Corrective Action Plans

Finding 502901 (2023-002)

Significant Deficiency 2023

IL

Cash Management Reporting Internal Control / Segregation of Duties

We will engage with an outside consultant/independent CPA firm to review and manage the internal control process. This corrective action will be implemented by December 31, 2024 by the Administrator and Board.

View Audit 324851

Finding 502748 (2023-003)

Significant Deficiency 2023

Butler County Health Center

MO

Reporting Equipment & Real Property Management Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN The Center will implement procedures requiring a monthly reconciliation of the vaccine received, vaccine expenditures incurred, and vaccine inventory amount held by the Center. Contact Person: Emily Goodin, Administrator

View Audit 324818

Finding 502738 (2023-007)

Significant Deficiency 2023

Martin University

IN

Questioned Costs Eligibility Significant Deficiency § 200.303

United States Department of Education 2023-007 Student Financial Aid Cluster – Assistance Listing No. 84.063 Condition: Students were disbursed Pell funds inaccurately. Auditors’ Recommendation: We recommend the University implement policies to review all student award packages at the start of the ...

United States Department of Education 2023-007 Student Financial Aid Cluster – Assistance Listing No. 84.063 Condition: Students were disbursed Pell funds inaccurately. Auditors’ Recommendation: We recommend the University implement policies to review all student award packages at the start of the academic year to ensure no over and under awards exist. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Summer 2023 Martin University’s main power source was struck by lightning. This caused all Summer processing, that had not yet been backed up on our servers, to be deleted from the system. All transactions that took place at that time had to be manually re-entered. During that manual process, there appears to be a human error in inputting the dates. SIS dates will be corrected to original and actual COD disbursement dates. Name(s) of the contact person(s) responsible for corrective action: Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: November 30, 2024

View Audit 324814 Questioned Costs: $1

Finding 502724 (2023-008)

Significant Deficiency 2023

Martin University

IN

Special Tests & Provisions Student Financial Aid Subrecipient Monitoring § 200.303

United States Department of Education 2023-008 Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Condition: Under an institution’s Program Participation Agreement with the Department of Education and the Gramm-Leach-Bliley Act, schools must protect student financ...

United States Department of Education 2023-008 Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Condition: Under an institution’s Program Participation Agreement with the Department of Education and the Gramm-Leach-Bliley Act, schools must protect student financial aid information, with particular attention to information provided to institutions by the Department or otherwise obtained in support of the administration of the federal student financial aid programs. Auditors’ Recommendation: We recommend the University engage a third party or perform the risk assessment for the two areas required by the Gramm-Leach-Bliley Act that have not been completed and documented and ensure that there are documented safeguards for identified risks. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented a new SIS and Financial Aid processing system. The new systems are Jenzebar products and are fully compliant. Name(s) of the contact person(s) responsible for corrective action: Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2024

View Audit 324814

Finding 502721 (2023-004)

Significant Deficiency 2023

Martin University

IN

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

United States Department of Education 2023-004 Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Condition: Student checks related to student refunds of Title IV federal financial aid was outstanding more than 240 days as of June 30, 2023. Auditors’ Recommendatio...

United States Department of Education 2023-004 Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Condition: Student checks related to student refunds of Title IV federal financial aid was outstanding more than 240 days as of June 30, 2023. Auditors’ Recommendation: We recommend that the University review its procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University engaged an external consultant in June 2023, hired a new staff accountant in September 2023 and a CFO in November 2023. The University is implementing financial internal controls policies and processes to improve the financial statements preparation and preparation of the schedule of expenditures and federal awards and ensure compliance with the DOE. This includes procedures related to outstanding student refund checks over 240 days. Name(s) of the contact person(s) responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration

View Audit 324814

Finding 502720 (2023-003)

Significant Deficiency 2023

Martin University

IN

Internal Control / Segregation of Duties Student Financial Aid Reporting § 200.303

United States Department of Education 2023-003 Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Condition: The University submitted inaccurate data in its annual FISAP report. Auditors’ Recommendation: We recommend the applicable campus revise procedures to ens...

United States Department of Education 2023-003 Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Condition: The University submitted inaccurate data in its annual FISAP report. Auditors’ Recommendation: We recommend the applicable campus revise procedures to ensure that the record retention requirements are met and supporting documentation agrees to the FISAP, including a supervisory review by someone other than the preparer. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Unduplicated Recipients for Ungrad/Dependent with salary range of $1000,000 and over was reported as one but should have been two. Completed FISAP reports are sent to the CFO for additional review prior to submission. Name(s) of the contact person(s) responsible for corrective action: Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2024

View Audit 324814

Finding 502719 (2023-002)

Material Weakness 2023

Martin University

IN

Internal Control / Segregation of Duties Material Weakness Reporting

MATERIAL WEAKNESS 2023-002 Segregation of Duties and Control Documentation Recommendation: The University should evaluate their financial reporting processes and controls, including the segregation of duties among its internal staff (including number of internal staff), to determine whether addition...

MATERIAL WEAKNESS 2023-002 Segregation of Duties and Control Documentation Recommendation: The University should evaluate their financial reporting processes and controls, including the segregation of duties among its internal staff (including number of internal staff), to determine whether additional processes and controls over the financial records of the University are complete, accurate, and retained to support the University’s financial statement prepared in accordance with U.S. GAAP. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University engaged an external consultant in June 2023, hired a new staff accountant in September 2023 and a CFO in November 2023. The University has begun to restructure all accounting and reconciliation functions, including implementation of new accounting software. The University is implementing financial internal controls to improve the financial statements preparation and preparation of the schedule of expenditures and federal awards. Name of the contact person responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration Planned completion date for corrective action plan: June 30, 2024

View Audit 324814

Finding 502718 (2023-001)

Material Weakness 2023

Martin University

IN

Material Weakness Reporting Internal Control / Segregation of Duties

MATERIAL WEAKNESS 2023-001 Financial Statement Preparation Recommendation: We recommend that management review controls related to financial statement preparation review at the end of each period. Financial statement preparation should include a review of reconciliations and balances to ensure that ...

MATERIAL WEAKNESS 2023-001 Financial Statement Preparation Recommendation: We recommend that management review controls related to financial statement preparation review at the end of each period. Financial statement preparation should include a review of reconciliations and balances to ensure that financial statement line items are properly stated and classified. Internally prepared financial statements should also be thoroughly reviewed by members of the board and management outside the finance department on a periodic (monthly or quarterly). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University engaged an external consultant in June 2023, hired a new staff accountant in September 2023 and a CFO in November 2023. The University has begun to restructure all accounting and reconciliation functions, including implementation of new accounting software. The University is implementing financial internal controls to improve the financial statements preparation and preparation of the schedule of expenditures and federal awards. Name of the contact person responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration Planned completion date for corrective action plan: June 30, 2024

View Audit 324814

Finding 502706 (2023-006)

Material Weakness 2023

Grady County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties

We will work to implement a risk assessment plan. We will implement controls to help make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance supplement...

We will work to implement a risk assessment plan. We will implement controls to help make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance supplement to work from.

View Audit 324754

Finding 502700 (2023-002)

Significant Deficiency 2023

Housing Authority of the City of Annapolis

MD

HUD Housing Programs Reporting Significant Deficiency § 200.512

Finding 2023-002 Late Submission of Financial Statements to FAC and REAC (Significant Deficiency) Recommendation: The Authority should review and enhance its policies, procedures, and internal controls to ensure the financial reporting package and audited financial statements are submitted by the re...

Finding 2023-002 Late Submission of Financial Statements to FAC and REAC (Significant Deficiency) Recommendation: The Authority should review and enhance its policies, procedures, and internal controls to ensure the financial reporting package and audited financial statements are submitted by the required due date. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will evaluate its’ financial reporting and close processes and controls to determine whether additional controls over the preparation of the final trial balances and related schedules should be implemented. As part of this process, we will create a yearend checklist with deadlines established, and set up status meetings to monitor the progress. Name(s) of the contact person(s) responsible for corrective action: Cia Cook, Deputy Executive Director & CFO Planned completion date for corrective action plan: August 31, 2024

View Audit 324736

Finding 502674 (2023-003)

Material Weakness 2023

City of Homer, Alaska

AK

Subrecipient Monitoring Material Weakness Reporting § 200.512

Finding 2023-003 Deadline for Federal Single Audit – Reporting – Noncompliance and Material Weakness in Internal Control over Compliance Planned Corrective Actions: The Finance Department is continuing its efforts in establishing and enforcing internal deadlines to ensure the financial statements ar...

Finding 2023-003 Deadline for Federal Single Audit – Reporting – Noncompliance and Material Weakness in Internal Control over Compliance Planned Corrective Actions: The Finance Department is continuing its efforts in establishing and enforcing internal deadlines to ensure the financial statements are audited within the appropriate reporting deadlines. The department has shifted staff duties to ensure the FY24 financial statements will be completed within the appropriate reporting deadlines. Individual(s) Responsible for Corrective Action Plan Elizabeth Fischer (Finance Director) Jenna deLumeau (Controller) Anticipated Completion Date: The department has developed internal deadlines to ensure the FY24 financial statements will be completed within the appropriate reporting deadlines. This has been completed.

View Audit 324691

Finding 502669 (2023-002)

Material Weakness 2023

Centerville Community School District

IA

Internal Control / Segregation of Duties

The District continues to have a limited number of office employees. The District will attempt, with advice from the auditors, to segregate duties as much as reasonably possible with limited office personnel

View Audit 324687

Finding 502634 (2023-008)

Significant Deficiency 2023

Promise Healthcare Nfp

IL

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.403

Action taken in response to finding: 1. Create a standard procedure for tracking grant expenses: Completed 2. Train staff on procedures: Completed 3. Create an independent review process for all grant tracking: In progress Name of the contact person responsible for corrective action: Keith Flores, C...

Action taken in response to finding: 1. Create a standard procedure for tracking grant expenses: Completed 2. Train staff on procedures: Completed 3. Create an independent review process for all grant tracking: In progress Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: End of 2024

View Audit 324609 Questioned Costs: $1

Finding 502631 (2023-007)

Significant Deficiency 2023

Promise Healthcare Nfp

IL

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.329

Action taken in response to finding: 1. Develop documentation procedures: In Progress a. Establish a standardized procedure for documenting the preparation and review of Federal Financial Reports. 2. Select appropriate party for independent review: Complete ...

Action taken in response to finding: 1. Develop documentation procedures: In Progress a. Establish a standardized procedure for documenting the preparation and review of Federal Financial Reports. 2. Select appropriate party for independent review: Complete 3. Store and maintain documentation in a shared location for future audit and review: Complete Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: End of 2024

View Audit 324609

Finding 502627 (2023-004)

Material Weakness 2023

Promise Healthcare Nfp

IL

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.317 § 200.320

Action taken in response to finding: 1. Review Current Procurement Policy: in progress a. Conduct a comprehensive review of Promise Healthcare’s existing procurement policy. b. Identify and revise and discrepancies or non-compliance with the requirements of the Uniform Guidance. c. Integrate industr...

Action taken in response to finding: 1. Review Current Procurement Policy: in progress a. Conduct a comprehensive review of Promise Healthcare’s existing procurement policy. b. Identify and revise and discrepancies or non-compliance with the requirements of the Uniform Guidance. c. Integrate industry best practices into revised policy to enhance compliance and efficiency 2. Training and Education: to start a. Provide training sessions for staff authorized to purchase along with relevant personnel on the revised procurement policy and procedures and raise awareness of the requirements of the Uniform Guidance and implications of non-compliance. b. Establish training on documentation standards for procurement activities including requisitions, solicitations, evaluations and contract awards. c. Establish training and procedure for retention of procurement-related documentation 3. Internal Controls and oversight: to start a. Implement mechanisms for monitoring and oversight to ensure compliance with the procurement policy. b. Conduct periodic internal audits to assess adherence to procurement procedures and identify areas for improvement or corrective action Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: Winter 2025

View Audit 324609 Questioned Costs: $1

Finding 502624 (2023-003)

Material Weakness 2023

Promise Healthcare Nfp

IL

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

Action taken in response to finding: 1. Create a grant matrix to track employee grant allocations in one file: Complete 2. Utilize the matrix to apply allocation to each employee on every payroll occurrence: In Progress 3. Review the matrix with grant project managers monthly to ensure accuracy and ...

Action taken in response to finding: 1. Create a grant matrix to track employee grant allocations in one file: Complete 2. Utilize the matrix to apply allocation to each employee on every payroll occurrence: In Progress 3. Review the matrix with grant project managers monthly to ensure accuracy and capture changes: In Progress 4. Maintain records of for each payroll of grant matrix application: In progress Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: End of 2024

View Audit 324609 Questioned Costs: $1

Finding 502620 (2023-002)

Material Weakness 2023

Promise Healthcare Nfp

IL

Cash Management Internal Control / Segregation of Duties § 200.305

Action taken in response to finding: 1. Develop documentation procedures: In Progress a. Establish a standardized procedure for documenting the preparation and review of drawdown requests. 2. Select appropriate party for independent review: Complete 3. Store and maintain documentation in a shared lo...

Action taken in response to finding: 1. Develop documentation procedures: In Progress a. Establish a standardized procedure for documenting the preparation and review of drawdown requests. 2. Select appropriate party for independent review: Complete 3. Store and maintain documentation in a shared location for future audit and review: Complete Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: End of 2024

View Audit 324609

Finding 502587 (2023-001)

Significant Deficiency 2023

Family Service and Guidance Center of Topeka, Inc.

KS

Reporting Internal Control / Segregation of Duties

Comments on the Finding Recommendation The Center experienced unusual and extensive staff shortages in the finance department in the reporting period. The Center does not expect these circumstances to be repeated, but will implement a policy that designates 2 staff/positions to monitor grant report ...

Comments on the Finding Recommendation The Center experienced unusual and extensive staff shortages in the finance department in the reporting period. The Center does not expect these circumstances to be repeated, but will implement a policy that designates 2 staff/positions to monitor grant report deadlines. Action Taken The Center has a Policy for Grant Reporting that designates the staff responsible for tracking grant deadlines. The policy will be updated so that multiple staff/positions are listed as being responsible for grant report deadlines.

View Audit 324583

Finding 502574 (2023-004)

Significant Deficiency 2023

Okanogan Behavioral Healthcare

WA

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Significant Deficiency

Action taken in response to finding: The program experienced transition in management and staff during FY23. The new Recovery Support Services staff are now fully trained and ensures expenditures are charged appropriately, approved by a knowledgeable supervisor, and supporting documentation is main...

Action taken in response to finding: The program experienced transition in management and staff during FY23. The new Recovery Support Services staff are now fully trained and ensures expenditures are charged appropriately, approved by a knowledgeable supervisor, and supporting documentation is maintained on file. Additionally, AP and Finance team review supporting documentation and ensure completeness. Name(s) of the contact person(s) responsible for corrective action: Floral Reed Planned completion date for corrective action plan: June 30, 2024

View Audit 324580

Finding 502573 (2023-003)

Significant Deficiency 2023

Okanogan Behavioral Healthcare

WA

Allowable Costs / Cost Principles Cash Management Period of Performance

Action taken in response to finding: The program experienced transition in management and staff during FY23. The new Recovery Support Services staff are now fully trained and ensures expenditures are incurred, charged appropriately and supporting documentation is maintained on file. Additionally, ...

Action taken in response to finding: The program experienced transition in management and staff during FY23. The new Recovery Support Services staff are now fully trained and ensures expenditures are incurred, charged appropriately and supporting documentation is maintained on file. Additionally, AP and Finance team review supporting documentation and ensure completeness. Name(s) of the contact person(s) responsible for corrective action: Floral Reed Planned completion date for corrective action plan: June 30, 2024

View Audit 324580

Finding 502571 (2023-001)

Significant Deficiency 2023

Okanogan Behavioral Healthcare

WA

Allowable Costs / Cost Principles Period of Performance Significant Deficiency

Action taken in response to finding: The Finance team corrected their processes to ensure proper recording of payroll costs during the time of the FY22 Audit procedures; however, the changes were made to subsequent months and previously submitted months were not retroactively corrected. Additionall...

Action taken in response to finding: The Finance team corrected their processes to ensure proper recording of payroll costs during the time of the FY22 Audit procedures; however, the changes were made to subsequent months and previously submitted months were not retroactively corrected. Additionally, the OBHC team is currently working with the HCA in restructuring the rate schedule to incorporate the payroll costs into the direct service rates for the SOR/SABG grants. This effectively removes this issue going forward in FY25 once approved by the HCA. Name(s) of the contact person(s) responsible for corrective action: Carrie Anthony Planned completion date for corrective action plan: Sep 2023 & New rates: Sep 30, 2024

View Audit 324580

Finding 502556 (2023-001)

Material Weakness 2023

Puerto Rico Health Insurance Administration

PR

Internal Control / Segregation of Duties

ASES contracted a Cybersecurity expert to review the Disaster Recovery Plan (DRP) and a Business Impact Analysis was completed to acquire space within the AZURE cloud with the approval of the Puerto Rico Innovation and Technology Service (PRITS). The strategy of protection and alternate space was d...

ASES contracted a Cybersecurity expert to review the Disaster Recovery Plan (DRP) and a Business Impact Analysis was completed to acquire space within the AZURE cloud with the approval of the Puerto Rico Innovation and Technology Service (PRITS). The strategy of protection and alternate space was designed to work on ASES applications and documents in case of a disaster. ASES already has a virtual RED environment where the resources are being replicated for users and area documentation and eventually the servers will be replicated in the AZURE space. Additionally, an internal Risk Assessment was performed that helped identify and remedy the vulnerabilities in the agency. It was prepared by the Information Systems Security Administrator, evaluated by the personnel hired at the executive level and signed in acceptance of the exercise carried out. As a result, the DRP was updated based on departmental needs and the current capabilities of the agency's information systems. ASES also implemented the use of OneDrive tools for users to save their documents in this application and SharePoint for departmental files and documents.

View Audit 324551

Finding 502525 (2023-002)

Material Weakness 2023

Iowa Falls Community School District

IA

Internal Control / Segregation of Duties

We will continue to review our control procedures to ensure we achieve the maximum internal control possible under the circumstances.

View Audit 324505

Finding 502502 (2023-003)

Material Weakness 2023

Catholic Charities West Michigan

MI

Questioned Costs Special Tests & Provisions Eligibility

Action Taken: The Senior Programs have undergone significant improvements in the last 6 months following an audit by the federal funder which resulted in a corrective action plan (CAP) and a repayment of $54,228. Plans were implemented during the spring of 2024 in response to the CAP which resulted...

Action Taken: The Senior Programs have undergone significant improvements in the last 6 months following an audit by the federal funder which resulted in a corrective action plan (CAP) and a repayment of $54,228. Plans were implemented during the spring of 2024 in response to the CAP which resulted in an overhaul of the processes in place to properly develop the volunteer checklists and assure all records for staff and volunteers are now compliant. Our Quality and Compliance and Finance team worked closely with the new Program Manager to assure that we will be fully compliant and remain so.

View Audit 324497 Questioned Costs: $1

Finding 502366 (2023-001)

Material Weakness 2023

City of Hughson

CA

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking

Future funding for the City of Hughson will be thoroughly vetted to determine if there are any federal funds included in the monies to be received. Each new source of funding will be documented as to the source of the funding and the restrictions on its use. A thorough review of these funds will be ...

Future funding for the City of Hughson will be thoroughly vetted to determine if there are any federal funds included in the monies to be received. Each new source of funding will be documented as to the source of the funding and the restrictions on its use. A thorough review of these funds will be made at year end to determine if the City has met the $750,000 threshold to request a single audit in a timely manner.

View Audit 324399

Corrective Action Plans

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