499893 (2023-003)

Significant Deficiency 2023

Lutheran Metropolitan Ministry

OH

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking § 200.303

LMM agrees that 4 out of 40 tested non-payroll costs did not have evidence of approval for payment. While the payments were for contracted services that were received by LMM the written approval for payment was not able to be located. LMM has recently adopted Concur for expense management. With this...

LMM agrees that 4 out of 40 tested non-payroll costs did not have evidence of approval for payment. While the payments were for contracted services that were received by LMM the written approval for payment was not able to be located. LMM has recently adopted Concur for expense management. With this platform all approvals are required electronically and evidence of approval will be able to be submitted.

View Audit 322823

Finding 499887 (2023-003)

Material Weakness 2023

Noble County

IN

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

FINDING 2023-003 Finding Subject: Suspension and Debarment Summary of Finding: Due to the lack of effective internal controls, Suspension and Debarment requirements were not met during the audit period. Contact Person Responsible for Corrective Action: Shelley Mawhorter, County Auditor Contact Phone...

FINDING 2023-003 Finding Subject: Suspension and Debarment Summary of Finding: Due to the lack of effective internal controls, Suspension and Debarment requirements were not met during the audit period. Contact Person Responsible for Corrective Action: Shelley Mawhorter, County Auditor Contact Phone Number and Email Address: (260) 636-2658; shelley.mawhorter@nobleco.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Noble County Auditor’s office will implement effective internal controls in reference to Suspension and Debarment requirements related to subawards and covered transactions to ensure that one of the three allowable methods of verifying that a vendor is not suspended or debarred is completed prior to entering into the contract or transaction. Anticipated Completion Date: We will have the Corrective Action Plan implemented by December 31, 2024.

View Audit 322810

Finding 499883 (2023-002)

Material Weakness 2023

Montgomery County

MS

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

FINDING 2023-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Audit Finding: Material Weakness, Noncompliance Contact Person Responsible for Corrective Action: Mindy Byers Contact Phone Number: 765-364-6401 Contact Email Address: mindy.byers@montgomerycou...

FINDING 2023-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Audit Finding: Material Weakness, Noncompliance Contact Person Responsible for Corrective Action: Mindy Byers Contact Phone Number: 765-364-6401 Contact Email Address: mindy.byers@montgomerycounty.in.gov Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Auditor and her Chief Deputy completed the P&E report together. Moving forward, the Auditor will print the report and have the Chief Deputy sign off on the report prior to submission. Anticipated Completion Date: April 1, 2025. If applicable: Document reason issue will NOT be corrected within six months: The 2024 Project & Expenditure report is not due until April 1, 2025.

View Audit 322791

Finding 499853 (2023-003)

Material Weakness 2023

Montana Alliance of Boys & Girls Clubs, Inc.

MT

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303 § 200.332

Individual Responsible for Corrective Action Plan: Alliance Director – Brian Dennis Corrective Action: The Organization will enhance its procedures and internal controls with respect to monitoring over subrecipient activities and reimbursement payments by working with the State of Montana grantor t...

Individual Responsible for Corrective Action Plan: Alliance Director – Brian Dennis Corrective Action: The Organization will enhance its procedures and internal controls with respect to monitoring over subrecipient activities and reimbursement payments by working with the State of Montana grantor to ensure local clubs are using subawards for authorized purposes. Anticipated Completion Date: December 31, 2024

View Audit 322714

Finding 499848 (2023-001)

Significant Deficiency 2023

American College of Occupational and Environmental Medicine

IL

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Identifying Number: 2023-001 Audit Recommendation: Procedures should be consistently applied requiring the reconciliation of employee timecards to actual costs allocated and charged to federal and other programs. Views of Responsible Officials and Planned Corrective Actions: To ensure compliance wi...

Identifying Number: 2023-001 Audit Recommendation: Procedures should be consistently applied requiring the reconciliation of employee timecards to actual costs allocated and charged to federal and other programs. Views of Responsible Officials and Planned Corrective Actions: To ensure compliance with grant requirements and address the issue with employee timecards and vouchers submitted, the following steps will be implemented: 1. Time Tracking: Employees will continue to be required to record their time every two weeks (through HourTimeSheet), ensuring that the hours worked align with the percentage of time allocated to the grant for those two weeks. 2. Clear Communication: The Project Director will clarify the importance of matching monthly hours with the percentage allocated to all staff participating in the grant. This will help prevent misunderstandings regarding time reporting. 3. Reviews: The Project Director will continue to conduct monthly reviews of timecards to verify that reported hours correspond with the grant’s allocation requirements before submitting vouchers. By implementing these measures, we aim to ensure that timecards accurately reflect the allocation of employee-related costs on a monthly basis, promoting compliance with grant requirements moving forward.

View Audit 322706

Corrective Action Plans

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