Corrective Action Plans

Finding 516660 (2023-004)

Significant Deficiency 2023

MO

Reporting Internal Control / Segregation of Duties

The Treasurer is preparing and reporting COVID-19 funds and will work with the County Clerk to ensure correct reporting in the future. The expected implementation date will be in the next reporting cycle of April 2024.

View Audit 334643

Finding 516658 (2023-001)

Significant Deficiency 2023

Envision Community Services INC

IL

Reporting Internal Control / Segregation of Duties

We will have our current accountant set a schedule for performing monthly closes of the financial statements so they can be presented in summary format to management and the board of directors. We will require that the President/CEO and other key members of the management team and the board of direc...

We will have our current accountant set a schedule for performing monthly closes of the financial statements so they can be presented in summary format to management and the board of directors. We will require that the President/CEO and other key members of the management team and the board of directors review the monthly financial reports provided by the accountant so that all board members understand the financial position and results of activities of ECS on a regular and consistent basis. Finally, we will develop a transition plan with procedures requiring that whomever is responsible for the accounting and financial reporting function for ECS reconcile all financial accounts and close the financial records for the month prior to departure to ensure a smooth transition ECS’s accounting and financial reporting function to the next person responsible for its maintenance

View Audit 334636

Finding 516587 (2023-002)

Significant Deficiency 2023

Southwestern Wisconsin Community Action Program, Inc.

WI

Questioned Costs Reporting Significant Deficiency § 200.512

2023-002: Late Audit Submission Auditor's Recommendation: SWCAP should take steps to ensure that its financial records are available in a timely manner to allow the audit to begin sufficiently before the audit due date. SWCAP also should work with their auditing firm to agree upon information that w...

2023-002: Late Audit Submission Auditor's Recommendation: SWCAP should take steps to ensure that its financial records are available in a timely manner to allow the audit to begin sufficiently before the audit due date. SWCAP also should work with their auditing firm to agree upon information that will and will not be prepared by SWCAP so that a proper audit plan can be developed for timely completion. Corrective Action: SWCAP acknowledges the delay in completing the 2023 audit. The unforeseen staffing challenges by our auditing firm in conjunction with our internal turnover significantly impacted our timeline. SWCAP has identified and implemented changes with its personnel and hired an outsourced accounting firm. SWCAP has implemented proactive measures to streamline its audit preparation and submission processes to prevent similar delays in the future. These include enhancing internal review procedures, ensuring clear communication with auditors, and allocating sufficient resources for timely compliance with reporting requirements, federal regulations, and guidelines. Responsible for Corrective Action: Finance Team (Outsourced accounting firm, Operations Manager, Executive Director). Anticipated Completion Date: Completed as of December 2024.

View Audit 334558

Finding 516515 (2023-001)

Significant Deficiency 2023

Camcare Health Corporation

NJ

Questioned Costs Special Tests & Provisions HUD Housing Programs

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 334424

Finding 516513 (2023-001)

Significant Deficiency 2023

Calvary Apartments, Inc.

WI

Internal Control / Segregation of Duties Reporting

The Company does not have the resources and/or staff to prepare the financial statements and the related notes but will continue to oversee the auditor’s services and review and approve the financial statements and the related notes.

View Audit 334422

Finding 516511 (2023-001)

Significant Deficiency 2023

Calvary Development Apartment, Inc.

WI

Internal Control / Segregation of Duties Reporting

The Company does not have the resources and/or staff to prepare the financial statements and the related notes but will continue to oversee the auditor’s services and review and approve the financial statements and the related notes.

View Audit 334421

Finding 516505 (2023-001)

None 2023

Housing Authority of the City of Fort Myers

FL

HUD Housing Programs Eligibility Internal Control / Segregation of Duties

The following procedure is put in place to prevent the conditins found during a recent audit review of the LIPH and HCV files: All staff will read HUD requirements for reexamining income and family composition for families in the Public Housing and Housing Voucher Programs. Property managers will ...

The following procedure is put in place to prevent the conditins found during a recent audit review of the LIPH and HCV files: All staff will read HUD requirements for reexamining income and family composition for families in the Public Housing and Housing Voucher Programs. Property managers will be reuqiqred to complete training courses in 2024. Property clerks and leasing specialists will be required to complete Rent Calculation courses that coorelate to their program type. HACFM is actively working on creating operation procedures and process manuals. the Procedure manaul will include the following reuqirements: Annual recertificaton packets will be sent to the resident 120 days from the houshold's annual effective date. Submission of reuqired documentation from resident will be enforced according to the lease agreements. A certification review checklist to support staff in ensuring all documnetation is in the file and all requried signatures are present. The Checklist will ensure that the submitter is verifying the file, the property manager has certified the file prior to finalizing the review in the tenant software program and uploading the file to the records. The property manager is reuqired to conduct 5% audit of the files monthly and correct any deficiencies found. An audit checklist will be created to support this required task. The management analyst position is required to audit 5 random files from each site on a quarterly basis. Ans audit checklist will be createdto support this required task.

View Audit 334417

Finding 516504 (2023-002)

Significant Deficiency 2023

Housing Authority of the City of Fort Myers

FL

Questioned Costs Eligibility HUD Housing Programs

The following procedure is put in place to prevent the conditins found during a recent audit review of the LIPH and HCV files: All staff will read HUD requirements for reexamining income and family composition for families in the Public Housing and Housing Voucher Programs. Property managers will ...

The following procedure is put in place to prevent the conditins found during a recent audit review of the LIPH and HCV files: All staff will read HUD requirements for reexamining income and family composition for families in the Public Housing and Housing Voucher Programs. Property managers will be reuqiqred to complete training courses in 2024. Property clerks and leasing specialists will be required to complete Rent Calculation courses that coorelate to their program type. HACFM is actively working on creating operation procedures and process manuals. the Procedure manaul will include the following reuqirements: Annual recertificaton packets will be sent to the resident 120 days from the houshold's annual effective date. Submission of reuqired documentation from resident will be enforced according to the lease agreements. A certification review checklist to support staff in ensuring all documnetation is in the file and all requried signatures are present. The Checklist will ensure that the submitter is verifying the file, the property manager has certified the file prior to finalizing the review in the tenant software program and uploading the file to the records. The property manager is reuqired to conduct 5% audit of the files monthly and correct any deficiencies found. An audit checklist will be created to support this required task. The management analyst position is required to audit 5 random files from each site on a quarterly basis. Ans audit checklist will be createdto support this required task.

View Audit 334417

Finding 516482 (2023-001)

Material Weakness 2023

Wahkiakum County

WA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Wahkiakum County January 1, 2023 through December 31, 2023 This schedule presents the corrective action the County is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Wahkiakum County January 1, 2023 through December 31, 2023 This schedule presents the corrective action the County is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-001 Finding caption: The County did not have adequate controls for ensuring compliance with federal requirements for allowable activities and costs. Name, address, and telephone of County contact person: Tammy Peterson, PO Box 85, 360-795-8005 Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). A request was made to the payroll department for a report for the Sheriff’s office for the August payroll. I meant the July time issued on August 5th. The report I received was for August time with a September 5th pay date. This was a misunderstanding and not an intentional oversight. In the future, we will ensure that the report dates match the payroll we are requesting. Anticipated date to complete the corrective action: September 13, 2024

View Audit 334391 Questioned Costs: $1

Finding 516472 (2023-009)

Material Weakness 2023

Academy of America

MI

Questioned Costs Subrecipient Monitoring Material Weakness § 200.303

View of Responsible Officials and Corrective Action Plan – Management will monitor the review and approval procedures for reporting to ensure that reports are signed off to indicated and document that review and approval has been made.

View Audit 334382

Finding 516365 (2023-001)

Significant Deficiency 2023

Urban Community School

OH

Questioned Costs Internal Control / Segregation of Duties

Corrective Actions: We have re-assigned responsibility for submitting receipts for credit card charges to the Manager of the Food Service Program, who has been running our program for 18 years. We sent our policy on receipt requirements for all credit card receipts to all relevant staff. The CFO and...

Corrective Actions: We have re-assigned responsibility for submitting receipts for credit card charges to the Manager of the Food Service Program, who has been running our program for 18 years. We sent our policy on receipt requirements for all credit card receipts to all relevant staff. The CFO and Business Manager will both review the monthly credit card charges for appropriate supporting documentation for credit card charges.

View Audit 334301

Finding 516325 (2023-002)

Material Weakness 2023

All Nations Health Center, Inc.

MT

Questioned Costs Subrecipient Monitoring Eligibility

All Nations Health Center has switched EHR systems that allows for intake coordinators to suspend/pause eligibility status until all proper documentation has been obtain from the client, scanned into the system, and filed appropriately.

View Audit 334164

Finding 516271 (2023-002)

Significant Deficiency 2023

Blackbelt Unincorporated Wastewater Program

AL

Reporting Internal Control / Segregation of Duties

The Program engaged a qualified CPA firm for the Single Audit as soon as possible and the report was submitted as soon as possible. Individual(s) Responsible Sherry Bradley Completion Date Plan has been implemented as soon as possible.

View Audit 334090

Finding 516134 (2023-002)

Material Weakness 2023

Kalama School District

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Questioned Costs

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Kalama School District No. 402 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Fed...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Kalama School District No. 402 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-002 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: James Capen Director of Business Services 360-673-5282 Corrective action the auditee plans to take in response to the finding: The Kalama School District has taken the following steps to ensure that we are currently in compliance, and will continue to stay in compliance, with the Davis-Bacon Act; 1. All new contractors and existing contractors covered by the Davis-Bacon Act will submit certification attesting to compliance of prevailing wage requirements. 2. District staff will review the State Labor and Industries prevailing wage and certification website on a weekly basis when work is performed or collect a certified payroll record from the contractor on a weekly basis. 3. All new staff that have purchasing or financial oversight will be trained on these procedures when hired and on an ongoing basis. Anticipated date to complete the corrective action: 7-26-24

View Audit 333974

Finding 516123 (2023-001)

None 2023

National Association of Police Athletic/activities Leagues, Inc.

DC

Reporting Internal Control / Segregation of Duties § 200.512

Management’s Response: Management acknowledges the delay in submission and is taking corrective action to address the issue. Steps include improving internal controls, implementing a detailed timeline for the audit process, etc. Management is committed to ensuring future compliance with reporting de...

Management’s Response: Management acknowledges the delay in submission and is taking corrective action to address the issue. Steps include improving internal controls, implementing a detailed timeline for the audit process, etc. Management is committed to ensuring future compliance with reporting deadlines.

View Audit 333940

Finding 516078 (2023-001)

Significant Deficiency 2023

Chesapeake Hospital Authority

VA

Questioned Costs Subrecipient Monitoring Reporting § 200.512

2023-001 – Reporting – Submission of the Data Collection Form Individuals Responsible for Corrective Action Plan: J. Neal Bolton, Director of Revenue Management & Budget Shemaine Rose, Controller Anticipated Completion Date: December 2024 Management acknowledges that the reporting package and dat...

2023-001 – Reporting – Submission of the Data Collection Form Individuals Responsible for Corrective Action Plan: J. Neal Bolton, Director of Revenue Management & Budget Shemaine Rose, Controller Anticipated Completion Date: December 2024 Management acknowledges that the reporting package and data collection form for the year ended June 30, 2023, was not filed with the Federal Audit Clearinghouse on or before the deadline of March 31, 2024. Management maintains that appropriate schedules and notes thereto were prepared accurately and timely, and that the delay was due primarily to the unique nature of Provider Relief Funds being reported, which resulted in evolving compliance requirements over the funding and reporting periods. Management will file the reporting package and data collection form immediately upon completion and will continue to monitor and adhere to future Federal compliance updates to prevent such delays in the future.

View Audit 333892

Finding 516060 (2023-002)

Material Weakness 2023

Red Oak Community School District

IA

Internal Control / Segregation of Duties Reporting

The District now has one less office employee and are initiating additional separation of duties such as mail opening, check and deposit handling, and additional cross handling on outgoing checks.

View Audit 333830

Finding 515976 (2023-005)

Significant Deficiency 2023

The National Judicial College

NV

Questioned Costs Reporting Internal Control / Segregation of Duties

Shifts in operational priorities during the Spring and Summer of 2024, led to resource conflicts that hindered the audit process during critical periods. These changes, driven by direction from the Board of Trustees created unforeseen challenges that affected the timely completion of certain audit-r...

Shifts in operational priorities during the Spring and Summer of 2024, led to resource conflicts that hindered the audit process during critical periods. These changes, driven by direction from the Board of Trustees created unforeseen challenges that affected the timely completion of certain audit-related tasks. The College is committed to accelerating the fieldwork of future audits to ensure it is better prepared to handle unscheduled resource demands that may lead to delays in the audit process. In addition, the College, the auditors and the Audit Chair will meet to establish a timeline and dates for the audit planning and preparation, completion of the audit field work and the submission of the audited report. Patrick Grimes is the individual responsible for oversight of this corrective action plan.

View Audit 333783

Finding 515835 (2023-008)

Material Weakness 2023

Isanti County

MN

Allowable Costs / Cost Principles Cash Management Material Weakness

Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Significant Deficiency in ...

Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Significant Deficiency in Internal Control over Compliance Recommendation: We recommend the County puts in place the proper procedures to ensure it has proper controls in place to properly document the review of all the LCTS reports submitted by each collaborative member each quarter for accuracy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will ensure there are proper financial procedures and controls in place to properly document the review of all required reports for the program. Name(s) of the contact person(s) responsible for corrective action: Angie Larson, Auditor-Treasurer / Chief Financial Officer Planned completion date for corrective action plan: December, 31 2024

View Audit 333691

Finding 515833 (2023-007)

Material Weakness 2023

Isanti County

MN

Allowable Costs / Cost Principles Material Weakness Internal Control / Segregation of Duties

Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Material Weakness in Inter...

Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Material Weakness in Internal Control over Compliance Recommendation: We recommend the County puts in place the proper procedures to ensure it has proper controls in place to properly document the review of all required reports for the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will ensure there are proper financial procedures and controls in place to properly document the review of all required reports for the program. Name(s) of the contact person(s) responsible for corrective action: Angie Larson, Auditor-Treasurer / Chief Financial Officer Planned completion date for corrective action plan: December, 31 2024

View Audit 333691

Finding 515831 (2023-006)

Material Weakness 2023

Isanti County

MN

Allowable Costs / Cost Principles HUD Housing Programs Material Weakness

Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Material Weakness in Inter...

Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Material Weakness in Internal Control over Compliance Recommendation: We recommend the County puts in place the proper procedures to ensure it has proper controls in place to properly document the review of the state time study listings each quarter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will ensure there are proper financial procedures and controls in place to properly document the review of the state time study listings each quarter. Name(s) of the contact person(s) responsible for corrective action: Angie Larson, Auditor-Treasurer / Chief Financial Officer Planned completion date for corrective action plan: December, 31 2024

View Audit 333691

Finding 515681 (2023-001)

Significant Deficiency 2023

Word of Hope Ministries, Inc.

WI

Internal Control / Segregation of Duties Reporting

The Company does not have the resources and/or staff to prepare the financial statements and notes but will continue to oversee the auditor’s services and review and approve the financial statements and notes.

View Audit 333495

Finding 515609 (2023-001)

Significant Deficiency 2023

Kansas Association of Conservation Districts

KS

Questioned Costs Procurement, Suspension & Debarment Significant Deficiency § 200.319

Management agrees with the findings and recommendation. The District will update its policies and procedures to ensure they meet the Uniform Guidance Requirements. .

View Audit 333385

Finding 515608 (2023-001)

Material Weakness 2023

City of Clarion

IA

Internal Control / Segregation of Duties

The City should review its control activities to obtain the maximum internal control possible under the circumstances utilizing currently available staff, including elected officials, to provide additional controls through review of financial transactions, reconciliations and financial report. The r...

The City should review its control activities to obtain the maximum internal control possible under the circumstances utilizing currently available staff, including elected officials, to provide additional controls through review of financial transactions, reconciliations and financial report. The reviews should be documented by the signature or initials of the reviewer and the date of the review.

View Audit 333381

Finding 515573 (2023-008)

Significant Deficiency 2023

Unity Health Care, Inc.

MD

Eligibility Internal Control / Segregation of Duties Subrecipient Monitoring

Management Response #2023-008: Due to staff turnover, the Corporation did not consistently enforce segregation of duties between the individual responsible for determining income eligibility and the one completing the medical risk assessment. The Corporation also failed to provide sufficient support...

Management Response #2023-008: Due to staff turnover, the Corporation did not consistently enforce segregation of duties between the individual responsible for determining income eligibility and the one completing the medical risk assessment. The Corporation also failed to provide sufficient support to verify that the applicant signed the Rights and Obligations statement. Corrective Action Plan: • All eligibility verification data, including screenshots and signed Rights and Obligations statements, will be stored in a centralized, secure shared drive maintained and managed by the WIC Director to ensure it is protected with limited access and password protection. The drive will be organized using a de-identified naming convention to ensure privacy while maintaining ease of access for authorized staff. • To maintain a robust system of checks and balances, tasks related to eligibility verification and documentation will be divided among different team members. This separation will prevent any one individual from having full control over the process, reducing the risk of oversight or potential errors. • The WIC Department’s policy and procedure manuals will be revised and updated to include the new eligibility verification process. • To ensure adherence to the new protocols, periodic audits and review sessions will be conducted by the WIC Director or designated compliance staff to verify that documentation is being properly maintained and that all procedures are followed. Staff will be required to undergo refresher training sessions as needed to reinforce the updated protocols and best practices. Responsible Party: Tracy Harrison, COO

View Audit 333283

Corrective Action Plans

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