Corrective Action Plans

Finding 520958 (2023-001)

Material Weakness 2023

HI

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Internal control over payroll and disbursements In January 2023 changes to any pay rates were submitted on a Personnel Action Form (PAF) by the Operations Manager. The PAF included the old pay rate and the new pay rate and was submitted to the Executive Director for review and approval. After app...

Internal control over payroll and disbursements In January 2023 changes to any pay rates were submitted on a Personnel Action Form (PAF) by the Operations Manager. The PAF included the old pay rate and the new pay rate and was submitted to the Executive Director for review and approval. After approval, the form was filed in the employees paper file, as well as uploaded to their electronic record on the ProService platform. In May 2024, we hired a Human Resources Specialist who is responsible for updating and maintaining all personnel files and processing of payroll records. In October 2023, we hired an Accounting Specialist (AS) who is responsible for the processing of all vendor disbursements. Prior to ordering items or services, a Purchase Requisiton (PR) is submitted by the program manager to the Executive Director or Programs Director for review and approval. Upon approval the PR is submitted to the Controller for expense and grant coding. PR is then submitted to the AS to assign a PR number and enter the expenses on the PR tracking log. When the PR has been assigned a PR number it is sent to the Operations Manager for purchasing. When the invoice is received the PR is matched to the invoice indicating proper approvals. If the purchase is over $5,000, a Procurement form is completed to solicit 3 bids and reviewed and approved by the Executive Director. If the purchase is over $20,000, the Procurement form is submitted to the Board of Directors for approval. All Procurement forms are attached to invoices for payment processing. Internal control over account balances During the fiscal year, it was noted that there were credit card entries that were duplicated, and have been corrected as of the date of this report. Due to miscommunication with the previous fiscal staff, payments made by credit card were entered as an invoice and as an adjusting journal entry.

View Audit 340855

Finding 520848 (2023-006)

Material Weakness 2023

Municipality of Ceiba

PR

HUD Housing Programs Eligibility Internal Control / Segregation of Duties

We concur with the finding. During the fiscal year 2024-2025, all participant files will be revised to include all missing documents referred to in the finding.

View Audit 340664

Finding 520776 (2023-001)

Material Weakness 2023

The Learning Tree, Inc.

AL

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

2023-001 – Special Test and Provision – Wage Rate Requirement – Material Weakness in Internal Controls over Compliance/Material Noncompliance Recommendation: The auditor recommends the Organization strengthen the controls in place to provide assurance that contract agreements entered into with subco...

2023-001 – Special Test and Provision – Wage Rate Requirement – Material Weakness in Internal Controls over Compliance/Material Noncompliance Recommendation: The auditor recommends the Organization strengthen the controls in place to provide assurance that contract agreements entered into with subcontractors contain the required clauses set by Davis-Bacon Act and projects that fall under the requirement maintain the weekly certified payrolls. Action Taken: The Director of Operations and management is aware of the noncompliance with the Davis-Bacon Act wage rate requirement. We understand the importance of implementing sound internal controls to ensure the company meets all federal and state compliance requirements. To prevent future noncompliance findings, The Learning Tree, Inc. will implement staff training to fully adhere to all applicable federal and state compliance requirements. In addition, the company will increase oversight over federal grant programs. Responsible Person: Ben Rogers, Director of Operations Anticipated Completion Date: December 31, 2024.

View Audit 340570 Questioned Costs: $1

Finding 520754 (2023-002)

Material Weakness 2023

East Marshall Community School District

IA

Internal Control / Segregation of Duties

The District continues to have segregation of duties as a priority. We accept the auditor’s guidance and continue to keep the task of segregation of duties as a priority.

View Audit 340517

Finding 520700 (2023-004)

Material Weakness 2023

Community Health and Emergency Services, Inc.

IL

Internal Control / Segregation of Duties Special Tests & Provisions Eligibility

2023-004 Ineffective Internal Controls over Sliding Fee Revenues Health Center Program – CFDA #93.527 & 93.224 Condition: During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted the following exceptions: • Three (3) out...

2023-004 Ineffective Internal Controls over Sliding Fee Revenues Health Center Program – CFDA #93.527 & 93.224 Condition: During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted the following exceptions: • Three (3) out of eighteen (18) sampled did not have the slide fee applied to the lab portion. • Two (2) out of eighteen (18) sampled were calculated incorrectly based on the sliding fee schedule (wrong sliding fee applied based on application). • Two (2) out of eighteen (18) sampled were missing applications. • One (1) out of eighteen (18) sampled were incorrectly in the system with a medical slide A on a dental charge. This patient was also one of the sampled items missing an application so it could not be determined if slide A would have been correct. Action Taken: • CHESI has implemented a new workflow process to ensure compliance with the program requirements of the sliding fee program. CHESI has developed a new sliding fee procedure and trained all staff to ensure the applications are complete and signed by the patient, income is verified, the proper discount is calculated based on the sliding fee schedule, the proper amount of discount is applied to the patient’s account, and the application is approved and signed by the CFO. All sliding fee applications will also be scanned into the patient’s chart once completed and approved. Anticipated Date of Completion and Name of Contact Person: December 31, 2023 – J.P. Champion, Chief Financial Officer

View Audit 340436

Finding 520582 (2023-001)

Material Weakness 2023

Centennial Square

MN

Material Weakness Reporting Internal Control / Segregation of Duties

Management will continue to rely on CliftonLarsonAllen to draft the financial statements and the related notes to the financial statements, and will review, approve, and accept responsibility for the annual financial statements prior to their issuance.

View Audit 340189

Finding 520555 (2023-001)

Significant Deficiency 2023

Housing Authority of Portage County

WI

Internal Control / Segregation of Duties

The Authority’s Board of Commissioners and management will continue to rely on the use of their outside auditors to prepare draft financial statements that were presented in accordance with generally accepted accounting principles. Management will assign a person within the Authority with the skills...

The Authority’s Board of Commissioners and management will continue to rely on the use of their outside auditors to prepare draft financial statements that were presented in accordance with generally accepted accounting principles. Management will assign a person within the Authority with the skills, knowledge and expertise to review and approve the draft financial statements.

View Audit 340118

Finding 520554 (2023-004)

Significant Deficiency 2023

Ventures

WA

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

Coronavirus State and Local Fiscal Recovery Funds -Assistance Listing No. 21.027 Recommendation: We recommend that approval of all expenditures, whether initiated by an invoice or a journal entry be documented. In the case where the expenditure is likely to be charged to a Federal program, it is rec...

Coronavirus State and Local Fiscal Recovery Funds -Assistance Listing No. 21.027 Recommendation: We recommend that approval of all expenditures, whether initiated by an invoice or a journal entry be documented. In the case where the expenditure is likely to be charged to a Federal program, it is recommended there be documentation of approval from someone knowledgeable of allowability of costs (it is permissible if this is the same individual as the initial approver). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Ventures has moved to keeping copies of the check requests/payment requests and invoice in a restricted folder. The check request is initiated by someone knowledgeable of the program and approved by an overseeing director, also knowledgeable of the program. These two documents are required for accounting to pay and will be returned without proper approval and corresponding invoice. Name(s) of the contact person(s) responsible for corrective action: Theo Everheart and Monique Valenzuela Planned completion date for corrective action plan: 09/30/2024

View Audit 340111 Questioned Costs: $1

Finding 520343 (2023-003)

Material Weakness 2023

Talbot County Board of Education

GA

Cash Management Subrecipient Monitoring Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.305 § 200.511

FA 2023-003 Improve Controls over Cash Management Compliance Requirement: Cash Management Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listi...

FA 2023-003 Improve Controls over Cash Management Compliance Requirement: Cash Management Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 84.010 - Title I Grants to Local Educational Agencies Federal Award Number: SO10A210010-21A (Year: 2022) SO10A220010 (Year: 2023) Questioned Costs: None Identified Repeat of Prior Year Finding: FA 2022-003, FA 2021-001, FA 2020-001, FA 2019-001, FA 2018-001, FA 2017-002, FA 2016-001, FA 2015-002, FA 2014-003 Description: The School District made cash drawdowns in excess of immediate cash needs for the Title I Grants to Local Educational Agencies and Elementary and School Emergency Relief Fund programs. Corrective Action Plans: District office has put procedures in action to make sure that all drawdowns are in line with expenditures. All draw down packets will be viewed and singed off by federal programs director. This packet will include detail expenditure sheet for the month, year to date expenditure report and a cover sheet. Estimated Completion Date: December 31, 2024 Contact Person: Torrence H. Freeman, III CFO Telephone: 706-665-8577 Email: tfreeman@talbot.k12.ga.us

View Audit 340053

Finding 520230 (2023-003)

Material Weakness 2023

New York State Sheriffs' Association

NY

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

Invoices received by NYSSA pertaining to Federal Grants will be given to the Deputy Director, Lucas Ashby for review. (current procedure). Invoices to be paid will be entered into Quickbooks financial software by the Finance Manager, Jon Greenwalt (current procedure). Checks for payment to grant ven...

Invoices received by NYSSA pertaining to Federal Grants will be given to the Deputy Director, Lucas Ashby for review. (current procedure). Invoices to be paid will be entered into Quickbooks financial software by the Finance Manager, Jon Greenwalt (current procedure). Checks for payment to grant vendors follow the same procedures and processes as listed in 2022-001 above, numbers 1 and 2 [New procedure implemented]. Based on the timeline of the 2022 audit, many of the corrective actions were made in late Oct/November 2023.

View Audit 339861

Finding 520210 (2023-007)

Material Weakness 2023

I&f Incorporated Nfp

IL

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles

FINDING 2023-007: LACK OF INTERNAL CONTROLS OVER COMPLIANCE Corrective Action Plan A compliance management framework will be developed by March 31, 2025, and training for relevant staff will begin shortly thereafter. Monitoring mechanisms and documentation practices will also be implemented to ensu...

FINDING 2023-007: LACK OF INTERNAL CONTROLS OVER COMPLIANCE Corrective Action Plan A compliance management framework will be developed by March 31, 2025, and training for relevant staff will begin shortly thereafter. Monitoring mechanisms and documentation practices will also be implemented to ensure ongoing compliance. Estimated Completion Date: 3/31/2025 Contact Person for Implementation of All Corrective Action Plans: Andre Thomas (Executive Director) (773) 756-6806

View Audit 339764

Finding 520151 (2023-004)

Significant Deficiency 2023

City of Alamogordo

NM

Internal Control / Segregation of Duties HUD Housing Programs Significant Deficiency

Auditor's Recommendation – CRI recommends that the contract immediately be amended to include the required prevailing wage rate clauses. Furthermore, a review process should be implemented to ensure all future contracts comply with prevailing wage requirements. Views of Responsible Officials and Pla...

Auditor's Recommendation – CRI recommends that the contract immediately be amended to include the required prevailing wage rate clauses. Furthermore, a review process should be implemented to ensure all future contracts comply with prevailing wage requirements. Views of Responsible Officials and Planned Corrective Action – Prior to the transfer of the Housing Authority to the Eastern Regional Housing Authority (ERHA), the City of Alamogordo did not understand the limitations of the ERHA accounting and financial system. Since this time, the City has had multiple conversations with ERHA leadership about their financials systems. The City has no authority over ERHA and does not expect any changes in their accounting practices. Responsible Person – ERHA Accounting Staff Targeted Date of Completion – Fiscal Year 2025

View Audit 339709

Finding 520108 (2023-002)

Material Weakness 2023

City of Allentown

PA

Special Tests & Provisions HUD Housing Programs Internal Control / Segregation of Duties

Finding 2023-002-SpecialTests and Provisions-Citizen Participation Repeat Finding-See Finding 2022-003 Recommendation: We recommend the City implement internal control procedures to ensure compliance with citizen participation requirements and such documentation is maintained for annual HUD submissi...

Finding 2023-002-SpecialTests and Provisions-Citizen Participation Repeat Finding-See Finding 2022-003 Recommendation: We recommend the City implement internal control procedures to ensure compliance with citizen participation requirements and such documentation is maintained for annual HUD submission. Action Taken: The City has adopted HUD regulations to comply with all citizen participation requirements (24 CFR 91.105). These were implemented January 1, 2024.

View Audit 339690

Finding 520094 (2023-002)

Significant Deficiency 2023

Village of Villa Park

IL

Internal Control / Segregation of Duties

Finding 2023 – 002: Audit Journal Entries Condition: During audit fieldwork, our testing resulted in audit adjustments in order to present materially accurate financial statements. Plan: The Finance Director, along with staff, will review year-end adjustments as part of the audit preparation process...

Finding 2023 – 002: Audit Journal Entries Condition: During audit fieldwork, our testing resulted in audit adjustments in order to present materially accurate financial statements. Plan: The Finance Director, along with staff, will review year-end adjustments as part of the audit preparation process and work to reduce the number of entries proposed by the auditors and prepare fully adjusted financial statements prior to audit fieldwork. Anticipated Date of Completion: December 31, 2024

View Audit 339645

Finding 520093 (2023-001)

Material Weakness 2023

Village of Villa Park

IL

Cash Management Reporting Internal Control / Segregation of Duties

Finding 2023 – 001: Restatement to Fund Balance Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to correct insurance improperly recorded in prior years. Plan: The Village will implement internal controls to properly record insurance expenses, payable...

Finding 2023 – 001: Restatement to Fund Balance Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to correct insurance improperly recorded in prior years. Plan: The Village will implement internal controls to properly record insurance expenses, payables, and prepaid expenses on a timely basis prior to audit fieldwork. Additionally, the Finance Director will provide monthly reviews of the financial statements. Anticipated Date of Completion: December 31, 2024

View Audit 339645

Finding 520087 (2023-001)

Significant Deficiency 2023

Camcare Health Corporation

NJ

Special Tests & Provisions HUD Housing Programs Internal Control / Segregation of Duties

CAMcare has made significant revisions to the financial screening department's leadership and workflows. We have since revised our Sliding Fee Scale Policy, the scale itself, and the SOPs for both Financial Screening of Uninsured and Underinsured Patients and Financial Assistance. All patient regist...

CAMcare has made significant revisions to the financial screening department's leadership and workflows. We have since revised our Sliding Fee Scale Policy, the scale itself, and the SOPs for both Financial Screening of Uninsured and Underinsured Patients and Financial Assistance. All patient registration areas have the latest board-approved sliding fee scale, and the changes were announced during a weekly staff huddle. All PSRs and Financial Screeners were made aware of the change. The new Manager of the financial screening department has provided the team with subject matter expertise, additional training, and increased accountability in work product. CAMcare also has a new EMR system, Epic, (December of 2023) where applications are housed and tracked, creating a single record for financial screening with patient changes being more streamlined. The latest sliding fee scales have been uploaded to the EMR. Patients with applications in progress can be edited as needed more efficiently.

View Audit 339613

Finding 520084 (2023-003)

Material Weakness 2023

City of Gary

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.303

CORRECTIVE ACTION PLAN FINDING 2023-003 Contact Person Responsible for Corrective Action: Ragen Hatcher Contact Phone Number: 219‐881‐5085 View of Responsible Officials: We Concur Description of Corrective Action: The City will work with the department to develop a review process for the PR29 quarte...

CORRECTIVE ACTION PLAN FINDING 2023-003 Contact Person Responsible for Corrective Action: Ragen Hatcher Contact Phone Number: 219‐881‐5085 View of Responsible Officials: We Concur Description of Corrective Action: The City will work with the department to develop a review process for the PR29 quarterly reports, Section 2 Summary Reports, and FFATA report prior to submission to address internal control concerns. Anticipated Completion Date: November 2025

View Audit 339577

Finding 520056 (2023-001)

Significant Deficiency 2023

Safer New Mexico Now, Inc.

NM

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

Department of Transportation Safer New Mexico Now, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: January 1, 2023 to December 31, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings...

Department of Transportation Safer New Mexico Now, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: January 1, 2023 to December 31, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT There were no findings or matters required to be reported in accordance with Governmental Auditing Standards. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY Department of Transportation 2023-01 ALLOWABILITY – INTERNAL CONTROLS OVER PAYROLL DISBURSEMENTS, FINANCIAL CLOSE, AND REPORTING (REPEATED - PREVIOUSLY 2022-02) Federal Program Title(s): ALN 20.600 – State and Community Highway Safety ALN 20.608 – Minimum Penalties for Repeat Offenders for Driving While Intoxicated ALN 20.616 – National Priority Safety Program Recommendation: CLA recommends management continue to assess the current procedures for payroll allocations to ensure that expenditures are not claimed in error.. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action Planned/Taken in response to finding: The individual directly responsible for the errors is no longer with the Organization and the duties related to payroll have been assigned to someone more familiar with the responsibility that the role entails. The Organization has retained the services of a skilled accounting team to conduct a thorough review and assessment of all payroll related policies and procedures. As a result, processes have been updated and duties have been segregated related to this process. The Organization has implemented new procedures to verify and confirm payroll allocations, added in additional layers of review, and reinforced accountability to ensure accurate reporting and allocation moving forward. Name(s) of the contact person(s) responsible for corrective action: Lisa Kelloff, CEO Planned completion date for corrective action plan: Safer has currently implemented the above noted responses to the finding during 2024. If the Department of Transportation or other Cognizant or Oversight Agency for Audit has questions regarding this plan, please call Lisa Kelloff, CEO at 505-856-6143.

View Audit 339565 Questioned Costs: $1

Finding 520043 (2023-001)

Significant Deficiency 2023

Northwestern Illinois Community Action Agency

IL

Internal Control / Segregation of Duties

NICAA will be strengthening their controls around year end close reporting. NICAA will be transitioning to MIP grant fund accounting system. This system will be implemented by year end of 2025

View Audit 339530

Finding 520009 (2023-004)

Significant Deficiency 2023

El Programa Hispano Catolico

OR

Internal Control / Segregation of Duties Reporting Significant Deficiency

The Director of Finance and Accounting Manager are working with the Billing Specialists to ensure all invoices are filed in a timely manner to funders. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instructed to save ...

The Director of Finance and Accounting Manager are working with the Billing Specialists to ensure all invoices are filed in a timely manner to funders. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instructed to save on SharePoint all communication with funders regarding changes of when invoices are to be filed when the instructions differ from the agreement. These conversations occurred with the team in July 2024.

View Audit 339475

Finding 520007 (2023-003)

Significant Deficiency 2023

El Programa Hispano Catolico

OR

Internal Control / Segregation of Duties Reporting Significant Deficiency

The Director of Finance and Accounting Manager are working with the Billing Specialists and program managers and directors to ensure all reports are filed in a timely manner to funders. The internal procedures include required communication between Accounting Manager and finance or program staff to ...

The Director of Finance and Accounting Manager are working with the Billing Specialists and program managers and directors to ensure all reports are filed in a timely manner to funders. The internal procedures include required communication between Accounting Manager and finance or program staff to verify the reports were prepared and submitted following the contract requirements. These conversations occurred with the finance team in July 2024 and program managers and directors in December 2024.

View Audit 339475

Finding 519993 (2023-002)

Material Weakness 2023

Lamoni Community School District

IA

Reporting Internal Control / Segregation of Duties

The District reviews this audit finding internally on an annual basis, identifying control procedures and processes that would leverage movement toward the maximum internal control possible with available staffing. The District does recognize this is difficult with a limited number of employees. We ...

The District reviews this audit finding internally on an annual basis, identifying control procedures and processes that would leverage movement toward the maximum internal control possible with available staffing. The District does recognize this is difficult with a limited number of employees. We will continue to review our procedures to best meet the needs of the District as well as have internal control in place. We will work on dividing out duties and responsibilities so no one person is handling all cash, receipts, and financial transactions without checks & balance in place. A Business Office employee will collect cash and count, and another person will create the deposit slip, with a 3rd person (front office secretary) taking the actual deposit to the bank. Then the Business office employee will be the one responsible for entering the cash receipt into Software.

View Audit 339431

Finding 519917 (2023-004)

Significant Deficiency 2023

Gateway Community Health Centers, Inc.

NC

Internal Control / Segregation of Duties Significant Deficiency Special Tests & Provisions

Responsible Parties: Board of Directors (Dr. Althea Riddick, Chair). Corrected. The Board Members are currently compliance. Anticipated Date of Completion: Deadline: This is an ongoing requirement.

View Audit 339360

Finding 519914 (2023-001)

Material Weakness 2023

Gateway Community Health Centers, Inc.

NC

Internal Control / Segregation of Duties Subrecipient Monitoring § 200.510

Responsible Parties: Chief Executive Officer (Rose Turner), Interim Chief Financial Officer (Dan Miles), Finance Director (Kelly Glover) Gateway’s Management will utilize the implemented Matrix duties and responsibilities Grid to help monitor the documentation of required procedures and Standard Ope...

Responsible Parties: Chief Executive Officer (Rose Turner), Interim Chief Financial Officer (Dan Miles), Finance Director (Kelly Glover) Gateway’s Management will utilize the implemented Matrix duties and responsibilities Grid to help monitor the documentation of required procedures and Standard Operating Procedures approved by the Board of Directors. The health center will use the approved Financial Policies and Procedures Manual as its Standard Operating Procedures. The Health Center’s Management employs key management staff that reflects the size and composition of a health center. Ongoing evaluations will be used to monitor the qualifications of the staff. This Audit is a late submission, however with the submission a qualified Chief Financial Officer is in place and has the qualifications needed to assess and train staff accordingly and provide recommended changes to the department. This new Chief Financial Officer will serve as a technical resource to assist with the implementation of all the resolutions to the findings of the 2022 and 2023 audits

View Audit 339360

Finding 519903 (2023-002)

None 2023

Rumford-Mexico Sewerage District

ME

Reporting Internal Control / Segregation of Duties § 200.512

Management will work with the audit firm to plan, schedule, and begin the audit process to meet the deadline set by Uniform Guidance.

View Audit 339272

Corrective Action Plans

Filters