Corrective Action Plans

Finding 402476 (2023-020)

Significant Deficiency 2023

State of Michigan

MI

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Special Tests & Provisions

Finding 2023-020 SNAP Cluster, ALN 10.551 and 10.561 - System and Organization Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For part a., the Electronic Benefits Transfer (EBT) service provider releases all SOC reports via an administrative view on the provide...

Finding 2023-020 SNAP Cluster, ALN 10.551 and 10.561 - System and Organization Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For part a., the Electronic Benefits Transfer (EBT) service provider releases all SOC reports via an administrative view on the provider website. MDHHS will maintain documentation of the date the reports are pulled from the EBT service provider site. Additionally, MDHHS will modify the review process so that the individual completing the evaluation is different from the individual approving the evaluation to ensure segregation of duties is maintained. For parts b. and c., MDHHS will assess the current process and make improvements as needed to ensure subservice organizations are adequately evaluated. Based on the evaluation, MDHHS will perform reviews of sub-organization SOC reports where required. Anticipated Completion Date September 30, 2024 Responsible Individual(s) Andrew Piper, DHHS Dani Wager, DHHS

View Audit 309982

Finding 402473 (2023-003)

Significant Deficiency 2023

State of Michigan

MI

Internal Control / Segregation of Duties § 200.303

Finding 2023-003 Bridges Change Management Process Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS updated change control processes on May 18, 2023, requiring documentation of an alternate validation approval following each Bridges Integrated Automated Eligibility D...

Finding 2023-003 Bridges Change Management Process Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS updated change control processes on May 18, 2023, requiring documentation of an alternate validation approval following each Bridges Integrated Automated Eligibility Determination System (Bridges) release that does not have field testers performing post implementation validation. For Bridges releases occurring after May 18, 2023, MDHHS sends a communication within three business days after each release that validates the changes to Bridges were applied as expected and this validation is documented and retained as part of the release close-out process. Each exception identified occurred prior to the implemented corrective action. Anticipated Completion Date Completed Responsible Individual(s) Holly Roderick, MDHHS

View Audit 309982

Finding 402472 (2023-002)

Material Weakness 2023

State of Michigan

MI

Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility § 200.303

Finding 2023-002 Bridges Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For parts a., c., and d., MDHHS implemented the Database Security Application (DSA) on October 2, 2023, which includes documenting incompatible role exception ...

Finding 2023-002 Bridges Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For parts a., c., and d., MDHHS implemented the Database Security Application (DSA) on October 2, 2023, which includes documenting incompatible role exception requests and user access request approvals. The DSA also includes semi-annual review of privileged users and annual review for all users. For parts b. and e., MDHHS will revise internal business processes to include an additional level of monitoring and review to ensure compliance with the existing directives related to monitoring and review requirements. Anticipated Completion Date a., c., and d. Completed b. and e. August 2024 Responsible Individual(s) a., c., and d. Deon Nelson, MDHHS b. and e. Veronica Maxson, MDHHS

View Audit 309982

Finding 402471 (2023-001)

Significant Deficiency 2023

State of Michigan

MI

Eligibility Internal Control / Segregation of Duties

Finding 2023-001 Bridges Interface Controls Management Views DTMB agrees with the finding. Planned Corrective Action DTMB applied a system fix on May 11, 2024, related to the coding issue to ensure the batch summary table control totals match the exceptions table. Anticipated Completion Date Co...

Finding 2023-001 Bridges Interface Controls Management Views DTMB agrees with the finding. Planned Corrective Action DTMB applied a system fix on May 11, 2024, related to the coding issue to ensure the batch summary table control totals match the exceptions table. Anticipated Completion Date Completed Responsible Individual(s) Heather Frick, DTMB Nathan Buckwalter, DTMB

View Audit 309982

Finding 402467 (2023-011)

Material Weakness 2023

City of Cambridge Massachusetts

MA

Period of Performance Internal Control / Segregation of Duties Material Weakness § 200.303

Cambridge Public Schools' CFO or Grants Coordinator will review and sign-off on all tuition requisitions that will be charged to grants to confirm the grant approval date and compliance with the period of performance.

View Audit 309973

Finding 402465 (2023-010)

Material Weakness 2023

City of Cambridge Massachusetts

MA

Reporting Material Weakness Internal Control / Segregation of Duties § 200.303 § 200.328

The Finance department will document the reconciliation of the City's GL ARPA expenditures and obligations to the Department of Treasury ARPA reporting portal report both quarterly and annually. All reconciling adjustments and GL report documentation will be properly retained.

View Audit 309973

Finding 402459 (2023-007)

Material Weakness 2023

City of Cambridge Massachusetts

MA

Subrecipient Monitoring HUD Housing Programs Material Weakness § 200.303

The City will work with all HOPWA subrecipients to ensure that a complete and accurate CAPER is completed in the appropriate format as required by HUD. This will include a focus on inputting the correct (eg, actual expended vs. award amount) funding amount.

View Audit 309973

Finding 402450 (2023-002)

Material Weakness 2023

City of Cambridge Massachusetts

MA

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management § 200.303

Based on prior year (FY22) findings, the City established the following procedures to ensure payment requests received from subrecipients are paid within 30 days of receipt of a complete request for reimbursement: 1. Department of Human Service Programs (DHSP) Contract Manager reviews invoices withi...

Based on prior year (FY22) findings, the City established the following procedures to ensure payment requests received from subrecipients are paid within 30 days of receipt of a complete request for reimbursement: 1. Department of Human Service Programs (DHSP) Contract Manager reviews invoices within 5 business days of receipt of request for reimbursement from subrecipient. a. If invoice is complete, original date of receipt is recorded. b. If invoice is incomplete, subrecipient is notified of items or documentation that is missing and receipt date is updated to reflect date of receipt of complete invoice. 2. Contract Manager approves payment request and submits to DHSP Fiscal staff for processing. 3. Fiscal staff processes and submits to Auditing Department as Priority payment. Four of the 19 sampled payment requests were received or processed after receipt of the FY22 audit findings, and all of those requests for reimbursement were paid within 30 days of receipt.

View Audit 309973

Finding 402425 (2023-002)

None 2023

Center for Cultural & Technical Interchange Between East & West, INC

HI

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.403

Activities Allowed and Unallowed / Allowable Costs and Cost Principles New payroll allocation procedures were implemented during fiscal 2023 in an effort to streamline the allocation process. Starting in fiscal 2024, management has reverted to the fiscal 2022 payroll allocation procedures to ensure...

Activities Allowed and Unallowed / Allowable Costs and Cost Principles New payroll allocation procedures were implemented during fiscal 2023 in an effort to streamline the allocation process. Starting in fiscal 2024, management has reverted to the fiscal 2022 payroll allocation procedures to ensure that the proper percentages are used in calculating charges to our contracts and grants. The procedures used in fiscal 2022 and prior resulted in clean audit opinions and can be trusted to allocate payroll properly. The allocation errors noted during the audit were corrected in the subsequent fiscal year.

View Audit 309953 Questioned Costs: $1

Finding 402423 (2023-006)

Material Weakness 2023

The Henry Francis Du Pont Winterthur Museum, Inc.

DE

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Management commits to documenting processes and procedures - in this case specifically for the endowment spending policy; instituting regular reviews for effectiveness and compliance and better defining the responsibilities and accountabilities of employee and outsourced staff.

View Audit 309950

Finding 402405 (2023-002)

Material Weakness 2023

Pike County Board of Education

AL

Internal Control / Segregation of Duties Material Weakness

CSFO will begin reviewing and signing the Prior Period Comparison Report before payroll is ran each month.

View Audit 309939

Finding 402388 (2023-001)

Material Weakness 2023

Semo Electric Cooperative

MO

Questioned Costs Subrecipient Monitoring Reporting

Material Weakness in Internal Control A. Comments on Findings and Recommendations: We concur with the auditor’s findings and recommendations regarding reporting of project expenses and unidentified errors in project reconciliations completed by staff. B. Actions Taken or Planned: Management...

Material Weakness in Internal Control A. Comments on Findings and Recommendations: We concur with the auditor’s findings and recommendations regarding reporting of project expenses and unidentified errors in project reconciliations completed by staff. B. Actions Taken or Planned: Management concurs. Large fiber installation project still in process at year-end. Subsequent reconciliations have been completed. Controls and other project processes have been improved to ensure more timely reconciliation of material charge-outs to the timing of the installation of material. Anticipated completion date: Completed Contact information for this finding: Amanda Burnett, Chief Financial Officer, 573-471-5821

View Audit 309920 Questioned Costs: $1

Finding 402387 (2023-001)

Significant Deficiency 2023

Hendersonville Housing Authority

NC

HUD Housing Programs Internal Control / Segregation of Duties Reporting

Corrective Action Plan: The Executive Director will advise the CPA of all purchases that exceed the capitalization threshold when they occur. Copies of the check(s) and invoice(s) will be scanned into the month they are paid (into the Laserfiche electronic storage system). The CPA will review the pa...

Corrective Action Plan: The Executive Director will advise the CPA of all purchases that exceed the capitalization threshold when they occur. Copies of the check(s) and invoice(s) will be scanned into the month they are paid (into the Laserfiche electronic storage system). The CPA will review the payments scanned monthly and also scan the disbursements for any that could have been missed. At the end of the fiscal year, the disbursements that meet the capitalization requirements of HAHC and RTS will be entered into the depreciation schedule. Person(s) responsible: Executive Director- Connie Stewart CPA- Barfield and Kinkead LLC Completion Date: Fiscal year ending September 30, 2024

View Audit 309918

Finding 402386 (2023-002)

Material Weakness 2023

The Water Works and Sewer Board of the Town of Sardis City, Alabama

AL

Reporting Internal Control / Segregation of Duties

Finding 2023-002 – Material Adjustments Description of Finding: The auditor found that The Entity relied on auditors to propose entries after audit procedures and had not recorded entries needed at the time of the audit. Statement of Concurrence or Nonconcurrence: Management concurs with this fi...

Finding 2023-002 – Material Adjustments Description of Finding: The auditor found that The Entity relied on auditors to propose entries after audit procedures and had not recorded entries needed at the time of the audit. Statement of Concurrence or Nonconcurrence: Management concurs with this finding. Corrective Action: The Entity will incorporate financial reporting internal controls to detect material adjustments, prevent materially misstated financial statements, and increase the accuracy of interim financial reports used by management.

View Audit 309917

Finding 402385 (2023-001)

Material Weakness 2023

The Water Works and Sewer Board of the Town of Sardis City, Alabama

AL

Internal Control / Segregation of Duties Reporting Subrecipient Monitoring

Finding 2023-001 – Segregation of Duties: Description of Finding: The auditor found that duties were not segregated in a number of areas where small adjustments to the policies of the Entity could help to further facilitate this important control. Statement of Concurrence or Nonconcurrence: Mana...

Finding 2023-001 – Segregation of Duties: Description of Finding: The auditor found that duties were not segregated in a number of areas where small adjustments to the policies of the Entity could help to further facilitate this important control. Statement of Concurrence or Nonconcurrence: Management concurs with this finding. Corrective Action: Management has issued written policies and required training of all employees that handle financial transactions and will continually evaluate processes to find ways to segregate duties where possible. Management and the board of directors will continue to oversee operations closely requiring approvals for all transactions.

View Audit 309917

Finding 402343 (2023-001)

Significant Deficiency 2023

Community Roots Housing

WA

Special Tests & Provisions HUD Housing Programs Significant Deficiency

Management Corrective Action Plan For the Year Ended December 31, 2023 Community Roots Housing US Department of Homeland Security auditee identification number: PMDC-PJ-10-WA-2018-010 Audit Firm: Clark Nuber PS Audit Period: Year ended December 31, 2023 Finding 2023-001 – Significant deficiency in i...

Management Corrective Action Plan For the Year Ended December 31, 2023 Community Roots Housing US Department of Homeland Security auditee identification number: PMDC-PJ-10-WA-2018-010 Audit Firm: Clark Nuber PS Audit Period: Year ended December 31, 2023 Finding 2023-001 – Significant deficiency in internal controls over compliance related to special tests and provisions. Requirement: Per the requirements contained in 24 CFR Part 982, property owners must perform housing quality inspections at the time of initial occupancy and at least annually thereafter to ensure that the units are decent, safe, and sanitary. Finding: Out of 12 units selected for testing, 2 units did not have documentation supporting that a housing quality standards inspection was completed during 2023. Recommendation: CRH should implement the necessary internal controls to ensure annual inspections are performed and documented. Comments Community Roots Housing agrees with this finding and recommendation. Corrective Action Plan Community Roots Housing maintains detailed listings of annual inspection work orders, including unit numbers and when they were finished. This listing is prepared by the maintenance department. An additional control will be added to include secondary review and oversight by the Director of Property Management. This review will occur quarterly, starting in the with the second quarter of 2024, to ensure that all inspections are completed before the end of 2024, and annually thereafter. The Director of Maintenance and the Director of Property Management will be responsible for ensuring these tasks are carried out. Corrective Action Plan prepared by: Leslie Woodworth, Chief Financial Officer, 206-895-2030

View Audit 309911

Finding 402340 (2023-003)

Significant Deficiency 2023

The Corporation for Manufacturing Excellence Dba Manex

CA

Cash Management Internal Control / Segregation of Duties Allowable Costs / Cost Principles

2023-003 Finding - Federal Award - Significant Deficiency - Reporting US Department ofCommerceAL#11.611 Context and Cause - The Organization was not made aware by grants, CMTC or prior auditors that the final upload package of the federal reports and requests for reimbursement should have internal c...

2023-003 Finding - Federal Award - Significant Deficiency - Reporting US Department ofCommerceAL#11.611 Context and Cause - The Organization was not made aware by grants, CMTC or prior auditors that the final upload package of the federal reports and requests for reimbursement should have internal control oversight procedures and did not exercise such oversight. Only one individual was responsible for preparing and filing these final documents after such details were reviewed individually throughout the month by other individuals responsible for that review. The payroll time sheet review process was consistently followed, however, and there is not a process for the final processed payroll rep01ts to be reviewed by a second individual.Recommendation: We recommend management implement procedures to ensure the Uniform Grant Guidance and the Compliance Supplement requirements for controls over Reporting, Allowable Costs, and Cash Management are designed and performed. The month end checklist currently being used is a good start, and this could be enhanced by adding sections for the above items, and having specific individuals' initial and date on the checklist when the procedures are completed. A fiscal policy and procedure manual would also be a good tool. Action Taken: Manex will update fiscal Policy to include oversight on reporting to funders

View Audit 309904

Finding 402330 (2023-008)

Material Weakness 2023

Family Health Centers, Inc.

SC

Special Tests & Provisions Internal Control / Segregation of Duties

In Finding 2023-008, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended December 31, 2023. Management recognizes the importance of complying with sliding fee guidelines. In response to F...

In Finding 2023-008, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended December 31, 2023. Management recognizes the importance of complying with sliding fee guidelines. In response to Finding 2023-008, proper training will be given to employees and sliding fee discounts will be reviewed by a supervisor on a periodic basis the ensure compliance with the sliding fee scale.

View Audit 309899

Finding 402308 (2023-001)

Significant Deficiency 2023

Infinity Health

IA

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.430

Allowable Activities and Costs – Assistance Listing No. 93.224/93.527 Recommendation: CLA recommends that the Organization consider completing time and effort attestation forms electronically to ensure none get lost or misplaced and are returned timely. Explanation of disagreement with audit finding...

Allowable Activities and Costs – Assistance Listing No. 93.224/93.527 Recommendation: CLA recommends that the Organization consider completing time and effort attestation forms electronically to ensure none get lost or misplaced and are returned timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Infinity Health’s current policy to support compliance with time and effort requirements is to obtain a statement from each employee with any time allocated for a grant, certifying the time spent on grant activities on a quarterly basis. Beginning 12/1/2023, Infinity Health has implemented a new electronic document management system which will improve our ability to track and monitor timely completion of time and effort statements each quarter. Name(s) of the contact person(s) responsible for corrective action: Kyle Ahlenstorf, CEO, and Michelle Leonard, CFO. Planned completion date for corrective action plan: June 30, 2024

View Audit 309894

Finding 401960 (2023-003)

Significant Deficiency 2023

Src, Inc.

NY

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

SRC will review and revise the disclosure statement to provide clarification on the treatment of SCI costs in the next disclosure statement revision. Contact Person Responsible for Corrective Action: Tasha Haynes, Sr Manager, Compliance Completion Date: All corrective action will be implemented by ...

SRC will review and revise the disclosure statement to provide clarification on the treatment of SCI costs in the next disclosure statement revision. Contact Person Responsible for Corrective Action: Tasha Haynes, Sr Manager, Compliance Completion Date: All corrective action will be implemented by September 30, 2024.

View Audit 309876

Finding 401959 (2023-002)

Significant Deficiency 2023

Src, Inc.

NY

Internal Control / Segregation of Duties Allowable Costs / Cost Principles

SRC implemented corrective action to address this finding by putting delegation letters in place. DCAA reviewed this corrective action as part of another audit engagement and in their audit memo determined that this corrective action was not sufficient. As a result, management re-evaluated possib...

SRC implemented corrective action to address this finding by putting delegation letters in place. DCAA reviewed this corrective action as part of another audit engagement and in their audit memo determined that this corrective action was not sufficient. As a result, management re-evaluated possible solutions and determined that going forward, approvals on all forms must be completed by an employee who works for the applicable company. A formal communication was sent to all program managers on March 5, 2024, notifying them of both the finding and the procedure change going forward Contact Person Responsible for Corrective Action: Tasha Haynes, Sr Manager, Compliance Completion Date: Corrective Action has been implemented.

View Audit 309876

Finding 401957 (2023-001)

Significant Deficiency 2023

Southern Nevada Regional Housing Authority

NV

HUD Housing Programs Subrecipient Monitoring Eligibility

Finding 2023 - 001: Housing Choice Voucher Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance and Material Weakness Corrective Action Plan: Training: Currently, we are having all HCV staff trained and refreshed on rent calculations through Nan McKay. Staff will also be...

Finding 2023 - 001: Housing Choice Voucher Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance and Material Weakness Corrective Action Plan: Training: Currently, we are having all HCV staff trained and refreshed on rent calculations through Nan McKay. Staff will also be trained in best practices for properly obtaining verification and following the verification hierarchy process. Also, we are hiring a Training and Development Specialist. Once filled, we will conduct monthly and quarterly training. We anticipate filling the position by July 2024. Quality Control: We conduct 100% quality control on all new hires', completed action files and 100% quality control on all contract files. Quality Control of 25% of all annuals and 25% of all interims completed monthly by all non provisional employees. Department Structure: The supervisors will quality-control any caseworkers with an error rate of 80% of their files. Once we fill all staff vacancies and complete the provisional period for all our new staff, we will audit up to 40% of all completed files. Anticipated Completion Date: The current staff is attending Nan McKay's rent calculations training on June 4-6, 2024. We anticipate completion of the plan by 12/31/2024. Person Responsible: Ms. Rhonda Jackson, Housing Program Manager II, and Ms. Malandria Watson, Housing Program Manager I, will review the Quality Control Report and error ratios monthly.

View Audit 309875

Finding 401946 (2023-002)

Material Weakness 2023

Turning Point, Inc.

MI

Allowable Costs / Cost Principles Cash Management Reporting

Finding 2023-002 Condition The Organization did not have timely approval of non-payroll expenditures to support preparation of reliable financial reports to grantors. Corrective Action Plan Corrective Action Planned: Improvements have already been made to this process in the current year rega...

Finding 2023-002 Condition The Organization did not have timely approval of non-payroll expenditures to support preparation of reliable financial reports to grantors. Corrective Action Plan Corrective Action Planned: Improvements have already been made to this process in the current year regarding the timely submission of supporting documentation and authorization and this will continue to be an area of focus in both operations and finance. Name(s) of Contact Person(s) Responsible for Corrective Action: The Director of Accounting, Dawn Bonderczuk, and the Account Payable Clerk or Accountant. Anticipated Completion Date: July 31, 2024.

View Audit 309873

Finding 401931 (2023-001)

None 2023

Centro Comprensivo De Cáncer De La Universidad De Puerto Rico

PR

Reporting Internal Control / Segregation of Duties § 200.512

The Comprehensive Cancer Center (CCC) has implemented a Corrective Action Plan on November 2023 and has significantly improved the submission of the Single Audit Report FY 2023 and the data collection. The result of the implementation of the corrective action plan for FY 2023 allows the CCC to begin...

The Comprehensive Cancer Center (CCC) has implemented a Corrective Action Plan on November 2023 and has significantly improved the submission of the Single Audit Report FY 2023 and the data collection. The result of the implementation of the corrective action plan for FY 2023 allows the CCC to begin the financial statement and Single Audit of FY 2024 on time. We establish a procedure to ensure that the information required to be disclosed in the Single Audit is scheduled. Despite efforts to complete the Single Audit FY 2023 on March 31, 2024, CCCUPR Management and auditors agreed that they require two (2) additional months to complete the process. To ensure the timely completeness of the Financial Statement and Single audit of FY 2024 before March 31, 2025 we implement the following aggressive work plan:  Management closing and submission Final Trial Balance to Auditors August 8, 2024.  Completion and Delivery to Auditors PBC items October 31, 2024.  Distribution of Financial Statement and Single Audit Draft for review (management and Auditors) November 11, 2024  Final review of the Draft by the auditors – November 15, 2024.  Final Issuance of Financial Statement, Single Audit, and data collection November 30, 2024.

View Audit 309869

Finding 401928 (2023-002)

Significant Deficiency 2023

East Phillips CO Hospital Dist Dba Melissa Memorial Hospital

CO

HUD Housing Programs Material Weakness Significant Deficiency

Policies and Procedures for Federal Awards Corrective action planned: Management will consult an advisory firm to assist with providing sample policies and procedures for tracking and usage of federal awards. Management will review and implement policies and procedures no later than 60 days to ensu...

Policies and Procedures for Federal Awards Corrective action planned: Management will consult an advisory firm to assist with providing sample policies and procedures for tracking and usage of federal awards. Management will review and implement policies and procedures no later than 60 days to ensure compliance with tracking and usage of federal awards. Anticipated completion date: June 30, 2024 Contact person responsible for corrective action: Angela St. John, CFO

View Audit 309848

Corrective Action Plans

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