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Corrective Action Plans

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Lafourche Parish Government
LA
Procurement, Suspension & Debarment Allowable Costs / Cost Principles Reporting § 200.328
CORRECTIVE ACTION PLAN: We will take the necessary steps to get clear deadlines from the awarding agency on the reporting dates for Head Start and update our formal reporting schedule with those dates. The Head Start Fund Accountant will work with the Administrative Assistant/Facilities Manager in g...
CORRECTIVE ACTION PLAN: We will take the necessary steps to get clear deadlines from the awarding agency on the reporting dates for Head Start and update our formal reporting schedule with those dates. The Head Start Fund Accountant will work with the Administrative Assistant/Facilities Manager in gathering the necessary information earlier in the year for the yearly property reporting (SF-429). The Head Start Fund Accountant will email copies of these reports to the Director of Head Start to ensure compliance.
View Audit 311215
Finding 404816 (2023-007)
Material Weakness 2023
Mobridge Regional Hospital
SD
Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s final expenditure listing identified as eligible and claimed under ...
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s final expenditure listing identified as eligible and claimed under the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution program (the program) was not reviewed and approved by a separate individual outside of the preparer. Additionally, the Hospital claimed mortgage reimbursements as expenditures under the program. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: A Grant Award Policy and Procedure Manual was established which includes, but not limited to, outlined internal controls around the review, approval, and tracking of grants/awards allowable expenses and reporting. Anticipated Completion Date: June 30, 2024
View Audit 311195 Questioned Costs: $1
Finding 404815 (2023-006)
Material Weakness 2023
Mobridge Regional Hospital
SD
Allowable Costs / Cost Principles Material Weakness Reporting § 200.303
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s lost revenue calculation was not reviewed and approved by a separat...
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s lost revenue calculation was not reviewed and approved by a separate individual outside of the preparer. The Hospital’s lost revenue calculation was based upon actual revenue billed and reported within the Hospital’s electronic medical records (EMR) system which does not consider monthly or quarterly adjustments. The Hospital’s special report submitted to the Department of Health and Human Services for Period 4 TIN#460255944 was not reviewed and approved by a separate individual outside of the individual who inputted and submitted the report. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: A Grant Award Policy and Procedure Manual was established which includes, but not limited to, outlined internal controls around the review, approval, and tracking of grants/awards allowable expenses and reporting. The Hospital did not have Period 2 or Period 3 reporting requirements. The Phase 4 special report was submitted without review and approval over the report and lost revenue calculation due to limited personnel in finance. The Hospital does not have any additional special reports to complete for this federal program. Anticipated Completion Date: June 30, 2024
View Audit 311195
Finding 404814 (2023-005)
Significant Deficiency 2023
Mobridge Regional Hospital
SD
Allowable Costs / Cost Principles Cash Management Eligibility § 200.303
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Hospital’s requests for reimbursement under the Community Facilities Grant Agreement were not reviewed and approved by a sep...
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Hospital’s requests for reimbursement under the Community Facilities Grant Agreement were not reviewed and approved by a separate individual. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: Hospital personnel will compile the initial requests for reimbursement with the help of Management to provide proof of invoices and payments. The final request for reimbursement will then be verified by Management prior to requesting reimbursement to the Communities Facilities Grant Coordinator. Anticipated Completion Date: June 30, 2024
View Audit 311195
Finding 404800 (2023-006)
Significant Deficiency 2023
Baltimore County, Maryland
MD
Allowable Costs / Cost Principles § 200.303 § 200.430
COVID-19 Emergency Rental Assistance – Assistance Listing No. 21.023 Recommendation: The County should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The County should not seek federal reimbursement unless it can substantia...
COVID-19 Emergency Rental Assistance – Assistance Listing No. 21.023 Recommendation: The County should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The County should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DHCD follows Baltimore County’s general payroll policies and procedures. DHCD allocates time and attendance based on a preset budgeted formula and monitors the staff’s time and attendance through biweekly timesheet prepared by the staff members and approved by unit managers and the review of payroll register. Baltimore County migrated to Workday system which has more robust features and capabilities to capture time and attendance. Name(s) of the contact person(s) responsible for corrective action: Amir Assadi Planned completion date for corrective action plan: 7/1/2024
View Audit 311187
Finding 404789 (2023-005)
Significant Deficiency 2023
Baltimore County, Maryland
MD
Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.430
CDBG Entitlement Grant Cluster – Assistance Listing No. 14.218 Recommendation: The County should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The County should not seek federal reimbursement unless it can substantiate tha...
CDBG Entitlement Grant Cluster – Assistance Listing No. 14.218 Recommendation: The County should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The County should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DHCD follows Baltimore County’s general payroll policies and procedures. DHCD allocates time and attendance based on a preset budgeted formula and monitors the staff’s time and attendance through biweekly timesheet prepared by the staff members and approved by unit managers and the review of payroll register. Baltimore County migrated to Workday system which has more robust features and capabilities to capture time and attendance. . Name(s) of the contact person(s) responsible for corrective action: Amir Assadi Planned completion date for corrective action plan: 7/1/2024
View Audit 311187 Questioned Costs: $1
Finding 404783 (2023-002)
Material Weakness 2023
Allegany County Human Resources Development Commission, Inc.
MD
Questioned Costs Allowable Costs / Cost Principles Reporting
An excel workbook will be created to include all reports that need submitted. The workbook will have the program dates, how often it needs submitted and when, as well as the person responsible for completing and submitting the reports. This will be a part of the aforementioned accounting calendar an...
An excel workbook will be created to include all reports that need submitted. The workbook will have the program dates, how often it needs submitted and when, as well as the person responsible for completing and submitting the reports. This will be a part of the aforementioned accounting calendar and will also be outlined in the Finance Policies due in September as an appendix.
View Audit 311182 Questioned Costs: $1
Finding 404782 (2023-003)
Material Weakness 2023
Santa Fe Recovery Center, Inc.
NM
Allowable Costs / Cost Principles § 200.403 § 200.430
2023-003 – Allowable Costs/Cost Principles Corrective action plan: Management implemented a process to evaluate time spent each month. That allocation is used to classify actual salary paid to particular federal awards on a pay period basis. Personnel responsible for corrective action: Timothy Jodw...
2023-003 – Allowable Costs/Cost Principles Corrective action plan: Management implemented a process to evaluate time spent each month. That allocation is used to classify actual salary paid to particular federal awards on a pay period basis. Personnel responsible for corrective action: Timothy Jodway, Interim Chief Financial Officer; Peg Clark, Grant Accountant; Reyann James, Senior Accountant. Estimated corrective action completion date: May 2024
View Audit 311180
Finding 404775 (2023-001)
Significant Deficiency 2023
Area Agency on Aging of Western Michigan, Inc.
MI
Questioned Costs Allowable Costs / Cost Principles
Views of Responsible Officials and Planned Conect Actions: Management of the Agency concurs with the audit finding. The individual preparing the reports this year did not realize that the account was included in the group of accounts used for billings. Additional training will be provided, and manag...
Views of Responsible Officials and Planned Conect Actions: Management of the Agency concurs with the audit finding. The individual preparing the reports this year did not realize that the account was included in the group of accounts used for billings. Additional training will be provided, and management will perform a quality control review over future grant billings to ensure that costs meet the criteria defined by the regulations and included in contracts and grant agreements. AAA WM's CFO, will implement a process to reconcile match amounts, on a monthly basis, to ensure compliance.
View Audit 311179 Questioned Costs: $1
American Soybean Association
MO
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties
Corrective Action Plan: USSEC will review expenses included in the Contribution Report more closely to ensure they are allowable under 2 CFR Part 200, Subpart E. For the report being submitted in June 2024 for program year 2023, all expenses related to meals, travel-related meals, and group meals at...
Corrective Action Plan: USSEC will review expenses included in the Contribution Report more closely to ensure they are allowable under 2 CFR Part 200, Subpart E. For the report being submitted in June 2024 for program year 2023, all expenses related to meals, travel-related meals, and group meals at events will be removed. Food and beverages, including alcoholic beverages will not be included in the 2023 EOY Report.
View Audit 311173
Finding 404765 (2023-001)
Material Weakness 2023
Troy City Board of Education
AL
Questioned Costs Allowable Costs / Cost Principles Special Tests & Provisions § 200.303 § 200.326
Item 2023-001 Special Tests and Provisions – Wage Rate Requirements Recommendation: We recommend the strengthening of controls to ensure the prevailing wage rate clauses are included in the contracts and that certified payrolls are received for each week in which construction work is performed. A...
Item 2023-001 Special Tests and Provisions – Wage Rate Requirements Recommendation: We recommend the strengthening of controls to ensure the prevailing wage rate clauses are included in the contracts and that certified payrolls are received for each week in which construction work is performed. Action Taken: The Board will strengthen the controls in place to provide assurance that proper prevailing wage rate clauses are added to construction contracts and certified payrolls are received from each week in which construction work is performed. Tricia Norman, CSFO, will be responsible for the corrective action plan and anticipates completion of corrective action will be taken before September 30, 2024.
View Audit 311161 Questioned Costs: $1
Finding 404734 (2023-012)
Significant Deficiency 2023
College Unbound
RI
Questioned Costs Allowable Costs / Cost Principles § 200.300 § 200.308 § 200.309 § 200.403
Finding number: 2023-012 Federal agency: U.S. Department of Treasury Programs: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance listing #: 21.027 Award year: 2023 Compliance requirement: Allowable Costs Corrective Action Plan: College Unbound has increased its adminis...
Finding number: 2023-012 Federal agency: U.S. Department of Treasury Programs: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance listing #: 21.027 Award year: 2023 Compliance requirement: Allowable Costs Corrective Action Plan: College Unbound has increased its administrative capacity and has implemented internal controls to properly track, account for and report on grant expenditures. CU hired the Vice President for Student and Institutional Sustainability in 2023 and subsequently a Controller and Bursar were hired in October 2023 to support the growing needs of the college. The Chief Development Officer, Program Staff and the Financial Team including the VP, Bursar, Financial Aid, and Controller have developed routines and procedures to ensure we are using grant funds as intended and have proper documentation. We are in the process of developing procurement protocols to align with federal grant expectations. Timeline for Implementation of Corrective Action Plan: Currently updating procedures to ensure compliance for FY25. Contact Person: Diana Perdomo, Vice President for Institutional and Student Sustainability/CFO
View Audit 311103 Questioned Costs: $1
Finding 404719 (2023-003)
Material Weakness 2023
Wise County Redevelopment and Housing Authority
VA
Allowable Costs / Cost Principles
The Housing Authority will initiate time studies each quarter to more accurately reflect costs charged to the effected programs.
The Housing Authority will initiate time studies each quarter to more accurately reflect costs charged to the effected programs.
View Audit 311099
Finding 404706 (2023-001)
Significant Deficiency 2023
M-1 Rail and Affiliates
MI
Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties
Program: 20.507 Urbanized Area Formula Program Finding: No evidence of the review of FY2021 payroll expenditures were available at the time of the audit Recommendation: Management should ensure that they have a documented control that includes required evidence retention for reviewing and approvin...
Program: 20.507 Urbanized Area Formula Program Finding: No evidence of the review of FY2021 payroll expenditures were available at the time of the audit Recommendation: Management should ensure that they have a documented control that includes required evidence retention for reviewing and approving employee time and payroll expenditures Responsible Party: Kenneth DiLaura, CFO Corrective Action Plan: All hourly employees have an electronic access card they scan on the Time Clock when they arrive and when they leave. They also scan in and out for their lunch period. At the end of each pay period, the employee’s supervisor logs into the Time Clock website and reviews time sheets for all the employees that report to them. They approve each time sheet in the website. Salaried employees do not scan in and out but there is a time sheet in the software for each salaried employee that is approved by their supervisor. The timesheets for the President and General Manager are approved by the CFO. Once all time sheets are approved, the CFO reviews all the timecards in the time clock software and then submits the hours shown to the Costaff Payroll System. The hours are then populated in the Costaff Payroll. The CFO will log into the Costaff Payroll System, review the hours again and submit the timesheet. A CoStaff employee reviews the payroll time sheet that is entered and submits it to be approved. A CoStaff employee generates an email stating that the payroll is ready for approval. The email goes to Paul Vollmerhausen of Quatrro Business Solutions. He reviews the payroll and approves the payroll in the CoStaff Payroll System. Anticipated Completion Date: Implemented June, 2022
View Audit 311090
Finding 404704 (2023-001)
Material Weakness 2023
Iliamna Village Council
AK
Allowable Costs / Cost Principles Special Tests & Provisions § 200.302 § 200.302(B)
MANAGEMENT WILL WORK WITH THEIR CONSULTANT AND DEVELOP WRITTEN POLICIES AND PROCEDURES OVER THEIR FEDERAL AWARDS IN ACCORDANCE WITH THE REQUIREMENTS OF THE UNIFORM GUIDANCE
MANAGEMENT WILL WORK WITH THEIR CONSULTANT AND DEVELOP WRITTEN POLICIES AND PROCEDURES OVER THEIR FEDERAL AWARDS IN ACCORDANCE WITH THE REQUIREMENTS OF THE UNIFORM GUIDANCE
View Audit 311087
Finding 404698 (2023-002)
Significant Deficiency 2023
Ke Ola Mamo
HI
Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting § 200.303
Ref No. 2023-002 SIGNIFICANT DEFICIENCYI It was noted one instance out of forty that the employee timesheet did not agree with the payroll register. The hours on the timesheet were 45, while the hours on the payroll register were 48 hours. This resulted in an overcharge of $159 to the program. I...
Ref No. 2023-002 SIGNIFICANT DEFICIENCYI It was noted one instance out of forty that the employee timesheet did not agree with the payroll register. The hours on the timesheet were 45, while the hours on the payroll register were 48 hours. This resulted in an overcharge of $159 to the program. It was also noted one out of seventy-one timesheets were not approved by the supervisor. Recommendation: Ke Ola Mamo should exercise greater care in reviewing timesheets and data entered into the payroll system to ensure that only allowable costs are charged to the program. Action Taken: Ke Ola Mamo was in the process of implementing an on-line payroll processing system during Fiscal Year 2023. The implementation was completed during Fiscal Year 2023. This process minimizes potential clerical errors as employees input the hours they work directly into the on-line payroll system, with employees’ supervisors and the Human Resources Specialist approving prior to the payroll being processed.
View Audit 311070
Finding 404542 (2023-001)
Significant Deficiency 2023
West Michigan Partnership for Children
MI
Allowable Costs / Cost Principles Significant Deficiency § 200.431
Responsible Person: Tim Bergsma, CFO - West Michigan Partnership for Children (WMPC). Management View: Management agrees with the finding and is in the process of implementing the recommendation. Corrective Action: WMPC will create a Compensation Adjustement Policy. This policy will reference the co...
Responsible Person: Tim Bergsma, CFO - West Michigan Partnership for Children (WMPC). Management View: Management agrees with the finding and is in the process of implementing the recommendation. Corrective Action: WMPC will create a Compensation Adjustement Policy. This policy will reference the compensation policy, connect to the budget approval process, and identify clear directions regarding the approval process for compensation adjustments. Anticipated Completion Date: August 15, 2024
View Audit 311062
Finding 404424 (2023-001)
Significant Deficiency 2023
Primary Care Medical Services of Poinciana, Inc.
FL
Subrecipient Monitoring Special Tests & Provisions Allowable Costs / Cost Principles § 200.303
MANAGEMENT’S CORRECTIVE ACTION PLAN Finding Number: 2023-001 Planned Corrective Action: We concur with the finding. We will continue with retaining documentation of sliding scale determination electronically. The CFO will continue to monitor whether the record retention policy is being followed. In ...
MANAGEMENT’S CORRECTIVE ACTION PLAN Finding Number: 2023-001 Planned Corrective Action: We concur with the finding. We will continue with retaining documentation of sliding scale determination electronically. The CFO will continue to monitor whether the record retention policy is being followed. In regard to the finding, we had usual turnover in the department during the year which resulted in procedures not being followed precisely. We have since hired new employees and have provided additional training to prevent similar documentation errors from occurring. In additional, we have instituted a monitoring process to ensure that all policies and procedures are followed without exception. Anticipated Completion Date: On-going Responsible Contact Person: Cynthia Diaz, Chief Financial Officer
View Audit 311030
Finding 404223 (2023-005)
Material Weakness 2023
Atrium Health, Inc.
NC
Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303
Corrective Action Plan: Atrium Health CMHA management will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT systems specific to the SFA program. Proposed Completion Date: ...
Corrective Action Plan: Atrium Health CMHA management will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT systems specific to the SFA program. Proposed Completion Date: Management will complete the corrective action plan by the end of 2024.
View Audit 310986
Finding 404222 (2023-004)
Material Weakness 2023
Atrium Health, Inc.
NC
Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303
Corrective Action Plan: Atrium Health CMHA management will address the current year finding either through system modifications to allow for electronic saving of the applicable notifications or by implementing a manual process to retain them. Proposed Completion Date: Management will complete...
Corrective Action Plan: Atrium Health CMHA management will address the current year finding either through system modifications to allow for electronic saving of the applicable notifications or by implementing a manual process to retain them. Proposed Completion Date: Management will complete the corrective action plan by October 2024.
View Audit 310986
Finding 404221 (2023-003)
Material Weakness 2023
Atrium Health, Inc.
NC
Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles
Corrective Action Plan: Atrium Health CMHA management will address the gap in SFA transactional review and approval internal controls, arising due to the SFA program size and limited number of subject matter experts, by implementing mitigating controls and policies to ensure accuracy and completene...
Corrective Action Plan: Atrium Health CMHA management will address the gap in SFA transactional review and approval internal controls, arising due to the SFA program size and limited number of subject matter experts, by implementing mitigating controls and policies to ensure accuracy and completeness of transactions. Proposed Completion Date: Management will complete the corrective action plan by October 2024.
View Audit 310986
Finding 404220 (2023-002)
Material Weakness 2023
Atrium Health, Inc.
NC
Student Financial Aid Matching / Level of Effort / Earmarking Special Tests & Provisions
Corrective Action Plan: As part of the audit planning for 2024, Atrium Health CMHA management will ensure that the internal controls within the SFA IT Systems are documented and tested, or compensating controls implemented. Proposed Completion Date: In November of 2024, management would intend ...
Corrective Action Plan: As part of the audit planning for 2024, Atrium Health CMHA management will ensure that the internal controls within the SFA IT Systems are documented and tested, or compensating controls implemented. Proposed Completion Date: In November of 2024, management would intend to incorporate and complete this IT systems controls testing into the planning phase of the December 31, 2024 reporting period audit.
View Audit 310986
Finding 404195 (2023-002)
Significant Deficiency 2023
Whitfield Place Inc.
GA
Allowable Costs / Cost Principles HUD Housing Programs Significant Deficiency
A new HUD lease will be prepared, presented, and signed at the time of the annual recertification for every tenant.
A new HUD lease will be prepared, presented, and signed at the time of the annual recertification for every tenant.
View Audit 310969
Finding 404194 (2023-001)
Significant Deficiency 2023
Dalton Senior Housing, Inc.
GA
Allowable Costs / Cost Principles HUD Housing Programs Significant Deficiency
A new HUD lease will be prepared, presented and signed at the time of the annual recertification for every tenant.
A new HUD lease will be prepared, presented and signed at the time of the annual recertification for every tenant.
View Audit 310967
Finding 404187 (2023-002)
Significant Deficiency 2023
National Federal of Families for Children's Mental Health
MD
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.430
Action Taken: NFFCMH plans to implement changes overall to the Federation’s timekeeping processes to ensure that payroll costs accurately reflect the work performed, and to reconcile and true up any budget estimates on a consistent basis.
Action Taken: NFFCMH plans to implement changes overall to the Federation’s timekeeping processes to ensure that payroll costs accurately reflect the work performed, and to reconcile and true up any budget estimates on a consistent basis.
View Audit 310958
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