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Corrective Action Plans

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Finding 392079 (2021-004)
Material Weakness 2021
Lss Housing Jamestown, Inc.
ND
Allowable Costs / Cost Principles Eligibility Special Tests & Provisions § 200.334
US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable ...
US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable to be recreated. The organization was lacking appropriate internal controls to ensure records were retained for the required period of time. Responsible Individual: Dawn Helmowski, Finance Director Corrective Action Plan: Subsequent to the audit period under review, the affiliated entity of Luther Social Services of North Dakota has been replaced with Beyond Shelter, Inc. Upon this change, the new LSS Jamestown Housing, Inc. Board of Directors, implemented a Document Retention and Destruction Policy that includes retention or required documents for the required time periods that will ensure documents are retained. This policy was put into place on April 19, 2023. Anticipated Completion Date: April 2023
View Audit 302211
Finding 390796 (2021-004)
Material Weakness 2021
Helping Hand House
WA
Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.400
1. All related administrative and program operational costs have been appropriately classified and documented in QuickBooks beginning in 2022. 2. Monthly review of administrative and program operational costs is performed by management and grant awarders.
1. All related administrative and program operational costs have been appropriately classified and documented in QuickBooks beginning in 2022. 2. Monthly review of administrative and program operational costs is performed by management and grant awarders.
View Audit 301528 Questioned Costs: $1
Finding 390795 (2021-003)
Material Weakness 2021
Helping Hand House
WA
Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303
1. Processes related to the program stating roles of each individual involved in the process were documented and implemented in September 2022. 2. Regular risk assessment and monitoring functions are performed by management and grant awarders.
1. Processes related to the program stating roles of each individual involved in the process were documented and implemented in September 2022. 2. Regular risk assessment and monitoring functions are performed by management and grant awarders.
View Audit 301528
Yuba Sutter Gleaners Food Bank, INC
CA
Allowable Costs / Cost Principles
A grant allocation workbook is prepared monthly by External Bookkeeper and reviewed/approved by Executive Director before allocations are entered in accounting software. The method used has been based on the percentage of time each employee works on the individual programs as determined by managemen...
A grant allocation workbook is prepared monthly by External Bookkeeper and reviewed/approved by Executive Director before allocations are entered in accounting software. The method used has been based on the percentage of time each employee works on the individual programs as determined by management. Both hourly and salaried employees use the percentage method. This method is determined based on the programs being performed for the month. A time study is now being performed on the first week of every quarter for all employees to determine the accuracy of the percentages used in the grant allocation workbook. Responsiblity: External Bookkeeper, PurserBKS, is responsible for preparing monthly Grant Allocation Worksheet for review and approval by Executive Director. Once this is approved then PurserBKS prepares the grant billing documents for Executive Director's review and approval. Responsibility: Marial Ball, Executive Director, reviews and approves all grant billing and submits billing documents to funders. Completion Date: Ongoing
View Audit 300971
Yuba Sutter Gleaners Food Bank, INC
CA
Allowable Costs / Cost Principles
A grant allocation workbook is prepared monthly by External Bookkeeper and reviewed/approved by Executive Director before allocations are entered in accounting software. The method used has been based on the percentage of time each employee works on the individual programs as determined by managemen...
A grant allocation workbook is prepared monthly by External Bookkeeper and reviewed/approved by Executive Director before allocations are entered in accounting software. The method used has been based on the percentage of time each employee works on the individual programs as determined by management. Both hourly and salaried employees use the percentage method. This method is determined based on the programs being performed for the month. A time study is now being performed on the first week of every quarter for all employees to determine the accuracy of the percentages used in the grant allocation workbook. Responsiblity: External Bookkeeper, PurserBKS, is responsible for preparing monthly Grant Allocation Worksheet for review and approval by Executive Director. Once this is approved then PurserBKS prepares the grant billing documents for Executive Director's review and approval. Responsibility: Marial Ball, Executive Director, reviews and approves all grant billing and submits billing documents to funders. Completion Date: Ongoing
View Audit 300971
Finding 387479 (2021-006)
Material Weakness 2021
Atoka County Healthcare Authority
OK
Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303
Tracking of Eligible Expenditures and Lost Revenues Finding 2021‐006 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: The Authority did not hav...
Tracking of Eligible Expenditures and Lost Revenues Finding 2021‐006 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: The Authority did not have internal controls established over the federal award to ensure the federal award has been managed in compliance with federal states, regulations and conditions of the federal award. Corrective Action Plan: The Authority’s management company is reviewing compliance with all laws and regulations and ensuring conditions are met. Responsible Individual: Priacilla Leatherman, VP of Finance Anticipated Completion Date: August 2022
View Audit 299648
Finding 387369 (2021-007)
Significant Deficiency 2021
Pembroke Hill School
NH
Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.430
Audit Finding Reference: 2021-007 Lack of Documentation to Support Distribution of Wages Management’s View and Planned Corrective Action: After review we have also determined that this documentation was lacking. Since 2021 many changes have occurred. A Time and Effort policy and procedure has been e...
Audit Finding Reference: 2021-007 Lack of Documentation to Support Distribution of Wages Management’s View and Planned Corrective Action: After review we have also determined that this documentation was lacking. Since 2021 many changes have occurred. A Time and Effort policy and procedure has been established, documented and implemented. Federally funded stipends are no longer processed until the Time and Effort Log of hours have been received. Once we have received the form(s), which we now attach to the position in our accounting system we then process in payroll. This procedure is also located in our Federal Funds Handbook. A communication will be sent to Grant Manager’s reminding them of the Time & Effort policy and procedures. Name of Contact Person and Completion Date: Name 1 Amber Wheeler Name 2 Danielle Rossetti Anticipated Completion Date : Procedure has changed a reminder will be communicated by March 30th.
View Audit 299544 Questioned Costs: $1
Finding 386627 (2021-001)
Material Weakness 2021
City of Huntington Park
CA
Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles
Management Response and Corrective Action Plan: City’s Response: The City concurs with the finding. Staff responsible for this control during FY 2021 are no longer employed by the City. Corrective Action Plan: CDBG staff worked with program auditors to resolve the issues. Finance Staff and related C...
Management Response and Corrective Action Plan: City’s Response: The City concurs with the finding. Staff responsible for this control during FY 2021 are no longer employed by the City. Corrective Action Plan: CDBG staff worked with program auditors to resolve the issues. Finance Staff and related CDBG staff have been trained to ensure there is not duplication of expenditures in multiple programs. In addition, the City has hired third-party consultants to provide guidance and oversight. Planned Implementation Date: started in Q4 of FY 2023 Responsible Person: Finance Staff and CDBG Staff
View Audit 298952 Questioned Costs: $1
Finding 383644 (2021-004)
Material Weakness 2021
Daviess Community Hospital
IN
Allowable Costs / Cost Principles Reporting
Management continues to evaluate the current controls related to reporting to ensure amounts are appropriately stated. Under a revised calculation, utilizing detailed listings of expenses and updated lost revenue calculations, we have adequate expenses and lost revenues to support funding reported ...
Management continues to evaluate the current controls related to reporting to ensure amounts are appropriately stated. Under a revised calculation, utilizing detailed listings of expenses and updated lost revenue calculations, we have adequate expenses and lost revenues to support funding reported for Periods 1 and 2.
View Audit 296677
Finding 383643 (2021-003)
Material Weakness 2021
Daviess Community Hospital
IN
Allowable Costs / Cost Principles Reporting
Management continues to evaluate the current controls related to reporting to ensure amounts are appropriately stated. Though the decrease was significant, we have adequate expenses and lost revenues to support funding reported for Periods 1 and 2.
Management continues to evaluate the current controls related to reporting to ensure amounts are appropriately stated. Though the decrease was significant, we have adequate expenses and lost revenues to support funding reported for Periods 1 and 2.
View Audit 296677
Finding 382376 (2021-009)
Material Weakness 2021
Children's Home of Kingston
NY
Allowable Costs / Cost Principles
2021-009 – Allocations of Salaries of Other Costs; In February 2024, J.E. Ryan & Associates determined the allocation methodology most appropriate for our Agency is to use square footage. Where appropriate and possible, employees will be directly charged to their funding source (project code). Quart...
2021-009 – Allocations of Salaries of Other Costs; In February 2024, J.E. Ryan & Associates determined the allocation methodology most appropriate for our Agency is to use square footage. Where appropriate and possible, employees will be directly charged to their funding source (project code). Quarterly time studies will be implemented as of April 2024 for employees who work across multiple programs and provide direct care. For employees working in Maintenance, Food Services, Human Resources, Finance, and IT, square footage allocation will be utilized. During the upcoming fiscal year, the Controller will review, on a monthly or quarterly basis, the incurred expenses compared to the UAC approved budget.
View Audit 296079
Finding 380907 (2021-008)
Material Weakness 2021
Love County Health Center D/b/a Mercy Health Love County
OK
Allowable Costs / Cost Principles Material Weakness Reporting § 200.303
Finding 2021-008 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy to ensure reported amounts agreed with under...
Finding 2021-008 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy to ensure reported amounts agreed with underlying supporting documentation. In addition the underlying supporting documentation contained errors. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process to a ensure the report agrees with the under lying supporting documentation. Anticipated Completion Date: Ongoing
View Audit 295601
Finding 380906 (2021-007)
Material Weakness 2021
Love County Health Center D/b/a Mercy Health Love County
OK
Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303
Finding 2021-007 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were bei...
Finding 2021-007 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were being reduced by Medicare's reimbursement or claimed on other grants. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process to ensure amounts claimed for this program are reduced by amounts reimbursed or obligated by another source and include a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission Anticipated Completion Date: Ongoing
View Audit 295601
Finding 380905 (2021-006)
Material Weakness 2021
Love County Health Center D/b/a Mercy Health Love County
OK
Allowable Costs / Cost Principles Reporting Procurement, Suspension & Debarment § 200.303
Finding 2021-006 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA# 93.498 Finding Summary: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were...
Finding 2021-006 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA# 93.498 Finding Summary: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were being in the proper period. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. Anticipated Completion Date: Ongoing
View Audit 295601
Finding 380904 (2021-005)
Material Weakness 2021
Love County Health Center D/b/a Mercy Health Love County
OK
Allowable Costs / Cost Principles Material Weakness Reporting § 200.303
Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues ...
Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues was reviewed and approved. Accordingly, the errors in the lost revenue calculation spreadsheet were not identified by management. In addition, the Hospital did not have an internal control process in place to ensure a review and approval of the Period 1 Report was performed by someone other than the preparer of the report. Responsible Individuals: Scott Callender Corrective Action Plan : The Hospital will implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. Anticipated Completion Date: Ongoing
View Audit 295601
Finding 377355 (2022-003)
Material Weakness 2021
Red Wind Consulting INC
CO
Allowable Costs / Cost Principles Cash Management Material Weakness § 200.43
Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of allowable costs. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document ...
Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of allowable costs. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document in writing, the process and review it with department leaders. Additionally, staff members working in areas concerning this process will be trained to ensure process adherence.
View Audit 295151
Finding 375834 (2021-004)
Significant Deficiency 2021
California Asian Pacific Chamber of Commerce
CA
Allowable Costs / Cost Principles Significant Deficiency § 200.400
Description of Finding: The allocation of payroll costs to programs are done manually instead of done based on entity-wide timesheets Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: The ERP system...
Description of Finding: The allocation of payroll costs to programs are done manually instead of done based on entity-wide timesheets Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: The ERP system will include electronic timesheets for daily charging to specific grants, as well as more visibility into the proper separation of direct, indirect, and unallowable costs per the CFR. An indirect cost pool allocation structure will be designed and implemented to properly allocate the allowable indirect costs to each work effort. Detailed paper timesheets will be provided in the interim for all employees to ensure compliance with the requirements and provide proper support for all grant costs. Monthly reviews by the Project Directors/Managers plus Accounting will be performed to identify any potential cost charging issues and corrective action(s) required. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Susan Wright, Controller, 256-689-7055, swright@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: March 2024 for detailed paper timesheets, December 2024 for ERP system
View Audit 294918
Finding 375833 (2021-003)
Material Weakness 2021
California Asian Pacific Chamber of Commerce
CA
Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.400
Description of Finding: Expenditure detail does not support the amounts billed Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian acknowledges the serious nature of this finding and the pote...
Description of Finding: Expenditure detail does not support the amounts billed Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian acknowledges the serious nature of this finding and the potential for damage to relationships with the grantors and Federal entities. The Interim Controller and Director of Finance are working to secure an ERP system which will allow for better cost collection, reporting and reviews of the grant-related expenses for accuracy, reliability, and reconciliation. Subcontractor invoices will be required to provide specific information related to the grant, scope of work and any other pertinent details for proper charging in the accounting system. Detailed paper timesheets will be provided in the interim for all employees to ensure compliance with the requirements and provide proper support for all grant costs. Monthly reviews by the Project Directors/Managers plus Accounting will be performed to identify any potential cost charging issues and corrective action(s) required. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: March 2024 for detailed paper timesheets, December 2024 for ERP system
View Audit 294918 Questioned Costs: $1
Finding 375524 (2021-004)
Significant Deficiency 2021
Lincoln Road Benevolent Corporation D/b/a Olenes Pop Vidrine Gardens
LA
HUD Housing Programs Allowable Costs / Cost Principles
Recommendation: We recommend that the management agent reimburse the entity for the overpayment of payroll expenses and implement additional controls to ensure that these fees are properly calculated in the future. Views of Responsible Officials and Planned Corrective Action: The management agent...
Recommendation: We recommend that the management agent reimburse the entity for the overpayment of payroll expenses and implement additional controls to ensure that these fees are properly calculated in the future. Views of Responsible Officials and Planned Corrective Action: The management agent reimbursed the entity the $1,620. They have also contracted with an outside payroll organization to administer payroll.
View Audit 294568
Finding 375498 (2021-017)
Material Weakness 2021
Okmulgee County
OK
Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.403
Management will work together to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.
Management will work together to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.
View Audit 294536 Questioned Costs: $1
Finding 375497 (2021-016)
Material Weakness 2021
Okmulgee County
OK
Internal Control / Segregation of Duties Allowable Costs / Cost Principles Period of Performance § 200.303
Management will work together to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.
Management will work together to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.
View Audit 294536
Finding 375496 (2021-015)
Material Weakness 2021
Okmulgee County
OK
Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303
Management will work together to design and implement procedures to address county wide controls over federal programs and to ensure compliance with grant agreements.
Management will work together to design and implement procedures to address county wide controls over federal programs and to ensure compliance with grant agreements.
View Audit 294536
Finding 375420 (2021-004)
Material Weakness 2021
Municipality of Morovis
PR
Subrecipient Monitoring Reporting Allowable Costs / Cost Principles § 200.302 § 200.403
We concur with the finding. The pandemic caused by the outbreak of COVID-19 disrupted and delayed many accounting and reporting processes during the fiscal years 2020 and 2021 since the Municipality had to shut down operations for various months. Consequently, several projects and tasks calendarized...
We concur with the finding. The pandemic caused by the outbreak of COVID-19 disrupted and delayed many accounting and reporting processes during the fiscal years 2020 and 2021 since the Municipality had to shut down operations for various months. Consequently, several projects and tasks calendarized were postponed or delayed, including certain reports and controls required by the Federal Regulations. As of the date of this Corrective Action Plan, the transaction detail of the Disaster Grant costs incurred on fiscal year ending on June 30, 2021 was produced, under alternate methods, from the Finance Department’s accounting system and submitted to the external auditor. Expected Implementation Date: The transaction details applicable to financial statements of fiscal periods ended June 30, 2021 were completed. Transactions detail analysis during the following fiscal years were already completed. Responsible Person: Finance Department Director and Federal Program Director.
View Audit 294483
Finding 375419 (2021-003)
Material Weakness 2021
Municipality of Morovis
PR
Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.302 § 200.403
We concur with the finding. The pandemic caused by the outbreak of COVID-19 disrupted and delayed many accounting and reporting processes during the fiscal years 2020 and 2021 since the Municipality had to shut down operations for various months. Consequently, several projects and tasks calendarized...
We concur with the finding. The pandemic caused by the outbreak of COVID-19 disrupted and delayed many accounting and reporting processes during the fiscal years 2020 and 2021 since the Municipality had to shut down operations for various months. Consequently, several projects and tasks calendarized were postponed or delayed, including certain reports and controls required by the Federal Regulations. As of the date of this Corrective Action Plan, the transaction detail of CDL costs incurred on fiscal year ending on June 30, 2021 was produced, under alternate methods, from the Finance Department’s accounting system and submitted to the external auditor. Expected Implementation Date: The transaction details applicable to financial statements of fiscal periods ended June 30, 2021 were completed. Transactions detail analysis during the following fiscal years were already completed.Responsible Person: Finance Department Director and Federal Program Director.
View Audit 294483
Cleveland County
OK
Questioned Costs Allowable Costs / Cost Principles Eligibility
21.019 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Requirements - Coronavirus Relief Fund The Cleveland County Board of County Commissioners (BOCC) will implement policies and procedures to ensure compliance with applicable grant requirements. Specifically,...
21.019 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Requirements - Coronavirus Relief Fund The Cleveland County Board of County Commissioners (BOCC) will implement policies and procedures to ensure compliance with applicable grant requirements. Specifically, the BOCC will ensure grant funds are expended on allowed costs as set forth by the grant. Anticipated Completion Date: On Going April 2021 Responsible Contact Person: Rod Cleveland,Chairman BOCC
View Audit 294443 Questioned Costs: $1
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