Corrective Action Plans

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Management has reviewed the loan requirements and will ensure that excess cash will not be pulled from the Project except as allowed under the Section 232 guidelines and at annual or semi‐annual intervals. Additional training was provided to the cash director as of November 2023 and will ensure that...
Management has reviewed the loan requirements and will ensure that excess cash will not be pulled from the Project except as allowed under the Section 232 guidelines and at annual or semi‐annual intervals. Additional training was provided to the cash director as of November 2023 and will ensure that excess cash will not be pulled from the Project.
Recommendation: We recommend that the Organization implement policies and procedures to ensure subrecipients are paid within 30 days of when the billing is received. If the request is believed to be improper, support for the delay in payment should be maintained. Explanation of disagreement with au...
Recommendation: We recommend that the Organization implement policies and procedures to ensure subrecipients are paid within 30 days of when the billing is received. If the request is believed to be improper, support for the delay in payment should be maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will review and update our policies and procedures for managing accounts payable. Furthermore, we will provide additional orientation and training sessions focused on disbursements for subrecipients involved in federal grant programs. We will improve the enforcement of policies and procedures by setting up a system to track the receipt and payment of bills. Additionally, we will implement a weekly review by the compliance team to ensure that payments are made on time and that accurate documentation is retained to support any delays in payment requests that are found to be inappropriate. Name(s) of the contact person(s) responsible for corrective action: Jan Warren/Amber Henderson (Compliance), Haydee Hill (CFO) Planned completion date for corrective action plan: 12/30/2024
2023-003: Internal Controls over Cash Management Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Management’s Corrective Actions: Management is working to establish...
2023-003: Internal Controls over Cash Management Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Management’s Corrective Actions: Management is working to establish the policies and procedures for reviewing and approving reimbursement claims to ensure that the claims are properly prepared and submitted timely.
Finding 500282 (2023-005)
Significant Deficiency 2023
Type of Finding: Significant Deficiency in Compliance and Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification N...
Type of Finding: Significant Deficiency in Compliance and Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year: H79TI083313 - 2020 Award Period: September 28, 2020, through September 27, 2025 Criteria or specific requirement: 2 CFR 200.302(a) on Financial management states that "... the other non-Federal entity's financial management systems, including records documenting compliance with Federal statutes, regulations, and the terms and conditions of the Federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions; and the tracing of funds to a level of expenditures adequate to establish that such funds have been used according to the Federal statutes, regulations, and the terms and conditions of the Federal award". Condition: During testing, 2 of the 5 samples selected did not include sufficient documentation to agree all amounts requested for reimbursement for the month in question to the expenditures listed in the general ledger detail by program. Questioned costs: Unknown. Context: A sample of 5 monthly reimbursement requests were taken from a population of 13. Of the 5 sampled, two were insufficiently supported to agree the amounts requested for reimbursement for the month in question to the expenditures listed in the general ledger detail by program. Cause: The Organization was using a cumulative profit and loss to file monthly reimbursement requests (beginning of the year through the reimbursement month). In addition, profit and loss reports were not consistently saved at the time the reports were prepared for reimbursement for January and February 2023. Effect: The Organization is currently in noncompliance with federal regulations with regard to adequate documentation. Without adequate documentation in place to ensure costs are evidenced and reconcile to the expenditures documented in the underlying accounting information that is used to prepare the SEFA, the Organization could incorrectly charge expenditures to the federal program, or not request appropriate reimbursement that the Organization is entitled to under the terms of the grant. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2022-005. Recommendation: Starting in March 2023, the Organization has already implemented a new process for the preparation of monthly reimbursement requests, including documentation retention. Point-in-time reports (i.e., profit and losses) are saved at the time of report preparation. This has enhanced clarity of costs attributable to each monthly period and reduces the chance that costs will be missed when requesting for reimbursement. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Previous corrective actions were completed in April 2024 upon receipt of our FY 2022 Audit from CLA. As noted above, we believe these corrective actions would have captured most, if not all, of the findings if they were in place for the entire FY23 period. That said we continue to review and strengthen our internal controls and training for admin staff for preparing reimbursement requests. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/1/2024
Finding 500280 (2023-003)
Significant Deficiency 2023
Type of Finding: Significant Deficiency in Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year:...
Type of Finding: Significant Deficiency in Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year: H79TI083313 - 2020 Award Period: September 28, 2020, through September 27, 2025 Criteria or specific requirement: The Organization, as part of their stated controls, require that expenditures must be approved by the ED, CFO, or program directors / managers. In addition, § 200.303(a) requires the Organization to establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition: During our testing, it was noted that 12 of 60 samples did not include sufficient records to substantiate approval of the disbursement. Questioned costs: None. Context: A sample of 60 was made from a population of over 250 disbursements charged to the major program. Of the 60 sampled costs, 12 did not have sufficient records to substantiate adequate approval. Cause: Approvals are not maintained for ACH transactions. Effect: Without adequate controls in place to ensure costs are reasonable and intended for the program charged, the Organization could incorrectly charge expenditures to the federal program, report fraudulent expenditures, or not request appropriate reimbursement that the Organization is entitled to under the terms of the grant. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2022-003. Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence should be obtained and retained by the Organization as proof of oversight of expenditure of federal funds. CLA would also recommend the use of an AP voucher, or similar, for each type of disbursement that leaves the Organization (check, ACH, EFT, credit card, etc.) to improve documentary evidence that costs are being reviewed and approved for appropriateness. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Previous corrective actions were completed in April 2024 upon receipt of our FY 2022 Audit from CLA. We believe these corrective actions would have captured most, if not all, of the findings if they were in place for the entire FY23 period. That said we have further reviewed and expanded our internal controls and training for all staff on documenting evidence of approvals, including obtaining and retaining necessary documentation and proof of expenditure oversight for federal funds to ensure there is adequate evidence that costs are being reviewed and approved for appropriateness. As noted above, we have added a procurement approval form and a standardized process for approval signature, quotes, sole source evidence and price analyses. We are also investigating an AP voucher process through our existing accounting software. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/1/2024
Management agrees with the finding and is in process of developing and implementing the appropriate policies and procedures.
Management agrees with the finding and is in process of developing and implementing the appropriate policies and procedures.
Finding No. 2023-002: Obligation Requirement for Capital Fund Program Drawdowns (Significant Deficiency Person Responsible: Reginal Barner Date of Completion: 12/31/2024 Corrective Action Plan: Our fee accountant will access the capital fund obligation and treasury process and implement corrective a...
Finding No. 2023-002: Obligation Requirement for Capital Fund Program Drawdowns (Significant Deficiency Person Responsible: Reginal Barner Date of Completion: 12/31/2024 Corrective Action Plan: Our fee accountant will access the capital fund obligation and treasury process and implement corrective actions, including adding internal controls and training.
View of Responsible Official: We agree with the auditors' comments, and the following action has been taken to improve the situation. We have adjusted the agency’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accountin...
View of Responsible Official: We agree with the auditors' comments, and the following action has been taken to improve the situation. We have adjusted the agency’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accounting personnel will ensure the agency’s General Ledger specifically details the month of rent and utility allowance being provided so eligible costs are clearly delineated. Someone other than the preparer will perform a review of each drawdown request to ensure that costs are not being drawn down prior to the operating start date of each individual grant. This issue was discussed with HUD in March 2024 at which time procedural changes were implemented. Additionally, as noted above, our agency was able to repay and redraw the funds drawn outside of the aforementioned period of performance without further penalty. Corrective Action: Effective March 2024 the preparer is required to include the month of rent and utility allowance being provided in the General Ledger detail. A review of the General Ledger detail supporting each draw request will be performed by someone other than the preparer to ensure that costs are not being drawn down prior to the operating start date of each individual grant.
AUDIT FINDINGS 2023-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, there was a system pr...
AUDIT FINDINGS 2023-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, there was a system pricing issue that resulted in an incorrect amount of expenses related to inventory that were submitted to FEMA for reimbursement. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: FEMA has been notified and the amount has been updated as part of the project closeout. Anticipated Completion Date: September 2024 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2023-001.
View Audit 323033 Questioned Costs: $1
Finding 500183 (2023-003)
Material Weakness 2023
Mhub
IL
Finding Number: 2023-003 Condition: The Organization does not have written procedures to implement the requirements of CFR 200.305. The advance payment of the Federal award was not maintained in an interest-bearing account and no interest was remitted back to the Federal government. Planned Cor...
Finding Number: 2023-003 Condition: The Organization does not have written procedures to implement the requirements of CFR 200.305. The advance payment of the Federal award was not maintained in an interest-bearing account and no interest was remitted back to the Federal government. Planned Corrective Action: Management is in the process of updating written procedures for Federal award compliance. Management will calculate and remit interest for 2023 to the Department of Health and Human Services Payment Management System (PMS). Contact person responsible for corrective action: Manas Mehandru, COO Anticipated Completion Date: October 15, 2024
Finding Reference Number: 2023-2 Recommendation The Company must deposit $13,918 into the residual receipts reserve. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for depositing surplus cash into the residual receipts reserve. Comple...
Finding Reference Number: 2023-2 Recommendation The Company must deposit $13,918 into the residual receipts reserve. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for depositing surplus cash into the residual receipts reserve. Completion date or proposed completion date: December 31, 2024 Action(s) taken or planned on the finding Management will make the required deposit to the residual receipts reserve.
View Audit 323019 Questioned Costs: $1
Finding Reference Number: 2023-2 Recommendation Management should establish internal controls and procedures to ensure that surplus cash is properly monitored and disbursed. Reporting views of responsible officials Auditee concurs with this finding. Auditee agrees with auditor recommendations. ...
Finding Reference Number: 2023-2 Recommendation Management should establish internal controls and procedures to ensure that surplus cash is properly monitored and disbursed. Reporting views of responsible officials Auditee concurs with this finding. Auditee agrees with auditor recommendations. Completion date or proposed completion date: December 31, 2024 Action(s) taken or planned on the finding Management agrees with the recommendation of the auditor and internal controls are being put in place to ensure that surplus cash is deposited into the residual receipts reserve prior to paying down intercompany balances.
View Audit 323017 Questioned Costs: $1
Finding Reference Number: 2023-1 Recommendation The Company must deposit $586,006 into the residual receipts reserve. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for depositing surplus cash into the residual receipts reserve. Com...
Finding Reference Number: 2023-1 Recommendation The Company must deposit $586,006 into the residual receipts reserve. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for depositing surplus cash into the residual receipts reserve. Completion date or proposed completion date: December 31, 2024 Action(s) taken or planned on the finding Management will make the required deposit to the residual receipts reserve.
View Audit 323017 Questioned Costs: $1
US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2022 – 6/30/2023 and 7/1/2023 – 6/30/2024 Cash Management Material Weakness in Internal Control Over Compliance Criteria...
US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2022 – 6/30/2023 and 7/1/2023 – 6/30/2024 Cash Management Material Weakness in Internal Control Over Compliance Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Organization is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. Condition: The Organization was unable to provide adequate documentation to support the number of meals claimed for reimbursement. Corrective Action Plan: Management is aware of the deficiency in internal control over compliance. Management is in the process of reviewing its existing controls over the tracking and submitting of its meal counts included in its attendance records for reimbursement. Individual Responsible for Corrective Action: Veronica Jones, Fiscal Services Director Anticipated Completion Date: December 31, 2024
US Department of Health and Human Services Federal Financial Assistance Listing #93.600 Head Start Cluster Applicable Federal Award Number and Year – 07CH011832-04-00 11/1/2023 – 10/31/2024, 07CH011832-03-00 11/1/2022 – 10/31/2023, 07CH011832-02-00 11/1/2021 – 10/31/2022 Activities Allowed or Unallo...
US Department of Health and Human Services Federal Financial Assistance Listing #93.600 Head Start Cluster Applicable Federal Award Number and Year – 07CH011832-04-00 11/1/2023 – 10/31/2024, 07CH011832-03-00 11/1/2022 – 10/31/2023, 07CH011832-02-00 11/1/2021 – 10/31/2022 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control Over Compliance Material Noncompliance Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: The Organization requested drawdowns of grant funds in excess of amounts awarded for the grant years ended 10/31/2023 and 10/31/2022 that were denied by the passthrough agency, Omaha Public Schools, resulting in an overstatement in grant revenue and receivables, and federal awards expended included in the schedule of expenditures of federal awards. Corrective Action Plan: Management is in the process of reviewing its accounting policies and procedures over grant monitoring to ensure amounts are tracked appropriately. Management has hired a new fiscal services director to oversee this process. Individual Responsible For Corrective Action: Veronica Jones, Fiscal Services Director Anticipated Completion Date: December 31, 2024
View Audit 322999 Questioned Costs: $1
The County Human Services department noted that the service providers were paid at their negotiated rates agreed upon by contract terms, however no reconciliation was completed for the remainder eligible cost adjustments to the service providers for the fiscal year ended June 30, 2023. The County Hu...
The County Human Services department noted that the service providers were paid at their negotiated rates agreed upon by contract terms, however no reconciliation was completed for the remainder eligible cost adjustments to the service providers for the fiscal year ended June 30, 2023. The County Human Services department will complete the reconciliation of the service providers costs reports for the fiscal year ended June 30, 2024 before March 2025.
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.
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
For Federal grants we will make it standard practice to request 1-2 months extension so that we get reimbursed for the work required to close out the grant after the grant end date. We have had federal employee's contact us as much as 4 months past the close date with erronious time consumming issu...
For Federal grants we will make it standard practice to request 1-2 months extension so that we get reimbursed for the work required to close out the grant after the grant end date. We have had federal employee's contact us as much as 4 months past the close date with erronious time consumming issues. Lynn Ketch, Executive Director, is the person responsible for the plan.
View Audit 322891 Questioned Costs: $1
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
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
The Organization secured Attain Partners, a professional services firm, to assist with grants management and reporting. Attain Partners reviewed the SEFA report, as well as the grantbudget, general ledger information, documentation, and drawdowns for the grant from the U.S. Department of Health and ...
The Organization secured Attain Partners, a professional services firm, to assist with grants management and reporting. Attain Partners reviewed the SEFA report, as well as the grantbudget, general ledger information, documentation, and drawdowns for the grant from the U.S. Department of Health and Human Services (CFDA 93.958) internally known as theSAMHSA R&R grant. They discovered that the budgets were submitted incorrectly, without requesting any indirect costs (IDC), which led to the grant being awarded without IDC. The FY23 draws totaled $2,094,362.95, while the FY23 expenditures recorded in the general ledger amounted to $1,754,696.48, excluding IDC, resulting in $339,667 in questioned costs. As the grant closed on 9/30/2023, the organization is unable to request reimbursement for the IDC. The Grants Management team will undertake a comprehensive revision of the existing policies and procedures and will develop new ones as needed. These policies and procedures will encompass the following processes to ensure proper levels of review and compliance with authorized drawdowns: • The Grants Management team will ensure grant budgets are submitted with the correct IDC and the award includes the IDC in the total amount. • The Grants Management team will ensure the IDC is calculated correctly and included in the drawdown amount. • The Grants Administrator and the Sr. Grants and Budget Analyst will reconcile the grant expenditures monthly to ensure the expenditures allocated to grants are documented, allowable and the drawdowns are equal to actual expenditures.
View Audit 322863 Questioned Costs: $1
2022-03: Approval for expenditures Name of contact person: J.R. Davis, Chief Executive Officer Corrective Action: A member of management or the Board of Directors will review and authorize all disbursements. This authorization will be evidenced by the initialing of each disbursement reviewed. ...
2022-03: Approval for expenditures Name of contact person: J.R. Davis, Chief Executive Officer Corrective Action: A member of management or the Board of Directors will review and authorize all disbursements. This authorization will be evidenced by the initialing of each disbursement reviewed. Proposed completion date: The Board will implement the above procedure immediately.
2022-01: Segregation of Duties Name of contact person: J.R. Davis, Chief Executive Officer Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to co...
2022-01: Segregation of Duties Name of contact person: J.R. Davis, Chief Executive Officer Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to compensate for lack of segregation. However, the risk of not segregated certain duties are not worth the additional costs. Nonfinancial employees will be trained and provide some assistance. Proposed completion date: The Board will implement the above procedure immediately.
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
Management’s Corrective Action Plan Audit Firm: Andrew Pieri CPA, PC. Audit Period: January 1, 2023 through December 31, 2023 The finding from the December 31, 2023 schedule of findings and question costs is discussed below. The finding is numbered consistent with the number assigned in the schedu...
Management’s Corrective Action Plan Audit Firm: Andrew Pieri CPA, PC. Audit Period: January 1, 2023 through December 31, 2023 The finding from the December 31, 2023 schedule of findings and question costs is discussed below. The finding is numbered consistent with the number assigned in the schedule. FINDING: 2023-001 Earmarking Federal Agency / Federal Program: U.S. Department of Education / Education Stabilization Fund Subject: Earmarking (G) ALN Number: 84.425 Metropolitan Learning Institute, Inc. agrees with the finding. Planned Corrective Action Plan: The School has contacted DOE to request the HEERF III students funds in order to distribute the funds to its student. If the School is unable to receive those funds, we will contact DOE to resolve the potential liability. Responsible for corrective action: James Bruce . Anticipated completion date: December 31, 2024
View Audit 322838 Questioned Costs: $1
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