Corrective Action Plans

Finding 401556 (2022-001)

Material Weakness 2022

Martin University

IN

Material Weakness Reporting Internal Control / Segregation of Duties

2022-001 Financial Statement Preparation Recommendation: We recommend that management review controls related to financial statement preparation review at the end of each period. Financial statement preparation should include a review of reconciliations and balances to ensure that financial statemen...

2022-001 Financial Statement Preparation Recommendation: We recommend that management review controls related to financial statement preparation review at the end of each period. Financial statement preparation should include a review of reconciliations and balances to ensure that financial statement line items are properly stated and classified. Internally prepared financial statements should also be thoroughly reviewed by members of the board and management outside the finance department on a periodic (monthly or quarterly). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University engaged an external consultant in June 2023, hired a new staff accountant in September 2023 and a CFO in November 2023. The University has begun to restructure all accounting and reconciliation functions, including implementation of new accounting software. The University is implementing financial internal controls to improve the financial statements preparation and preparation of the schedule of expenditures and federal awards. Name of the contact person responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration Planned completion date for corrective action plan: June 30, 2024

View Audit 309593

Finding 401429 (2022-006)

Significant Deficiency 2022

County of Columbia, Pennsylvania

PA

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

Federal Program: Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Condition/Context: The County’...

Federal Program: Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Condition/Context: The County’s required report for the quarter ended December 31, 2022 was due to be filed by January 31, 2023. The County filed its report on March 23, 2023, 48 days after the required due date. Recommendation: We recommend that the County revisit its policies and procedures related to reporting to ensure future reports are completed and submitted within the appropriate time period. Planned Corrective Actions: The County is current on all reporting. Name(s) of Contact Person(s) Responsible for Corrective Action: David Witchey, Chief Clerk

View Audit 309542

Finding 401388 (2022-012)

Significant Deficiency 2022

Libson Regional School District

NH

School Nutrition Programs Cash Management Reporting

Audit Finding Reference: 2022-12 Management’s View and Planned Corrective Action A procedure is currently in place and being followed. In 2021-2022 there were new forms sent from the State to do our meal counts, this was the second COVID year and free lunch for all students. In our one room plus ...

Audit Finding Reference: 2022-12 Management’s View and Planned Corrective Action A procedure is currently in place and being followed. In 2021-2022 there were new forms sent from the State to do our meal counts, this was the second COVID year and free lunch for all students. In our one room plus a modular school housethat receives vended meals from Lisbon, Landaff, they used both the State form and MealTimes and then sometimes called and made changes at the last minute to the number of servable meals. We believe the glitch was at Landaff in terms of procedure so part of our plan will be to review with the Landaff staff how to correctly enter the information into MealTimes. I spot checked 22-23 and found that our claims are accurate to Meal Times. Name of Contact Person and Completion Date: Name 1 Toni Butterfield Name 2 Anticipated Completion Date – 6/30/2025

View Audit 309473

Finding 401387 (2022-011)

Material Weakness 2022

Libson Regional School District

NH

Questioned Costs School Nutrition Programs Internal Control / Segregation of Duties § 200.303

Audit Finding Reference: 2022-011 Management’s View and Planned Corrective Action: Management learned about 7 CFR, 210.14(b) when asked to create an Excess Food Service Fund Spend Down Plan this school year. We are now monitoring this and will make sure to spend down funds appropriately each year...

Audit Finding Reference: 2022-011 Management’s View and Planned Corrective Action: Management learned about 7 CFR, 210.14(b) when asked to create an Excess Food Service Fund Spend Down Plan this school year. We are now monitoring this and will make sure to spend down funds appropriately each year when operating the food service program. In addition, management is taking on a bigger role in overseeing the entire Food Service operation in regards to the Federal Regulations associated with the National School Lunch Program. Name of Contact Person and Completion Date: Name 1 Toni Butterfield Name 2 Anticipated Completion Date – 6/30/25

View Audit 309473 Questioned Costs: $1

Finding 401315 (2022-003)

Material Weakness 2022

Westwood Community School District

IA

Internal Control / Segregation of Duties Reporting

The District will review internal control procedures and implement as current staff allows. The District did hire a 2nd secretary to help with some segregation of duties such as activity cash boxes etc. in FY22.

View Audit 309391

Finding 401244 (2022-004)

Significant Deficiency 2022

Hale County Hospital

AL

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding 2022-004 – Reporting (Late Filing) – Significant Deficiency We are implementing policies to address the audit finding 2022-004 as follows: We are continuing to institute processes and procedures to complete timely reconciliations to allow for future filings to be made prior to the deadline....

Finding 2022-004 – Reporting (Late Filing) – Significant Deficiency We are implementing policies to address the audit finding 2022-004 as follows: We are continuing to institute processes and procedures to complete timely reconciliations to allow for future filings to be made prior to the deadline. Anticipated completion date: September 30, 2024

View Audit 309234

Finding 401082 (2022-006)

Significant Deficiency 2022

Promise Healthcare Nfp

IL

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.329

Reporting – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare maintain supporting documentation for all reports required to be filed to the federal agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Acti...

Reporting – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare maintain supporting documentation for all reports required to be filed to the federal agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. Create procedure to deposit all supporting files and schedules in a shared and accessible location: in progress a. Develop steps in the UDS process that outlines where working and final supporting schedules will be stored for future access b. Identify role or job that will handle responsibility for following the procedure. c. Formalize the process into a written procedure and add to the UDS Report or other relevant policy. d. After UDS submission, review data folders to check that all relevant supporting schedules and documents have been deposited.

View Audit 309100

Finding 401079 (2022-004)

Material Weakness 2022

Promise Healthcare Nfp

IL

Questioned Costs Special Tests & Provisions Significant Deficiency

Procurement – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare revise its procurement policy to be consistent with the requirements of the Uniform Guidance and follow the stated procedures. Explanation of disagreement with audit finding: There is no disagre...

Procurement – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare revise its procurement policy to be consistent with the requirements of the Uniform Guidance and follow the stated procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. Review Current Procurement Policy: in progress a. Conduct a comprehensive review of Promise Healthcare’s existing procurement policy. b. Identify and revise and discrepancies or non-compliance with the requirements of the Uniform Guidance. c. Integrate industry best practices into revised policy to enhance compliance and efficiency 2. Training and Education: to start a. Provide training sessions for staff authorized to purchase along with relevant personnel on the revised procurement policy and procedures and raise awareness of the requirements of the Uniform Guidance and implications of non-compliance. b. Establish training on documentation standards for procurement activities including requisitions, solicitations, evaluations and contract awards. c. Establish training and procedure for retention of procurement-related documentation 3. Internal Controls and oversight: to start a. Implement mechanisms for monitoring and oversight to ensure compliance with the procurement policy. b. Conduct periodic internal audits to assess adherence to procurement procedures and identify areas for improvement or corrective action

View Audit 309100 Questioned Costs: $1

Finding 401076 (2022-003)

Significant Deficiency 2022

Promise Healthcare Nfp

IL

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

Special Tests and Provisions – Assistance Listing No. 93.224/93.527 Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection a...

Special Tests and Provisions – Assistance Listing No. 93.224/93.527 Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection and verification of patient information for each patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: to start 1. Review current policies and procedures: in progress a. Conduct a comprehensive review of existing procedures for collection and verification of patient information to identify weaknesses, gaps, and areas for improvement. b. Conduct review of current front desk workflow to determine if policies and procedures are followed correctly. c. Enhance policies and procedures as necessary to improve accuracy and consistency of patient information 2. Verification Process: to start a. Review documentation requirements for verifying accuracy of sliding fee information and standardize/improve where necessary. 3. Training and Education: to start a. Review training materials and create/improve where necessary to provide clear instructions and comply with policy and procedure b. Train front desk staff on standardized forms, templates and scripts for collecting information from patients c. Require periodic training and re-training to improve front desk workflow and retention of process to consistently collect and verify information from patients 4. Quality Assurance: to start a. Conduct regular audits and quality assurance checks to monitor the accuracy and integrity of sliding fee information and implementation of sliding fee discount b. Implement corrective actions to address any discrepancies or deficiencies identified during audits or reviews Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: Summer/Fall 2024

View Audit 309100

Finding 400905 (2022-006)

Material Weakness 2022

West Virginia School of Osteopathic Medicine Clinic, Inc. D/b/a Robert C. Byrd Clinic

WV

Allowable Costs / Cost Principles Material Weakness Period of Performance § 200.303

Federal Agency Name: Department of Homeland Security Program Name: COVID‐19 Disaster Grants – Public Assistance Federal Financial Assistance Listing #97.036 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs Principles and Period of Performance Finding Summary: The rev...

Federal Agency Name: Department of Homeland Security Program Name: COVID‐19 Disaster Grants – Public Assistance Federal Financial Assistance Listing #97.036 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs Principles and Period of Performance Finding Summary: The review and approval of the expenditure listing was not retained. Responsible Individuals: David Meadows, Interim CFO Corrective Action Plan: Management agrees with the finding and has reviewed the operating procedures of Robert C. Byrd Clinic. Furthermore, we will implement procedures to retain expenditure listings and other support for federal awards as well as the related review. Anticipated Completion Date: Ongoing

View Audit 308944

Finding 400903 (2022-005)

Material Weakness 2022

West Virginia School of Osteopathic Medicine Clinic, Inc. D/b/a Robert C. Byrd Clinic

WV

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 2 TIN#4550559322 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activitie...

Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 2 TIN#4550559322 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs Principles and Reporting Finding Summary: The original expenditure listing which would have included the review of the expenditure listing, was not retained. As a part of the single audit, the Clinic recreated the expenditure listing to support the expenditures reported on the special report submitted to the Department of Health and Human Services for Period 2, however there was no control in place to retain the original documentation of the determination of expenditures and their related review. In addition, there was no retained documentation of the review and approval of the Clinic’s special report submitted to the Department of Health and Human Services for Period 2 TIN #4550559322. Responsible Individuals: David Meadows, Interim CFO Corrective Action Plan: Management agrees with the finding and has reviewed the operating procedures of Robert C. Byrd Clinic. Furthermore, we will implement procedures to retain expenditure listings and other support for federal awards as well as the related review. Anticipated Completion Date: Ongoing

View Audit 308944

Finding 400874 (2022-005)

Significant Deficiency 2022

City of South Fulton, Ga

GA

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

Name of the Contact Person Responsible: Rodney Green, Deputy Chief Financial Officer Corrective Action Plan: The City will strengthen its internal controls over federal reporting to ensure compliance with all requirements of the federal award program and other reporting requirements. Anticipated ...

Name of the Contact Person Responsible: Rodney Green, Deputy Chief Financial Officer Corrective Action Plan: The City will strengthen its internal controls over federal reporting to ensure compliance with all requirements of the federal award program and other reporting requirements. Anticipated Completion Date: June 30, 2024

View Audit 308897

Finding 400806 (2022-008)

Material Weakness 2022

Healthhiv

DC

Material Weakness Reporting Internal Control / Segregation of Duties

The transitioning to the new Finance Director continued during year and additional account reviews were required. This has caused a delay in the timing of our filing. HealthHIV will continue to addressed our internal control on filing our audit report timely and by the FAC due date.

View Audit 308831

Finding 400773 (2022-004)

Significant Deficiency 2022

Great Northwest Education Cooperative

ND

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

Contact Person – Ben Schafer, Executive Director Corrective Action Plan – The Executive Director will review and approve, with documentation, all invoices prior to payment being made. Completion Date – The Coop will implement this corrective action plan in the next fiscal year.

View Audit 308791

Finding 400604 (2022-005)

Significant Deficiency 2022

Tca Health, Inc.

IL

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

TCA Health will address the Allowable Costs and Activities first, by hiring additional accounting professionals both internally and as third- party consultants to support the grants management process in place at TCA. As part of that work, the third-party consultant will review the Time and Effort r...

TCA Health will address the Allowable Costs and Activities first, by hiring additional accounting professionals both internally and as third- party consultants to support the grants management process in place at TCA. As part of that work, the third-party consultant will review the Time and Effort reporting policy and model. TCA currently feels that what the process that they utilized to allocate salary and wage expense to the grant related to this finding was allowable from a Uniform Grants Guidance perspective, however they were not compliant with their policy and will work to revise their policy to less restrictive (although still in compliance with the UGG). The iCFO will create greater monitoring of the month-end process as it relates to the allocation of payroll costs to be consistent with the personnel activity reports and the Health Center’s revised policy.

View Audit 308641

Finding 400602 (2022-004)

Material Weakness 2022

Tca Health, Inc.

IL

Cash Management Material Weakness Matching / Level of Effort / Earmarking § 200.303

The COO at TCA Health will address Cash Management first, reviewing the policy and procedure to ensure it’s up to date with today’s best practices and modern standards. In doing so, TCA will review the organization chart to assess if the policy and procedure to match the personnel structure that’s c...

The COO at TCA Health will address Cash Management first, reviewing the policy and procedure to ensure it’s up to date with today’s best practices and modern standards. In doing so, TCA will review the organization chart to assess if the policy and procedure to match the personnel structure that’s currently in place. Changes will be made if necessary. Additionally, TCA has hired a third-party consulting firm that can assist with grant best practices.

View Audit 308641

Finding 400600 (2022-003)

Material Weakness 2022

Tca Health, Inc.

IL

Eligibility Material Weakness Internal Control / Segregation of Duties

The COO at TCA Health will address the Special Provisions weakness by coaching and training front desk staff members. Specifically, staff will be trained in the sliding fee scale and its requirements. Staff will become proficient in the collection of data from patients, properly storing and recordin...

The COO at TCA Health will address the Special Provisions weakness by coaching and training front desk staff members. Specifically, staff will be trained in the sliding fee scale and its requirements. Staff will become proficient in the collection of data from patients, properly storing and recording it in the EMR, and the calculation of the slide according to the Federal Poverty Guidelines. Lastly, the team will be updated on the latest EMR module that experienced an upgrade and taught how to effectively apply the slide. TCA will also assess the current staff to ensure the proper personnel is in in place.

View Audit 308641

Finding 400572 (2022-003)

Material Weakness 2022

Lutheran Family Services of Nebraska, Inc. and Affiliates

NE

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

Condition: Refugee case files, specifically related to the Afghan Placement and Assistance Program, lacked certain documentation required by the Cooperative Agreements. Planned Corrective Action Management is reviewing and improving internal controls over review of refugee case file documentation. T...

Condition: Refugee case files, specifically related to the Afghan Placement and Assistance Program, lacked certain documentation required by the Cooperative Agreements. Planned Corrective Action Management is reviewing and improving internal controls over review of refugee case file documentation. The Cooperative Agreement specific to the Afghan Placement and Assistance Program directed the Organization to focus on the provision of services and to include documentation of such activities to the extent possible. Furthermore, the Organization’s funding agencies have performed numerous monitoring reviews of the case files, including reviews specific to the Afghan Placement and Assistance Program. While the results of these reviews did note similar findings, subsequent to year-end, the Organization received written documentation that all such findings have satisfactorily been resolved and that the Organization is in compliance with the terms and conditions of the Cooperative Agreement. Contact Person: Amy Carolus, Chief Financial Officer Anticipated Completion Date: December 31, 2023

View Audit 308632

Finding 400566 (2022-006)

Material Weakness 2022

Pembroke Hill School

NH

Questioned Costs School Nutrition Programs Internal Control / Segregation of Duties § 200.303

Audit Finding Reference: 2021-006 Cross Training of Staff and Review of Responsibilities Management’s View and Planned Corrective Action: Management does not agree with this deficiency. We do agree that Management is actively working on some changes as improvements are made each year to improve effi...

Audit Finding Reference: 2021-006 Cross Training of Staff and Review of Responsibilities Management’s View and Planned Corrective Action: Management does not agree with this deficiency. We do agree that Management is actively working on some changes as improvements are made each year to improve efficiency. Each position in the Business Office other than HR has been crossed trained with one-to-two other team members. Cross training throughout the business office was implemented in 2016 and has continued to exist. Each position has the ability to have someone step in case of emergency, elongated vacations and when/if someone resigns or is terminated. The positions are not covered in entirety, but the important items that must be dealt with can be and are accomplished. Examples are as such: Accounts Payable is covered by our Special Ed Bookkeeper, and other staff have the ability to review manifest once generated. Payroll has been covered by the Assistant Business Administrator when vacations or vacancies have existed, Grants can be covered by the Business Administrator when vacations or vacancies have existed. The Assistant Business Administrator is covered by the Business Administrator during vacations and vacancies. Each position continues to do their own assigned job duties and takes on the other tasks as necessary. The work may not get completed in the same timely fashion as if the actual staff member holding the position was there because they are also completing their own tasks, but the work does get accomplished. When there are multiple turnovers and/illness occurring at the sometime it makes it challenging even when cross training exists. Every year the Business Administrator reviews workloads and reassesses if changes should occur to help create efficiencies and create equivalent workload between all staff members. While some positions have more deadlines than others it can appear that their plates are larger than others, but frequently tasks are divided out throughout the team to help alleviate this. These discussions are brought forth to COLT, the Senior Leadership team at the SAU, and restructuring is finalized at that time. Name of Contact Person and Completion Date: Name 1 Amber Wheeler Name 2 Danielle Rossetti Anticipated Completion Date – Already occurs

View Audit 308621 Questioned Costs: $1

Finding 400552 (2022-003)

Significant Deficiency 2022

Meals on Wheels of Middle Georgia, Inc.

GA

Internal Control / Segregation of Duties Special Tests & Provisions

Views of Responsible Officials and Planned Corrective Actions: See Comment 2022-001 and 002. Date to be implemented: See Comment 2022-001 and 002. Persons responsible: See Comment 2022-001 and 002.

View Audit 308581

Finding 400260 (2022-002)

Material Weakness 2022

Red Wind Consulting INC

CO

Subrecipient Monitoring Material Weakness Reporting

Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of reporting. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document in wri...

Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of reporting. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document in writing, the process and review it with department leaders. Additionally, staff members working in areas concerning this process will be trained to ensure process adherence.

View Audit 308375

Finding 400243 (2022-002)

Significant Deficiency 2022

Housing Authority of the City of Annapolis

MD

HUD Housing Programs Reporting Significant Deficiency § 200.512

Finding 2022-002 Late Submission of Financial Statements to FAC and REAC (Significant Deficiency) Recommendation: The Authority should review and enhance its policies, procedures and internal controls to ensure the financial reporting package and audited financial statements are submitted by the req...

Finding 2022-002 Late Submission of Financial Statements to FAC and REAC (Significant Deficiency) Recommendation: The Authority should review and enhance its policies, procedures and internal controls to ensure the financial reporting package and audited financial statements are submitted by the required due date. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action Taken in response to finding: The Authority will evaluate its financial reporting, close processes and controls to determine whether additional controls over the preparation of the final trial balances and related schedules should be implemented. As part of this process, we will create a year end checklist with deadlines established and monitor status to ensure deadlines are met. Name of Contact Person responsible for Corrective Action: Cia Cook, Deputy Executive Director & CFO Planned Date for Corrective Action plan: June 30, 2024

View Audit 308359

Finding 400098 (2022-001)

Material Weakness 2022

Boys & Girls Clubs of Central Nh INC

NH

Material Weakness Reporting Internal Control / Segregation of Duties

The Club has evaluated the cost vs. benefit of establishing internal controls over the preparation of financials statements in accordance with GAAP and determined that it is in the best interest of the Club to outsource this task to its external auditors, and to carefully review the draft financial ...

The Club has evaluated the cost vs. benefit of establishing internal controls over the preparation of financials statements in accordance with GAAP and determined that it is in the best interest of the Club to outsource this task to its external auditors, and to carefully review the draft financial statements and notes prior to approving them and accepting responsibility for their content and presentation.

View Audit 308212

Finding 400097 (2022-003)

Material Weakness 2022

Boys & Girls Clubs of Central Nh INC

NH

Material Weakness Reporting Internal Control / Segregation of Duties

A new employee prepared the final grant reporting to the grantor (State of NH) who had no knowledge or participation in the FY21 audit. In FY21 the auditors had tested the multi-year grant, and the Club did not clearly label the most up-to-date and final audited files, and incomplete information was...

A new employee prepared the final grant reporting to the grantor (State of NH) who had no knowledge or participation in the FY21 audit. In FY21 the auditors had tested the multi-year grant, and the Club did not clearly label the most up-to-date and final audited files, and incomplete information was used for preparation of the final report. The Club has engaged an IT consultant to improve its technology. Additionally, the finance team will also institute best practices for digital file management.

View Audit 308212

Finding 399995 (2022-005)

Material Weakness 2022

Lincoln-King Adams-Young Academy

MI

Internal Control / Segregation of Duties

Management has procured New ERP software that supports clear invoicing and purchasing approval processes within the system. Management will have individual training with building leaders to refine the purchasing approval process through the new accounting software, as well as training with front off...

Management has procured New ERP software that supports clear invoicing and purchasing approval processes within the system. Management will have individual training with building leaders to refine the purchasing approval process through the new accounting software, as well as training with front office staff on the collection of the appropriate paperwork upon receipt of deliveries.

View Audit 308166

Corrective Action Plans

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