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Corrective Action Plans

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Finding 514613 (2024-002)
Significant Deficiency 2024
Sma Healthcare, Inc.
FL
Allowable Costs / Cost Principles Eligibility
For ALN 93.959, a Financial Assessment Form was not properly signed for 1 of the 60 clients tested. Additionally, 2 of the 60 clients tested had service dates that did not fall within one year of the Financial Assessment Form completion date. Obtaining a client's signature on the form has been chall...
For ALN 93.959, a Financial Assessment Form was not properly signed for 1 of the 60 clients tested. Additionally, 2 of the 60 clients tested had service dates that did not fall within one year of the Financial Assessment Form completion date. Obtaining a client's signature on the form has been challenging, particularly during recent years as use of telehealth services has expanded. As a corrective action, team members will be trained in how to properly document receipt of verbal approval. Our internal tracking of completion of the Financial Assessment Form at admission indicates that compliance with this requirement occurs about 89% of the time. As a corrective action plan, SMA will include the completion of the Financial Assessment Form both at admission and annually to be reviewed monthly by the programs. In addition, an action plan will be required to be present at the quarterly Quality Assurance Committee meeting if not at 100%.
View Audit 332958
Finding 514612 (2024-001)
Significant Deficiency 2024
Sma Healthcare, Inc.
FL
Allowable Costs / Cost Principles Eligibility
For ALN 93.958, the discount fee that was shown on their Financial Assessment Form was not used for 7 of the 60 clients tested. Additionally, 8 of the 60 clients tested had service dates that did not fall within one year of the Financial Assessment Form. Our internal tracking of completion of the Fi...
For ALN 93.958, the discount fee that was shown on their Financial Assessment Form was not used for 7 of the 60 clients tested. Additionally, 8 of the 60 clients tested had service dates that did not fall within one year of the Financial Assessment Form. Our internal tracking of completion of the Financial Assessment Form at admission indicates that compliance with this requirement occurs about 89% of the time. As acorrective action, the Client Service Specialist will be trained to ensure data is entered accurately. SMA will also include the completion of the Financial Assessment Form both at admission and annually to be reviewed monthly by the programs. In addition, an action plan will be required to be present at the quarterly Quality Assurance Committee meeting if not at 100%.
View Audit 332958
Davenport Community School District
IA
School Nutrition Programs Subrecipient Monitoring Allowable Costs / Cost Principles
Response and Corrective Action Plan: The District will annually prepare the indirect cost charged to the program based on the actual fiscal year trial balance. The District will provide an estimate to the Board each June to ensure proper approval of fund transfers.
Response and Corrective Action Plan: The District will annually prepare the indirect cost charged to the program based on the actual fiscal year trial balance. The District will provide an estimate to the Board each June to ensure proper approval of fund transfers.
View Audit 332889
Finding 514557 (2024-003)
Material Weakness 2024
Elkhorn Area School District
WI
Questioned Costs Allowable Costs / Cost Principles
Corrective Action Plan: The District will complete a cross-check of all Medicaid claims to ensure we are not also claiming those costs to other federal grants. Anticipated Corrective Action Plan C...
Corrective Action Plan: The District will complete a cross-check of all Medicaid claims to ensure we are not also claiming those costs to other federal grants. Anticipated Corrective Action Plan Completion Date: November 2025 Contact Information: For additional information regarding this finding please contact Bill Trewyn, Business Manager, at 262-741-9143.
View Audit 332869 Questioned Costs: $1
Finding 514528 (2024-002)
Significant Deficiency 2024
Haven - Violence Prevention and Support Services
NH
Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.420
When reallocation occurs, a spreadsheet shall be created to document the changes and the Finance Director will ensure that the invoices reflect the changes accordingly.
When reallocation occurs, a spreadsheet shall be created to document the changes and the Finance Director will ensure that the invoices reflect the changes accordingly.
View Audit 332831
Finding 514527 (2024-001)
Significant Deficiency 2024
Haven - Violence Prevention and Support Services
NH
Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.430
To ensure that employees are using the correct timesheet, the Office Manager now reviews the timesheets each pay period for grant allocation, formatting and hours prior to executing payroll.
To ensure that employees are using the correct timesheet, the Office Manager now reviews the timesheets each pay period for grant allocation, formatting and hours prior to executing payroll.
View Audit 332831
Finding 514422 (2024-003)
Significant Deficiency 2024
Arlington Baptist University
CO
Student Financial Aid Allowable Costs / Cost Principles Significant Deficiency
Lack of Documentation of Exit Counseling Planned Corrective Action: Current SIS is set to trigger the Exit Counseling to all students that are coded anything other than E (Enrolled). The Registrar updates all student files with any enrollment changes triggering the email to go to the student. The FA...
Lack of Documentation of Exit Counseling Planned Corrective Action: Current SIS is set to trigger the Exit Counseling to all students that are coded anything other than E (Enrolled). The Registrar updates all student files with any enrollment changes triggering the email to go to the student. The FA Director will run a report in the middle of each term to pick up any students that may have been missed by the Registrar. Person Responsible for Corrective Action Plan: Stephanie Castillo, Director of Financial Aid Anticipated Date of Completion: Fall 2024
View Audit 332741
Finding 514411 (2024-001)
Material Weakness 2024
Natchitoches Parish Housing Authority
LA
HUD Housing Programs Allowable Costs / Cost Principles
HOUSING AUTHORITY OF NATCHITOCHES PARISH, LOUISIANA CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2024 NATCHITOCHES PARISH HOUSING AUTHORITY 525 4th St. Natchitoches, LA 71457 Phone No. (318) 357-0553 Fax No. (318) 352-2086 Corrective Action Plan Finding: Finding 2024-001-Administrative Eq...
HOUSING AUTHORITY OF NATCHITOCHES PARISH, LOUISIANA CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2024 NATCHITOCHES PARISH HOUSING AUTHORITY 525 4th St. Natchitoches, LA 71457 Phone No. (318) 357-0553 Fax No. (318) 352-2086 Corrective Action Plan Finding: Finding 2024-001-Administrative Equity Deficit, and Related Large Interfund Payable Condition: At June 30, 2024, the Housing Choice Voucher (HCV) Fund owes the General Fund $101,216. Corrective Action Planned: I am Rhonda Kay, Executive Director and Designated Person to answer this finding. We will carefully review them again, as the auditor recommends. Person responsible for corrective action: Rhonda Kay, Executive Director Telephone: (318) 357-0553 Housing Authority of Natchitoches Parish Fax: (318) 352-2086 525 4th St Natchitoches, LA 71457 Anticipated Completion Date: June 30, 2025
View Audit 332715
Finding 514390 (2024-005)
Significant Deficiency 2024
Independent School District No. 361
MN
Internal Control / Segregation of Duties Allowable Costs / Cost Principles Significant Deficiency
Recommendation: We recommend that the District retain supporting documentation on file as required by federal guidelines for all transactions related to federal grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to f...
Recommendation: We recommend that the District retain supporting documentation on file as required by federal guidelines for all transactions related to federal grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will implement policies to ensure all documentation is kept. Name of the contact person responsible for corrective action: Phan Tu, Business Manager Planned completion date for corrective action plan: June 30, 2025
View Audit 332666
Finding 514266 (2024-001)
Significant Deficiency 2024
S.a.f.e. House, Inc.
NM
Allowable Costs / Cost Principles
SAFE House agrees with this finding. In order to ensure that internal controls related to payroll costs allocation are sufficient to prevent or detect errors in compliance with the standards The Executive Director shall review biweekly payroll allocations for propriety and initial them.
SAFE House agrees with this finding. In order to ensure that internal controls related to payroll costs allocation are sufficient to prevent or detect errors in compliance with the standards The Executive Director shall review biweekly payroll allocations for propriety and initial them.
View Audit 332513
Finding 514264 (2024-006)
Significant Deficiency 2024
Alameda Health System, A Public Hospital Authority
CA
Allowable Costs / Cost Principles Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303
Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will review, modify, and implement policies and procedures over the program to ensure that expenditures being charged to the program are specifically identified in the grant contract.
Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will review, modify, and implement policies and procedures over the program to ensure that expenditures being charged to the program are specifically identified in the grant contract.
View Audit 332508
Finding 514262 (2024-004)
Significant Deficiency 2024
Alameda Health System, A Public Hospital Authority
CA
Allowable Costs / Cost Principles Period of Performance Cash Management § 200.403
Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System has finalized the standard work procedure titled, Request for Funds/Reimbursement Claims (2-201’s), to ensure costs are appropriately charged based on the contract’s performance period...
Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System has finalized the standard work procedure titled, Request for Funds/Reimbursement Claims (2-201’s), to ensure costs are appropriately charged based on the contract’s performance periods. Review of cost activity will occur in fiscal year 2025 to ensure policy is followed.
View Audit 332508
Finding 514260 (2024-002)
Significant Deficiency 2024
Alameda Health System, A Public Hospital Authority
CA
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303
Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System finalized the standard work procedures titled, Internal Controls for Proper Verification, which include procedures to ensure reported timesheet hours agree to hours on the time study a...
Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System finalized the standard work procedures titled, Internal Controls for Proper Verification, which include procedures to ensure reported timesheet hours agree to hours on the time study and costs incurred are appropriately charged based on the contracts’ performance periods. Staff is implementing policy in fiscal year 2025.
View Audit 332508
Finding 514254 (2024-002)
Material Weakness 2024
Monroe-Gregg School District
IN
Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.403
FINDING 2024-002 Subject: COVID-19 - Education Stabilization Fund - Activities Allowed or Unallowed Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): ...
FINDING 2024-002 Subject: COVID-19 - Education Stabilization Fund - Activities Allowed or Unallowed Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School District to ensure compliance with requirements related to the Education Stabilization Fund and Activities Allowed or Unallowed. FINDING 2024-002 (Continued) Context: During the testing of payroll disbursements charged to the Education Stabilization Fund grant awards during the audit period, the following exceptions were noted: • For 16 payroll disbursements, in a sample of 40, management was unable to provide an approved employee contract or hourly rate ordinance to support the selected employees' bi-weekly pay rate. • For one transaction selection, an employee received a $730.43 one-time payment for a Teacher Appreciation Grant (TAG) funded by the 84.425U award. The Teacher Appreciation Grant has its own fund and is a state/local grant received to reward high-performing, eligible certified staff. The selected employee is a noncertified employee and did not qualify for a TAG award. There was no documentation provided to support work performed under this award to support allowability of the cost incurred. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will ensure records of approved contracts are maintained for all employees and that payroll charged to federal awards is reviewed each pay period for allowability. The HR Coordinator is currently storing each contract both by hard copy in the employee file and digitally in our software. The Deputy Treasurer/Payroll Coordinator reviewing the distribution report prior to payroll submission. The Treasurer is also reviewing and will sign off on the distribution report for each payroll. Responsible Party and Timeline for Completion: Kelli Kizzee - HR Coordinator, Jessica Elliot - Payroll Coordinator, Moriah Crane - Treasurer. The process is already in place.
View Audit 332497 Questioned Costs: $1
Finding 514252 (2024-004)
Material Weakness 2024
Monroe-Gregg School District
IN
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.403
FINDING 2024-004 Subject: Special Education Cluster (IDEA) - Activities Allowed or Unallowed Federal Agency: Department of Education Federal Program: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Number: 84.027 Federal Award Numbers and Years (or Other...
FINDING 2024-004 Subject: Special Education Cluster (IDEA) - Activities Allowed or Unallowed Federal Agency: Department of Education Federal Program: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Number: 84.027 Federal Award Numbers and Years (or Other Identifying Numbers): H027A220084, H027A230084 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School District to ensure compliance with requirements related to the Special Education Cluster and Activities Allowed or Unallowed. Context: During the testing of a sample of 40 payroll disbursements charged to the Special Education Cluster during the audit period, the following exceptions were noted: • For eight transactions selected, management was unable to provide an approved contract to support the selected employees' bi-weekly pay rate. • For two transactions selected, management was unable to provide approved timecards for the selected hourly employee and time period. • For seven transactions selected, management was unable to provide time and effort logs to support the allocation of one employee's salary between the federal grant and the Education fund. The lack of controls was systematic throughout the audit period. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will ensure records of approved contracts and approved timecards are maintained for all employees. Management will ensure payroll charged to federal awards is reviewed each pay period for allowability. The HR Coordinator is currently storing each contract both hard copy in the employee file and digitally in our software. The Deputy Treasurer/Payroll Coordinator will review the distribution report prior to payroll submission. As time cards are being approved in our software system, a print out of the approvals will be maintained for each payroll. The Treasurer will review and sign off on the distribution and approval report for each payroll. Responsible Party and Timeline for Completion: Kelli Kizzee - HR Coordinator, Jessica Elliot - Payroll Coordinator, Moriah Crane - Treasurer. The process is already except for the printed time card approval report which will be in place starting with the January 2025 payrolls.
View Audit 332497
Finding 514214 (2024-002)
Significant Deficiency 2024
Sports Leadership and Management Academy of Nevada
NV
Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.303
Finding Number: 2024-002 – Approval of Payroll Expense Transactions Corrective Action Plan: A process was put in place in January 2024 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be ...
Finding Number: 2024-002 – Approval of Payroll Expense Transactions Corrective Action Plan: A process was put in place in January 2024 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be run, nor grants submitted until proper approval is received. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2025
View Audit 332414
Finding 514203 (2024-003)
Significant Deficiency 2024
Doral Academy of Nevada
NV
Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.303
Finding Number: 2024-003 – Approval of Payroll Expense Transactions Corrective Action Plan: A process was put in place in January 2024 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be ...
Finding Number: 2024-003 – Approval of Payroll Expense Transactions Corrective Action Plan: A process was put in place in January 2024 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be run, nor grants submitted, until proper approval is received. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2025
View Audit 332410
Sweetwater Union High School District
CA
Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties
Management concurs with findings. District management will continue to provide staff members internal control procedure training specifically in the areas of federal procurement. This will ensure adherence to Federal program requirements.
Management concurs with findings. District management will continue to provide staff members internal control procedure training specifically in the areas of federal procurement. This will ensure adherence to Federal program requirements.
View Audit 332409 Questioned Costs: $1
Finding 514194 (2024-002)
Significant Deficiency 2024
Austin Achieve Public Schools, Inc.
TX
Allowable Costs / Cost Principles Reporting School Nutrition Programs
AAPS has corrected for this finding at the beginning of FY25 by having offer letters issued by our HR Manager to all employees. Offer letters are securely stored in individual employees’ personnel folders.
AAPS has corrected for this finding at the beginning of FY25 by having offer letters issued by our HR Manager to all employees. Offer letters are securely stored in individual employees’ personnel folders.
View Audit 332402
Finding 514176 (2024-101)
Significant Deficiency 2024
Southwest Leadership Academy
AZ
Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.430
2024-101: Significant Deficiency in Internal Controls Over Compliance and Noncompliance Required to be Reported in Accordance with 2 CFR §200.516(c): Payroll Recommendation: To help ensure employees receive accurate compensation, the School should implement internal control procedures that include t...
2024-101: Significant Deficiency in Internal Controls Over Compliance and Noncompliance Required to be Reported in Accordance with 2 CFR §200.516(c): Payroll Recommendation: To help ensure employees receive accurate compensation, the School should implement internal control procedures that include thorough verification of payroll data against authorized pay rates before payroll is processed. Action Taken: 1. Pay rate change requests will be accumulated and organized by effective date. 2. For each payroll, all (100%) of the pay rate change requests that became effective during the pay period will be compared to the pay rates for the impacted employee that appear in the preliminary payroll reports. For example, for a pay period from 10/16/2024 to 10/30/2024, all pay rate change requests with effective dates between 10/16/2024 and 10/30/2024 will be compared to the pay rates for the impacted employees in the preliminary payroll reports. 3. If any discrepancies between the pay rate change requests and the pay rates in the preliminary payroll reports are identified, the pay rate will be corrected in the payroll system, the preliminary payroll reports will be reproduced, and steps 1 and 2 will be repeated. 4. If no discrepancies between the pay rate change requests and the pay rates in the preliminary payroll reports are identified, the payroll will proceed as usual. 5. For pay rate change requests with retroactive effective dates, the date of receipt of the change request will be documented, pay rate changes will be implemented immediately, and retroactive pay will be paid in the next payroll. The retroactive change requests will be verified as described in steps 1 and 2. Anticipated Completion Date: 12/31/2024 Contact Person: Keith Chilton
View Audit 332377
Finding 514137 (2024-004)
Material Weakness 2024
Cherokee County School District
SC
Questioned Costs Allowable Costs / Cost Principles
CONTACT PERSON: Sandra Isom, Executive Director of Finance, sandy.isom@cherokee1.org CORRECTIVE ACTION: The District will ensure that all employees charged to federal programs have appropriate time and effort documentation. PROPOSED COMPLETION DATE: Prior to June 30, 2025
CONTACT PERSON: Sandra Isom, Executive Director of Finance, sandy.isom@cherokee1.org CORRECTIVE ACTION: The District will ensure that all employees charged to federal programs have appropriate time and effort documentation. PROPOSED COMPLETION DATE: Prior to June 30, 2025
View Audit 332320 Questioned Costs: $1
Finding 513976 (2024-005)
Significant Deficiency 2024
Community Unit School District 100
IL
Reporting Subrecipient Monitoring Allowable Costs / Cost Principles
Condition: Quarterly expenditure reports for the projects expenditures were not timely filed for ESSER III D3 (2 of 4 quarters required). Plan: To avoid this reporting and internal control issue, the District should schedule the due dates of all expenditure reports in order to avoid late filings. ...
Condition: Quarterly expenditure reports for the projects expenditures were not timely filed for ESSER III D3 (2 of 4 quarters required). Plan: To avoid this reporting and internal control issue, the District should schedule the due dates of all expenditure reports in order to avoid late filings. Anticipated Date of Completion: June 30, 2025 Name of Contact Person: Jason Brunaugh, Assistant Superintendent of Finance and Human Resources Management Response: This District is aware of the issue and has determined that the majority of the problem occurs when a grant is first approved, and the first reporting period is missed or if a grant continues into subsequent project years. Management has found a dashboard within IWAS that has a listing of all grants by project year and dates that the grants and budgets are approved that will help determine when the first expenditure reports are due. Additionally, management will work on a process to ensure that expenditure reports are no longer missed or filed late.
View Audit 332183
Finding 513974 (2024-006)
Significant Deficiency 2024
Community Unit School District 100
IL
Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles
Condition: Expenditures claimed on the projects’ quarterly reports were not included in the detailed budget approved by ISBE resulting in questioned costs for the projects. Plan: To avoid this reporting issue, the District should compare expenditure reports to the program budget that has been submi...
Condition: Expenditures claimed on the projects’ quarterly reports were not included in the detailed budget approved by ISBE resulting in questioned costs for the projects. Plan: To avoid this reporting issue, the District should compare expenditure reports to the program budget that has been submitted. Budget policies per the State and Federal Grant Administration Policy should be reviewed and followed accordingly. Anticipated Date of Completion: June 30, 2025 Name of Contact Person: Jason Brunaugh, Assistant Superintendent of Finance and Human Resources Management Response: The District will work to properly report transactions in the future and follow the guidelines set forth in the policy manual.
View Audit 332183 Questioned Costs: $1
Finding 513972 (2024-004)
Significant Deficiency 2024
Community Unit School District 100
IL
Reporting Subrecipient Monitoring Allowable Costs / Cost Principles
Condition: Quarterly expenditure reports for the projects expenditures were not timely filed for ESSER II CP (1 of 1 quarters required) and ESSER II D2 (1 of 1 quarters required). Plan: To avoid this reporting and internal control issue, the District should schedule the due dates of all expenditure...
Condition: Quarterly expenditure reports for the projects expenditures were not timely filed for ESSER II CP (1 of 1 quarters required) and ESSER II D2 (1 of 1 quarters required). Plan: To avoid this reporting and internal control issue, the District should schedule the due dates of all expenditure reports in order to avoid late filings. Anticipated Date of Completion: June 30, 2025 Name of Contact Person: Jason Brunaugh, Assistant Superintendent of Finance and Human Resources Management Response: This District is aware of the issue and has determined that the majority of the problem occurs when a grant is first approved, and the first reporting period is missed or if a grant continues into subsequent project years. Management has found a dashboard within IWAS that has a listing of all grants by project year and dates that the grants and budgets are approved that will help determine when the first expenditure reports are due. Additionally, management will work on a process to ensure that expenditure reports are no longer missed or filed late.
View Audit 332183
Eastern Oklahoma State College
OK
Student Financial Aid Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking
Management Response: The College acknowledges the finding and agrees with the recommendation to proactively obtain the waiver to ensure compliance with federal matching requirements. For the fiscal year 2025, we have already verified and obtained the waiver letter, ensuring that the College qualifie...
Management Response: The College acknowledges the finding and agrees with the recommendation to proactively obtain the waiver to ensure compliance with federal matching requirements. For the fiscal year 2025, we have already verified and obtained the waiver letter, ensuring that the College qualifies for the matching exemption. To prevent future occurrences, we have added the waiver verification process to our compliance tracking spreadsheet. This ensures that the waiver is requested and obtained from the appropriate department each year and documentation is presented to management to verify it has been obtained. We are committed to maintaining accurate oversight of matching requirements and will take all necessary steps to ensure full compliance moving forward.
View Audit 332174
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