Corrective Action Plans

Finding 525091 (2023-004)

Material Weakness 2023

Confluence Health

WA

Material Weakness Reporting Internal Control / Segregation of Duties

Finding 2023-004 Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 5 TIN# 910171250 Finding Summary: For certain quarters, the am...

Finding 2023-004 Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 5 TIN# 910171250 Finding Summary: For certain quarters, the amounts reported for net patient revenue were based on gross charges. Additionally, amounts did not agree to the supporting documentation provided. Corrective Action Plan: Confluence Health during the next pandemic will confirm reporting requirements before submitting reporting data. Confluence developed a Grant Committee to oversee the reporting guidelines before approving grants. This will make the information for reporting requirements clearer to the organization and Financial Reporting Department. The 2023 data was reported at net patient revenue as required by the grant. Responsible Individual: Eric Caldwell, VP of Finance is responsible for this corrective action plan that was put into place after the audit.

View Audit 344374

Finding 525090 (2023-003)

Material Weakness 2023

Confluence Health

WA

Material Weakness Reporting Internal Control / Segregation of Duties

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 5 TIN# 910171250 Finding Summary: Confluence Health selected option ii to calculat...

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 5 TIN# 910171250 Finding Summary: Confluence Health selected option ii to calculate lost revenue which consists of a comparison of actual results during the period of availability to a budget approved before March 27, 2020, for the entire period of availability. The budget used in the calculation of lost revenue for quarters in 2021, 2022 and 2023 was not approved prior to March 27, 2020. Corrective Action Plan: Confluence Health during the next pandemic will issue a budget for the entire period required by the grant. Confluence developed a Grant Committee to oversee the reporting guidelines before approving grants. This will make the information for reporting requirements clearer to the organization and Financial Reporting Department. Responsible Individual: Eric Caldwell, VP of Finance is responsible for this corrective action plan that was put into place after the audit.

View Audit 344374

Finding 524948 (2023-001)

Material Weakness 2023

City of Manhattan, Kansas

KS

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.303

Management’s Response (Unaudited) – The Community Development staff is in the process of preparing all outstanding FFATA reports and is developing a compliance checklist to ensure that these reports are filed timely. Corrective Action Plan (Unaudited) – The Community Development staff will create a...

Management’s Response (Unaudited) – The Community Development staff is in the process of preparing all outstanding FFATA reports and is developing a compliance checklist to ensure that these reports are filed timely. Corrective Action Plan (Unaudited) – The Community Development staff will create a checklist to ensure that these reports are filed timely once the agreements with the subrecipients have been approved.

View Audit 344293

Finding 524733 (2023-001)

Material Weakness 2023

Aiken/barnwell Counties Community Action Agency INC

SC

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

We agree with the finding. Management is in the process of assessing the operational controls to prepare adequate financial reporting. The financial staff will be trained to the various steps in monitoring the financial position and operations of the Agency. Additional staff with be hired and traine...

We agree with the finding. Management is in the process of assessing the operational controls to prepare adequate financial reporting. The financial staff will be trained to the various steps in monitoring the financial position and operations of the Agency. Additional staff with be hired and trained to assist with the performance of accurate and timely reporting. We plan to complete these processes by May 31, 2025.

View Audit 344155

Finding 524711 (2023-002)

Material Weakness 2023

Lake Mills Community School District

IA

Internal Control / Segregation of Duties Reporting

The District will review its control procedures and attempt to maximize internal control with a limited number of office employees.

View Audit 344142

Finding 524581 (2023-001)

Significant Deficiency 2023

City of Clarksville

TN

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Management’s Corrective Action Plan: Due to changes in departmental management and responsibilities submission was not timely. We have now implemented policies and procedures to ensure grant activity is reported in accordance with the grant requirements. This matter was resolved subsequent to June 3...

Management’s Corrective Action Plan: Due to changes in departmental management and responsibilities submission was not timely. We have now implemented policies and procedures to ensure grant activity is reported in accordance with the grant requirements. This matter was resolved subsequent to June 30, 2023.

View Audit 344028

Finding 524486 (2024-002)

Significant Deficiency 2023

Pop Biotechnologies Inc.

NY

Procurement, Suspension & Debarment Internal Control / Segregation of Duties

In 2024, POP Biotechnologies, Inc is implementing procurement processes. The company will develop a procurement process. This process will help the company improve compliance with 2 C.F.R. Subpart F and 2 C.F.R. Subpart D

View Audit 343831

Finding 524485 (2024-001)

Significant Deficiency 2023

Pop Biotechnologies Inc.

NY

Procurement, Suspension & Debarment Internal Control / Segregation of Duties

In 2024, POP Biotechnologies, Inc is implementing new processes and exploring solutions including Bill.com. These solutions will improve oversight and add an approval process to our procurement process and comply § 75.303 Internal controls

View Audit 343831

Finding 524426 (2023-002)

Material Weakness 2023

Wapello Community School District

IA

Internal Control / Segregation of Duties Reporting

The District will continue to review procedures and make adjustments as necessary to obtain the maximum internal control possible under the circumstances utilizing current personnel and elected officials.

View Audit 343708

Finding 524378 (2023-002)

Significant Deficiency 2023

The International Centre for Missing & Exploited Children and Affiliates

VA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Views of Responsible Officials and Planned Corrective Actions: Monthly reconciliations were not being done throughout 2023. The 2022 Audit that identified the need for such a process was not completed until February 2024. ICMEC does not prepare a consolidated financial statement or reconcile interco...

Views of Responsible Officials and Planned Corrective Actions: Monthly reconciliations were not being done throughout 2023. The 2022 Audit that identified the need for such a process was not completed until February 2024. ICMEC does not prepare a consolidated financial statement or reconcile intercompany accounts. Essentially the issue is that balance sheet schedules were not maintained from month to month during the year. However, we did provide the auditors with reconciled schedules at year end. Additionally, ICMEC did not historically keep a consolidated (including the Australian affiliate) financial statement via its accounting system, so all Australia affiliate activity was added manually during the audit. Action plan: we began maintaining regular monthly balance sheet schedules for all accounts in June 2024. Furthermore, the Australian affiliate was deconsolidated as of July 6, 2023 so ICMEC no longer needs to maintain the activity of the Australian affiliate in the consolidated financial statements.

View Audit 343616

Finding 524376 (2023-003)

Significant Deficiency 2023

Seventy-Five North Revitalization Corporation

NE

Procurement, Suspension & Debarment Internal Control / Segregation of Duties

We concur with the finding and agree that we should have written procurement policies to comply with 2 CFR 200 Subpart D. We have developed and implemented comprehensive written policies that align with the provisions of 2 CFR 200 Subpart D and other relevant sections. These policies have been inco...

We concur with the finding and agree that we should have written procurement policies to comply with 2 CFR 200 Subpart D. We have developed and implemented comprehensive written policies that align with the provisions of 2 CFR 200 Subpart D and other relevant sections. These policies have been incorporated into the organization's accounting procedures and policy manual. Additionally, a specific procurement policy has been created and implemented as a component of the broader financial policy document. Procedures were implement in 1st Quarter 2024 and will be applied indefinitely.

View Audit 343606

Finding 524333 (2023-002)

Material Weakness 2023

Lenox Community School District

IA

Internal Control / Segregation of Duties

The District will continue to review the duties of office employees and segregate duties where possible.

View Audit 343524

Finding 524240 (2023-002)

Material Weakness 2023

Next Move Homeless Services

CA

Questioned Costs Special Tests & Provisions HUD Housing Programs

Program: Continuum of Care Federal Financial Assistance Listing No.:14.267 Federal Agency: U.S. Department of Housing and Urban Development Pass-through: Sacramento Steps Forward Award Year: 2023 Compliance Requirement: Special Tests and Provisions – Reasonable Rental Rates Grant Award Number: ...

Program: Continuum of Care Federal Financial Assistance Listing No.:14.267 Federal Agency: U.S. Department of Housing and Urban Development Pass-through: Sacramento Steps Forward Award Year: 2023 Compliance Requirement: Special Tests and Provisions – Reasonable Rental Rates Grant Award Number: CA0955L9T032108, CA0955L9T032209, CA0143L9T032114, CA0143L9T032215, CA1303L9T032107, CA1303L9T032208 Finding Summary: • As a result of our procedures performed, we noted for 8 out of 17 rental participants tested, the organization could not provide documentation to demonstrate the reasonableness of contract rents being paid for individual housing units in relation to rents being charged for comparable units. This should have included an analysis of rents in the immediate area of the participants housing. • For 3 out of 41 rental payments tested, we noted the rent paid exceed the HUD-determined fair market rents for the fiscal year. Repeat Finding from Prior Years: Yes, Finding 2022-002 Management’s Response: We concur. Views of Responsible Officials and Corrective Action: • Develop policies and procedures for staff working on grants to ensure that all contract rents being paid for individual housing units are reasonable in relation to rents being charged for comparable units. Additionally, the policies and procedures will ensure that grant funds being used to pay rent will not exceed HUD-determined fair market rents. • Train grant staff on new policies and procedures. Name of Responsible Person: Bryan Wagner, CFO Projected Implementation Date: December 31, 2024

View Audit 343437 Questioned Costs: $1

Finding 524237 (2023-003)

Significant Deficiency 2023

Young Women's Christian Association of St Joseph Missouri

MO

Internal Control / Segregation of Duties

Significant Deficiency Finding: Segregation of Duties -Internal controls should be in place that provide an adequate segregation of duties that separates initiating, processing, recording and reconciling a transaction. Questioned Costs None Status Sustained Corrective Action Additional positions/ro...

Significant Deficiency Finding: Segregation of Duties -Internal controls should be in place that provide an adequate segregation of duties that separates initiating, processing, recording and reconciling a transaction. Questioned Costs None Status Sustained Corrective Action Additional positions/roles will be created or redesigned and implemented so that the duties required involve more participants and would include the following suggested plan: 1. Cash Receipts a. All mail will be opened by the Executive/Administrative Assistant and cash receipts recorded by the Administrative Specialist. b. All other accounts receivables (AR) will be collected by Administrative Specialist and recorded by Executive/Administrative Assistant. c. The cash receipts journal will be totaled by the Chief Financial Officer (CFO), Administrative Specialist will prepare the corresponding deposit and CFO will deposit cash receipts. d. Executive/Administrative Assistant will reconcile the depository bank receipt with the cash receipts journal to verify that all funds are deposited. e. CFO will review AR ledger. f. CEO will authorize write-offs of delinquent accounts. g. CFO will independently investigate AR discrepancies. h. CEO will maintain or authorize AR adjustments. i. Administrative Specialist will edit the AR master file. j. Executive/Administrative Assistant will process customer service calls and CEO will handle complaints. k. CFO will investigate discrepancies or issues related to revenue and CEO will authorize adjustments as needed. I. CFO will reconcile bank accounts. 2. Accounts Payable a. Vendor payments will be initiated by Executive/Ad m in istrative Assista nt. b. Checks will be prepared by Administrative Specialist. c. CEO will review and authorize/sign checks or approve electronic payments. d. Checks $1000 or greater require 2 signatures. The second signer (an Executive Committee member of the Board of Directors) will also review and authorize/sign checks or approve electronic payments. e. Executive/Administrative Assistant will mail checks. f. Administrative Specialist will edit the vendor master file. g. CFO will investigate discrepancies or issues involving expenditures. h. Executive/Administrative Assistant will open the mail or copy checks received. i. CFO will reconcile bank accounts. 3. Payroll a. Human Resources (HR) Director will prepare payroll checks. b. CEO will sign payroll checks. c. CFO will review and authorize electronic payroll disbursements. d. CFO will resolve employee payroll inquiries. e. HR Director will edit the payroll master file. f. Executive/Administrative Assistant will open the mail or copy checks received. 4. Other a. CFO is required to take 1 full week of vacation a year and will not enter the building for at least 10 days. b. A budget is prepared by CEO/CFO and approved annually by the Operations Committee and the Board of Directors. c. Budget revisions are prepared by CEO/CFO and approved by the Operations Committee and the Board of Directors d. An Income Statement Report is prepared monthly by CFO and reviewed by the CEO, Operations Committee and Board of Directors. e. A Balance Sheet report is prepared quarterly by CFO and reviewed by CEO, Operations Committee and the Board of Directors f. A Budget Variance report is prepared monthly and per department quarterly by CFO, reviewed by CEO, Operations Committee and Board of Directors.

View Audit 343431

Finding 524228 (2023-006)

Significant Deficiency 2023

Young Women's Christian Association of St Joseph Missouri

MO

Internal Control / Segregation of Duties

Significant Deficiency Finding: Segregation of Duties -Internal controls should be in place that provide an adequate segregation of duties that separates initiating, processing, recording and reconciling a transaction. Questioned Costs None Status Sustained Corrective Action Additional positions/ro...

Significant Deficiency Finding: Segregation of Duties -Internal controls should be in place that provide an adequate segregation of duties that separates initiating, processing, recording and reconciling a transaction. Questioned Costs None Status Sustained Corrective Action Additional positions/roles will be created or redesigned and implemented so that the duties required involve more participants and would include the following suggested plan: 1. Cash Receipts a. All mail will be opened by the Executive/Administrative Assistant and cash receipts recorded by the Administrative Specialist. b. All other accounts receivables (AR) will be collected by Administrative Specialist and recorded by Executive/Administrative Assistant. c. The cash receipts journal will be totaled by the Chief Financial Officer (CFO), Administrative Specialist will prepare the corresponding deposit and CFO will deposit cash receipts. d. Executive/Administrative Assistant will reconcile the depository bank receipt with the cash receipts journal to verify that all funds are deposited. e. CFO will review AR ledger. f. CEO will authorize write-offs of delinquent accounts. g. CFO will independently investigate AR discrepancies. h. CEO will maintain or authorize AR adjustments. i. Administrative Specialist will edit the AR master file. j. Executive/Administrative Assistant will process customer service calls and CEO will handle complaints. k. CFO will investigate discrepancies or issues related to revenue and CEO will authorize adjustments as needed. I. CFO will reconcile bank accounts. 2. Accounts Payable a. Vendor payments will be initiated by Executive/Ad m in istrative Assista nt. b. Checks will be prepared by Administrative Specialist. c. CEO will review and authorize/sign checks or approve electronic payments. d. Checks $1000 or greater require 2 signatures. The second signer (an Executive Committee member of the Board of Directors) will also review and authorize/sign checks or approve electronic payments. e. Executive/Administrative Assistant will mail checks. f. Administrative Specialist will edit the vendor master file. g. CFO will investigate discrepancies or issues involving expenditures. h. Executive/Administrative Assistant will open the mail or copy checks received. i. CFO will reconcile bank accounts. 3. Payroll a. Human Resources (HR) Director will prepare payroll checks. b. CEO will sign payroll checks. c. CFO will review and authorize electronic payroll disbursements. d. CFO will resolve employee payroll inquiries. e. HR Director will edit the payroll master file. f. Executive/Administrative Assistant will open the mail or copy checks received. 4. Other a. CFO is required to take 1 full week of vacation a year and will not enter the building for at least 10 days. b. A budget is prepared by CEO/CFO and approved annually by the Operations Committee and the Board of Directors. c. Budget revisions are prepared by CEO/CFO and approved by the Operations Committee and the Board of Directors d. An Income Statement Report is prepared monthly by CFO and reviewed by the CEO, Operations Committee and Board of Directors. e. A Balance Sheet report is prepared quarterly by CFO and reviewed by CEO, Operations Committee and the Board of Directors f. A Budget Variance report is prepared monthly and per department quarterly by CFO, reviewed by CEO, Operations Committee and Board of Directors.

View Audit 343431

Finding 524077 (2023-004)

Material Weakness 2023

Cam Community School District

IA

Internal Control / Segregation of Duties

The District will redesignate recording of disbursements and posting of payroll to the School Business Official. Otherwise, there are 2 people involved in the cash process, 2 people involved in the receipts process and, 2 people involved in computer systems.

View Audit 343238

Finding 523996 (2023-006)

Material Weakness 2023

Magnolia School District

CA

Internal Control / Segregation of Duties Special Tests & Provisions Material Weakness

We agree with the recommendation and moving forward the Director of MOTF will ensure that all contractors and subcontractors submit required certified payrolls weekly and ensure that all construction contracts funded by the program include the prevailing wage rate requirement clause. These records w...

We agree with the recommendation and moving forward the Director of MOTF will ensure that all contractors and subcontractors submit required certified payrolls weekly and ensure that all construction contracts funded by the program include the prevailing wage rate requirement clause. These records will be maintained a minimum of three years.

View Audit 343203

Finding 523988 (2023-005)

Material Weakness 2023

Magnolia School District

CA

Material Weakness Reporting Internal Control / Segregation of Duties

We agree with the recommendation and moving forward all federal expenditures and full-time equivalent positions are reported accurately on the ESSER annual and quarterly reports, and that supporting documentation is maintained to support the amounts reported.

View Audit 343203

Finding 523670 (2023-002)

Significant Deficiency 2023

Fair & Balanced Pf Pa, Inc.

PA

Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties

We understand the importance of proper monitoring of providers and are taking steps to improve our system.

View Audit 343096

Finding 523669 (2023-001)

Significant Deficiency 2023

Fair & Balanced Pf Pa, Inc.

PA

Questioned Costs Cash Management Significant Deficiency

We understand the importance of proper review of reimbursement requests and are working to improve our system.

View Audit 343096 Questioned Costs: $1

Finding 523668 (2023-004)

Material Weakness 2023

Young Womens Christian Association of Greater Lafayette

IN

Reporting Internal Control / Segregation of Duties

2023-004: REPORTING--RPE Recommendation: Internal controls and procedures should be established and documentation maintained to support all program metrics surrounding each grant reporting. Corrective Actions: YWCA acknowledges discrepancies in data metrics reported. • Utilize & document consiste...

2023-004: REPORTING--RPE Recommendation: Internal controls and procedures should be established and documentation maintained to support all program metrics surrounding each grant reporting. Corrective Actions: YWCA acknowledges discrepancies in data metrics reported. • Utilize & document consistent process and tools (Client Track database) for effective tracking and reporting for all program reports. • Establish a routine for random and planned audits to verify reporting accuracy. • Provide training on proper reporting procedures, best audit practices, and data entry accuracy. Tracking and Documentation: • All program reports will be organized by grant name, month, and year with program report and source document with two signatures to confirm the process (manager and Department Director). • All staff will sign off on training topics, with documentation saved in their personnel folder. • Random internal audits will be conducted bi-weekly throughout the year to ensure compliance. Overall Implementation Plan: • Timeline: Begin implementation immediately and complete all actions by the end of Q1 2025. • Responsibility: Department Director to oversee implementation and report progress to management monthly. Controller will be responsible for implementing staff education and audit best practices. HR will ensure documentation is saved in personnel folder. Department Director program report organization and source documentation • Monitoring: Follow-up audits every quarter to ensure ongoing compliance and improvement.

View Audit 343088

Finding 523667 (2023-003)

Material Weakness 2023

Young Womens Christian Association of Greater Lafayette

IN

Reporting Internal Control / Segregation of Duties

Issue: Reports tested had deviations between the source documents and submitted report metrics. Recommendation: Internal controls and procedures should be established and documentation maintained to support all program metrics surrounding each grant reporting. Corrective Actions: YWCA acknowledges...

Issue: Reports tested had deviations between the source documents and submitted report metrics. Recommendation: Internal controls and procedures should be established and documentation maintained to support all program metrics surrounding each grant reporting. Corrective Actions: YWCA acknowledges discrepancies in data metrics reported. • Utilize & document consistent process and tools (Client Track database) for effective tracking and reporting for all program reports. • Establish a routine for random and planned audits to verify reporting accuracy. • Provide training on proper reporting procedures, best audit practices, and data entry accuracy. Tracking and Documentation: • All program reports will be organized by grant name, month, and year with program report and source document with two signatures to confirm the process (manager and Department Director). • All staff will sign off on training topics, with documentation saved in their personnel folder. • Random internal audits will be conducted bi-weekly throughout the year to ensure compliance.

View Audit 343088

Finding 523666 (2023-002)

Material Weakness 2023

Young Womens Christian Association of Greater Lafayette

IN

Internal Control / Segregation of Duties

2023-002: DOCUMENTATION OF APPROVALS--VOCA Issue: One employee from the ten tested did not contain an approved pay rate in the employee’s file. Recommendation: Internal controls and procedures should be established and documentation maintained to support all employee pay rate approvals. Correctiv...

2023-002: DOCUMENTATION OF APPROVALS--VOCA Issue: One employee from the ten tested did not contain an approved pay rate in the employee’s file. Recommendation: Internal controls and procedures should be established and documentation maintained to support all employee pay rate approvals. Corrective Actions: YWCA acknowledges discrepancies in data metrics reported. • Develop a written procedure to support all employee pay rate approvals to be signed by employee, supervisor (if applicable), Director, and CEO. • Conduct training sessions to ensure approval procedure is followed and proper documentation obtained. • Implement a digital tracking system for file management of approval documents.

View Audit 343088

Finding 523665 (2023-001)

Material Weakness 2023

Young Womens Christian Association of Greater Lafayette

IN

HUD Housing Programs Internal Control / Segregation of Duties

2023-001: EMPLOYMENT VERIFICATION--VOCA Issue: Employment Verification form for one employee from a sample of ten was missing from the employee’s files. Recommendation: Internal controls and procedures should be established, and documentation maintained to support all employee verification for emp...

2023-001: EMPLOYMENT VERIFICATION--VOCA Issue: Employment Verification form for one employee from a sample of ten was missing from the employee’s files. Recommendation: Internal controls and procedures should be established, and documentation maintained to support all employee verification for employment. Corrective Actions: YWCA acknowledges discrepancies in data metrics reported. • Implement a standardized checklist for employment documentation. • Educate HR staff on audit best practices, emphasizing complete and accurate employee files. • Schedule quarterly reviews to ensure compliance with documentation requirements.

View Audit 343088

Finding 523548 (2023-003)

Material Weakness 2023

Pennsylvania Housing Finance Agency

PA

Material Weakness Internal Control / Segregation of Duties

U.S. Department of Treasury Housing Assistance Fund Program – Assistance Listing No. 21.026 Recommendation: CLA recommended that PHFA review their procedures around the debt verification during the HAF program application process. Explanation of disagreement with audit finding: There is no disagre...

U.S. Department of Treasury Housing Assistance Fund Program – Assistance Listing No. 21.026 Recommendation: CLA recommended that PHFA review their procedures around the debt verification during the HAF program application process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Based on this and other similar inadequacies with the vendor, the Agency terminated the contract of the non-compliant vendor (IEM) and moved the administration of the program in house. The new procedures and software being utilized provide the required documentation and verification to support disbursements as evidenced by the audit review. The Agency also anticipates making a mandatory discovery demand for all supporting program documentation to include the debt verification data and will seek judicial enforcement if IEM does not comply with the request. Name of the contact person responsible for corrective action: Kelly Wilson, PAHAF Program Manager. Planned completion date for corrective action plan: The migration to in house administration was completed in March of 2023. The discovery request is expected to be made by no later than Monday, March 25th, 2024.

View Audit 342838

Corrective Action Plans

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