Corrective Action Plans

Finding 479715 (2023-002)

Significant Deficiency 2023

NE

Internal Control / Segregation of Duties Reporting Significant Deficiency

The City council closely monitors all accounting functions and is aware of the limited number of personnel in the Finance Office and the distribution of duties.

View Audit 316282

Finding 479710 (2023-002)

Material Weakness 2023

Harvest Regional Food Bank, Inc.

AR

Special Tests & Provisions Material Weakness Reporting

All federal food commodities received will be entered into the SMF QuickBooks system and reported to the Arkansas Department of Education (ADE) within 48 hours of delivery by the Operations Manager or his assistant. All federal food receipts will be verified by a secondary employee monthly to ensure...

All federal food commodities received will be entered into the SMF QuickBooks system and reported to the Arkansas Department of Education (ADE) within 48 hours of delivery by the Operations Manager or his assistant. All federal food receipts will be verified by a secondary employee monthly to ensure ADE has received and properly processed the submission into their system. Any discrepancies will be discussed and corrected as necessary. Harvest will perform an inventory count quarterly and adjust inventory amounts as needed in the SMF QuickBooks system.

View Audit 316274

Finding 479691 (2023-002)

Material Weakness 2023

Family Life Center, Inc.

AL

Reporting Internal Control / Segregation of Duties

The Organization had a complex acquisition transaction that was not recorded correctly. This type of transaction is not common to the organization and additional information was obtained from the auditor to determine the correct accounting. Management will implement policies to insure that these t...

The Organization had a complex acquisition transaction that was not recorded correctly. This type of transaction is not common to the organization and additional information was obtained from the auditor to determine the correct accounting. Management will implement policies to insure that these types of transactions are reviewed and recorded correctly on a more timely basis in the future.

View Audit 316236

Finding 479690 (2023-001)

Material Weakness 2023

Family Life Center, Inc.

AL

Internal Control / Segregation of Duties Reporting Subrecipient Monitoring

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 appro...

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 316236

Finding 479689 (2023-006)

Significant Deficiency 2023

Housing Authority of Newberry

SC

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

2023-006 ALN 14.872 - Capital Funds Program - Special Tests - Environmental Reviews Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Jessica Holcomb, Executive D...

2023-006 ALN 14.872 - Capital Funds Program - Special Tests - Environmental Reviews Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Jessica Holcomb, Executive Director Projected Completion Date: December 31, 2024

View Audit 316234

Finding 479687 (2023-004)

Significant Deficiency 2023

Housing Authority of Newberry

SC

Eligibility HUD Housing Programs Internal Control / Segregation of Duties

2023-004 ALN 14.871 – Housing Voucher Cluster – Eligibility Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Jessica Holcomb, Executive Director Projected Comple...

2023-004 ALN 14.871 – Housing Voucher Cluster – Eligibility Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Jessica Holcomb, Executive Director Projected Completion Date: December 31, 2024

View Audit 316234

Finding 479686 (2023-003)

Significant Deficiency 2023

Housing Authority of Newberry

SC

Eligibility HUD Housing Programs Internal Control / Segregation of Duties

2023-003 ALN 14.850 - Public & Indian Housing Program - Eligibility Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Jessica Holcomb, Executive Director Projecte...

2023-003 ALN 14.850 - Public & Indian Housing Program - Eligibility Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Jessica Holcomb, Executive Director Projected Completion Date: December 31, 2024

View Audit 316234

Finding 479685 (2023-002)

Significant Deficiency 2023

Housing Authority of Newberry

SC

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

2023-002 ALN 14.850 - Public & Indian Housing Program - Allowable Activities - Use of Operating Funds for Capital Improvements Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correcti...

2023-002 ALN 14.850 - Public & Indian Housing Program - Allowable Activities - Use of Operating Funds for Capital Improvements Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Jessica Holcomb, Executive Director Projected Completion Date: December 31, 2024

View Audit 316234 Questioned Costs: $1

Finding 479661 (2023-005)

Material Weakness 2023

Universal Academy Charter School

MN

Reporting Internal Control / Segregation of Duties § 200.502 § 200.510

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE – SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS 2023-005 Reporting Compliance Requirement Finding Summary 2 CFR § 200.510 requires that the Academy prepare appropriate financial statements, including the Schedule of Expenditures of Federal Awar...

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE – SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS 2023-005 Reporting Compliance Requirement Finding Summary 2 CFR § 200.510 requires that the Academy prepare appropriate financial statements, including the Schedule of Expenditures of Federal Awards (SEFA) for the year ended June 30, 2023, which must include the total federal awards expended as determined in accordance with 2 CFR § 200.502. Management is responsible for establishing and maintaining effective internal controls over compliance with requirements applicable to federal programs, including separately tracking federal expenditures within the finance system to provide for accurate preparation of the SEFA. During our audit, we noted the Academy did not have sufficient controls in place to ensure completeness of the SEFA and compliance with this requirement. The Academy’s SEFA was understated by $158,815 in federal expenditures related to the Emergency Connectivity Fund federal program. Corrective Action Plan Actions Planned – The Academy will implement new processes and procedures which address this internal control finding to comply with the Uniform Guidance in the future. Official Responsible – The Academy’s Executive Director, Farhiya Einte. Planned Completion Date – June 30, 2024. Disagreement With or Explanation of Finding – The Academy agrees with this finding. Plan to Monitor – The Academy’s Executive Director, Farhiya Einte, will assure appropriate internal controls and procedures are in place to ensure compliance with reporting compliance requirements in the future.

View Audit 316231

Finding 479620 (2023-002)

Significant Deficiency 2023

Iowa Regional Utilities Association

IA

Internal Control / Segregation of Duties Significant Deficiency

The Association has implemented controls to help mitigate the segregation of duties issue noted. The CEO reviews and approves all invoices prior to payment. The Association provides a list of disbursements to the Board of Directors monthly as well as a completed set of financial statements. Manageme...

The Association has implemented controls to help mitigate the segregation of duties issue noted. The CEO reviews and approves all invoices prior to payment. The Association provides a list of disbursements to the Board of Directors monthly as well as a completed set of financial statements. Management, including the Board of Directors, continues to have discussions regarding cost effective methods to obtain additional controls, including potential new staff and realignment of duties, however, at this time, the Association has determined that the cost of eliminating this deficiency would exceed its benefit.

View Audit 316211

Finding 479605 (2023-003)

Significant Deficiency 2023

Iron County Hospital District Dba: Iron County Medical Center

IL

Allowable Costs / Cost Principles Reporting Significant Deficiency

DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023 – 003 COVID-19 Provider Relief Funding and American Rescue Plan Rural Payments Recommendation: We recommend the Medical Center design controls to ensure documentation is completed timely and sufficiently on how costs are necessary to respond to COVID-19....

DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023 – 003 COVID-19 Provider Relief Funding and American Rescue Plan Rural Payments Recommendation: We recommend the Medical Center design controls to ensure documentation is completed timely and sufficiently on how costs are necessary to respond to COVID-19. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management has identified that the Medical Center has more than a sufficient amount of lost revenues related to COVID-19 to offset this difference. Action taken in response to finding: The Medical Center will ensure that controls are put into place to capture Covid specific costs in accordance with HHS guidelines. Name of the contact person responsible for corrective action: Kayla Chamberlin, Controller Planned completion date for corrective action plan: July 1, 2023

View Audit 316188

Finding 479601 (2023-002)

Significant Deficiency 2023

City of Peoria, Illinois

IL

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Significant Deficiency

U.S. DEPARTMENT OF COMMERCE 2023-002 COVID 19 – Coronavirus State and Local Fiscal Recovery Funds (Federal Assistance Listing Number 21.027) Recommendation: To ensure compliance, we recommend strengthening of internal control by training multiple staff how to complete vendor checks required by the U...

U.S. DEPARTMENT OF COMMERCE 2023-002 COVID 19 – Coronavirus State and Local Fiscal Recovery Funds (Federal Assistance Listing Number 21.027) Recommendation: To ensure compliance, we recommend strengthening of internal control by training multiple staff how to complete vendor checks required by the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The vendor status was not properly checked due to staff oversight and unfamiliarity with compliance requirements. The City has educated staff entering contracts that will use grant funding on the importance of checking for suspended or debarred status before engaging. Training of staff on procedures to check suspended or debarred status will also be implemented. Name of the contact person responsible for corrective action: Kyle Cratty, Finance Director Planned completion date for corrective action plan: On-going

View Audit 316174

Finding 479596 (2023-001)

Significant Deficiency 2023

Town of Westernport

MD

Internal Control / Segregation of Duties

TOWN PLANS TO REVIEW INTERNAL CONTROLS

View Audit 316141

Finding 479582 (2023-001)

Material Weakness 2023

Care Alliance Health Center

CT

Special Tests & Provisions Subrecipient Monitoring Eligibility

To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2023 The findings from the October 31, 202...

To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2023 The findings from the October 31, 2023, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Federal Award Findings: Finding 2023.001 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken We will invest the time and resources into improving all areas related to the Sliding Fee Scale. We will implement the following steps to our process to ensure all federal guidelines and requirements are met. 1. Documented Process: Design and implement an internal control process to ensure sliding fee discounts are accurately calculated based on family size and income. 2. Documented Procedures: Establish clear procedures and guidelines for front desk staff to follow when determining discounts, including appropriate documentation requirements, eligibility criteria, and fee structure. These procedures will be aligned with our written policy to ensure consistency and accuracy in discount calculations. 3. Training and Education: Provide training to front desk staff members responsible for determining eligibility and applying sliding fee discounts to ensure they understand the process. 4. Regular Reviews: Implement regular reviews and monthly audits to verify that all discounts are properly supported and documented. Quarterly reviews will be conducted to verify compliance, identify areas for improvement, and evaluate the effectiveness of the sliding scale fee program to ensure it meets our patients' needs and complies with all federal guidelines. Responsible Parties: 1. The Controller and revenue cycle staff will develop the written procedure. 2. The Clinical Support Supervisor and revenue cycle staff will overseE3 the training. 3. The Revenue Cycle Manager_will monitor adherence to the procedure, conduct regular monthly audits, and report results to the Controller. 4. The Controller will conduct quarterly documentation reviews of the internal audit results. Timeline: 1. Procedure draft completion: Completed 2. Review and approval by senior management: July 24, 2024 3. Initial staff training session: July 25, 2024 4. Follow-up training sessions: As needed 5. Monthly compliance audits: Starting September 1, 2024

View Audit 316128

Finding 479530 (2023-002)

Material Weakness 2023

Worker Education & Resource Center INC

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness

The Organization had a significant turnover in both Fiscal Manager Consultant and Executive Director during the year being audited. The Fiscal Manager Consultant was replaced by the Director of Finance in the later part of the fiscal year 2022-2023. This required the new Director of Finance to creat...

The Organization had a significant turnover in both Fiscal Manager Consultant and Executive Director during the year being audited. The Fiscal Manager Consultant was replaced by the Director of Finance in the later part of the fiscal year 2022-2023. This required the new Director of Finance to create and implement as many internal controls that were needed, that were not implemented, and/or recommended by our current CPA firm who had been previously auditing prior years. Additionally, our Director of Finance has engaged the Board of Directors in taking a more active role in the financial statement overview that was not previously recommended to them by our CPA firm.

View Audit 316070

Finding 479521 (2023-001)

Significant Deficiency 2023

End Domestic Abuse Wisconsin: the Wisconsin Coalition Against Domestic

WI

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

Condition and Cause: Due to staff turnover in Finance and the level of workload there were difficulties creating financial statements on a timely basis. Status: The Coalition is implementing a process to prepare, review, and approve financial statements to ensure that financials are reviewed and...

Condition and Cause: Due to staff turnover in Finance and the level of workload there were difficulties creating financial statements on a timely basis. Status: The Coalition is implementing a process to prepare, review, and approve financial statements to ensure that financials are reviewed and approved by Management on a regular basis. Corrective Action: End Abuse will take the following corrective actions: (1) End Abuse will create a process that involves the creation, review, and approval of financial statements. (2) The Finance Director will create the financial statements; the Executive Director or the Associate Director will review and approve them. (3) The Finance Director is currently recruiting for a staff accountant to help ease the workload. (4) The Board of Directors will review financial statements and/or financial reports on a quarterly basis to ensure that proper procedures are followed. Expected Completion Date: September 30, 2024

View Audit 316053

Finding 479513 (2023-003)

Material Weakness 2023

Christian Community Health Center

IL

Material Weakness Internal Control / Segregation of Duties

Finding Number: 2023-003 Sliding Scale Assessment Planned Corrective Action: CCHC has created a workflow for staff as a guide in processing the sliding fee scale. This workflow is approved by the Head Nurse Supervisor and signed. Please see attached workflow sheet. CCHC will verify with Athena EHR...

Finding Number: 2023-003 Sliding Scale Assessment Planned Corrective Action: CCHC has created a workflow for staff as a guide in processing the sliding fee scale. This workflow is approved by the Head Nurse Supervisor and signed. Please see attached workflow sheet. CCHC will verify with Athena EHR system to make sure that the most up to date poverty guidelines are in the system that is being used to calculate sliding fee discounts. Person Responsible for Corrective Action Plan: Pasue Mahan, Chief Clinic Officer Anticipated Date of Completion: 07/01/2024

View Audit 316037

Finding 479500 (2023-003)

Material Weakness 2023

Stoddard County Public Health Center

MO

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

Name of Contact Person: Ben Godwin, Director. Recommendation: We recommendthe Center verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000. Corrective Action: We will verify...

Name of Contact Person: Ben Godwin, Director. Recommendation: We recommendthe Center verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000. Corrective Action: We will verify all vendors' status using the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000. Proposed Completion Date: Immediately.

View Audit 316025

Finding 479493 (2023-001)

Significant Deficiency 2023

Summit Community Care Clinic, Inc.

CO

Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee ra...

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization acknowledges the error identified in the sliding fee discount. To address this issue and prevent future occurrences, the following corrective actions will be implemented: • Internal Audit Procedure o An internal audit procedure will be established to review 10% of the applications processed by each eligibility worker. This review will include verification of application accuracy, calculation correctness, and appropriate selection of sliding fee scales. • Identification of Errors o During the internal audit, if any errors are found, immediate action will be taken to rectify the identified mistakes. • Retraining and Testing o In cases where errors are detected, affected staff will undergo retraining. This retraining will cover all relevant processes and guidelines to ensure a thorough understanding. o Post-retraining, the staff will be subjected to a period of testing to confirm their competence in handling the sliding fee discount applications accurately. These steps will help ensure the integrity and accuracy of the Sliding Fee Discount program moving forward. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Dan Becker, CEO, at 970-423-8833.

View Audit 316020

Finding 479485 (2023-002)

Significant Deficiency 2023

City of Torrington, Connecticut

CT

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding 2023-002 - Reporting (COVID-19 American Rescue Plan Act Local Fiscal Recovery) Significant Deficiency – Internal Control over Compliance Other Matters (Noncompliance) Description of Finding - Controls over Project and Expenditure Reports did not exist to ensure accuracy of submitted data. ...

Finding 2023-002 - Reporting (COVID-19 American Rescue Plan Act Local Fiscal Recovery) Significant Deficiency – Internal Control over Compliance Other Matters (Noncompliance) Description of Finding - Controls over Project and Expenditure Reports did not exist to ensure accuracy of submitted data. Statement of Concurrence or NonConcurrence - Management agrees with the finding. Corrective Action - The City has implemented additional processes and controls related to the review of treasury reporting. However, these were not in place for all of the current year. Name of Contact Person - John Monks, Comptroller Projected Completion Date - June 30, 2024

View Audit 316014

Finding 479474 (2023-002)

Significant Deficiency 2023

City of Dillon

SC

Internal Control / Segregation of Duties

The Mayor and Council review monthly financial statements and budget reports to review and question the City Manager and Finance Director accordingly. The City Manager also performs supervisory checks on many areas. Due to the size of the City, the lack of segregation of duties will always exist, ...

The Mayor and Council review monthly financial statements and budget reports to review and question the City Manager and Finance Director accordingly. The City Manager also performs supervisory checks on many areas. Due to the size of the City, the lack of segregation of duties will always exist, but the City has instituted these safeguards to better monitor the City's financial reporting.

View Audit 316003

Finding 479460 (2023-001)

Material Weakness 2023

Feeding Illinois

IL

Cash Management Internal Control / Segregation of Duties

All future federal grant programs that require substantial lines of information and calculations to be submitted for reimbursement of allowable costs will be reviewed by at least two qualified persons before submission to the administering agency (e.g. IDHS)..

View Audit 315994

Finding 479458 (2023-004)

Material Weakness 2023

Frazer School District

MT

Internal Control / Segregation of Duties § 200.303

FINDING 2023-004: Impact Aid Application Controls Response: The District will review its internal control systems over its Impact Aid application and ensure that the document management systems are adequate to ensure appropriate filing of supporting documentation to the applications maintained.

View Audit 315988

Finding 479455 (2023-001)

Significant Deficiency 2023

Juneau County Housing Authority

WI

Internal Control / Segregation of Duties Reporting

Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongo...

Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongoing

View Audit 315985

Finding 479448 (2023-001)

Significant Deficiency 2023

Prairie View, Inc.

KS

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties

Criteria or Specific Requirement – Reporting (Reference number 2023-001) Recommendation – The Organization should continue to improve understanding of the guidance related to this type of reporting and work to identify areas for improvement prior to submission to the Provider Relief Fund reporting ...

Criteria or Specific Requirement – Reporting (Reference number 2023-001) Recommendation – The Organization should continue to improve understanding of the guidance related to this type of reporting and work to identify areas for improvement prior to submission to the Provider Relief Fund reporting portal. Management should ensure proper internal controls are put into place to ensure that allowable expenses reported are not reimbursed by other sources or in previous submission period. Views of Responsible Officials and Corrective Action Plan – Management agrees with the finding. The reporting discrepancy was due to a misunderstanding of how the cost portion of the report should have been presented. The presentation was submitted with the same methodology as the lost revenue presentation, which was on a cumulative basis vs. the incremental period required for costs. In addition, staff turnover, including the responsible official (CFO), during this period of time impacted the execution of the last repoting requirement and improper reporting to HHS. The Organization believes that it had sufficient lost revenues to justify retention of all PRF Period 4 funds. There is no expected future reporting for the Provider Relief Funds. Personnel Responsible – John Hydock, Interim CFO Timeline – There is no expected future PRF submissions, but in the event one is required, the Organization will have a quality control process in place to review reporting of expenses to ensure no duplication or carry-over of expenses occurs.

View Audit 315978

Corrective Action Plans

Filters