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Corrective Action Plans

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Finding 1206241 (2024-004)
Material Weakness 2024
Ramsey County
MN
Eligibility Material Weakness Internal Control / Segregation of Duties § 200.303
Finding Number: 2024-004 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Janelle White – Controller Health and Wellness Service Team Melody Santana-Marty – Controller Community Services and Supports Corrective Action Pla...
Finding Number: 2024-004 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Janelle White – Controller Health and Wellness Service Team Melody Santana-Marty – Controller Community Services and Supports Corrective Action Planned: Internal quality controls specific to the Medicaid program, will be reviewed and updated. Department-wide communication to staff regarding the importance of complete and adequate supporting documentation in the case file prior to case approval has been implemented and will continue on an ongoing basis. This communication will include guidance on how to determine whether documentation is sufficient, along with examples of acceptable support. At a minimum, required documentation will include: • Documentation verifying citizenship. • Examples of properly completed applications. • Reconciliation of the income verification in MAXIS and the documentation in the case file. • Reconciliation of the asset verification in MAXIS and the documentation in the case file. The Quality Assurance review process and Corrective Action Plan have been documented and communicated to provide guidance for new staff, serve as refresher training for existing staff, and ensure that appropriate actions are consistently followed. This documentation will be reviewed and revised as necessary to maintain compliance and consistency across the department. Supervisory review has been implemented for new hires. When issues are identified with current staff, enhanced review strategies and procedures will be applied to ensure required documentation is properly reviewed prior to case approval. Supervisors will conduct periodic reviews of case files to ensure that all required documentation is on file. If errors are identified and overpayments occur, the Department will follow established protocols of the Minnesota Department of Human Services regarding the identification, reporting, and recovery of overpayments. Anticipated Completion Date: 06/10/2026
View Audit 398206
Finding 1206240 (2024-003)
Material Weakness 2024
Ramsey County
MN
Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303
Finding Number: 2024-003 Finding Title: Eligibility and Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Janelle White – Controller Health and Wellness Service Team Melody Santana-Marty – Controller Commun...
Finding Number: 2024-003 Finding Title: Eligibility and Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Janelle White – Controller Health and Wellness Service Team Melody Santana-Marty – Controller Community Services and Supports Corrective Action Planned: Internal quality control review checklists, specific to each program area, will be reviewed and updated, and additional controls will be developed to ensure that required documentation is obtained and maintained. Department-wide communication to staff regarding the importance of complete and adequate supporting documentation in the case file prior to case approval has been implemented and will continue on an ongoing basis. This communication will include guidance on how to determine whether supporting documentation is sufficient, along with examples of acceptable documentation. At a minimum, required documentation will include: • Documentation verifying client eligibility for the key eligibility-determining factors. • Evidence of the verification process recorded in MAXIS. • Documentation confirming that child support files have been reviewed and updated for non-cooperation, as applicable. Supervisors will conduct periodic reviews of case files to ensure that all required documentation is on file. Anticipated Completion Date: June 30, 2026
View Audit 398206
Finding 1206153 (2024-004)
Material Weakness 2024
Town of Flora
IN
Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303
FINDING 2024-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Pamela J. Beck Flora Clerk-Treasurer Contact Phone Number and Email Address: 574-967-4844 clerktreasurer@townofflora.org Views of Responsible O...
FINDING 2024-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Pamela J. Beck Flora Clerk-Treasurer Contact Phone Number and Email Address: 574-967-4844 clerktreasurer@townofflora.org Views of Responsible Officials: Option 1: “We concur with the finding.” . Description of Corrective Action Plan: Follow internal controls to obtain a second internal signature for Federal reports. Anticipated Completion Date: 12-1-2025
View Audit 398141
Finding 1206117 (2024-002)
Material Weakness 2024
City of Agawam
MA
Internal Control / Segregation of Duties Procurement, Suspension & Debarment
CORRECTIVE ACTION PLAN The City of Agawam, Massachusetts respectfully submits the following corrective action plan for the year ended June 30. 2024. Audit period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. The ...
CORRECTIVE ACTION PLAN The City of Agawam, Massachusetts respectfully submits the following corrective action plan for the year ended June 30. 2024. Audit period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Audit Finding Reference: 2024-002 Reporting to the Federal Government – Significant Deficiency Views of responsible officials: The City agrees with the recommendation to implement procedures to ensure that the eligible expenditures reported on the Project and Expenditure (P&E) report include all eligible costs in the reporting period. The City will implement the proper segregation of duties by including an independent review of the P&E report prior to submitting the report. Planned Implementation Date of Corrective Action: The City plans to implement recommendations for the next P&E report filing. Official Responsible for Implementing Corrective Action: Cheryl St. John Town Auditor
View Audit 398086
Finding 1206074 (2024-001)
Material Weakness 2024
Burlington-Alamance Airport Authority
NC
Internal Control / Segregation of Duties
Corrective Action: The duties will be separated as much as possible and alternative controls will continue to be used to compensate for lack of separation. The governing board has become more involved in providing some of these controls. Proposed Completion Date: The Board is remaining involved by p...
Corrective Action: The duties will be separated as much as possible and alternative controls will continue to be used to compensate for lack of separation. The governing board has become more involved in providing some of these controls. Proposed Completion Date: The Board is remaining involved by providing authorization and monitoring controls on a regular and timely basis.
View Audit 397984
Finding 1206066 (2024-003)
Material Weakness 2024
Boulder City Hospital, Inc.
NV
Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking § 200.303
Finding 2024-003 Federal Agency Name: U.S. Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants, Community Facilities Loans and Grants Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not sufficiently f...
Finding 2024-003 Federal Agency Name: U.S. Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants, Community Facilities Loans and Grants Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not sufficiently fund their reserve account. As of December 31, 2024, the Hospital should have USDA debt reserves at least equal to $459,326. Responsible Individuals: Doug B. Lewis, Chief Financial Officer Corrective Action Plan: Management will review the reserve account requirements and ensure appropriate contributions are made during the fiscal year.
View Audit 397947
Finding 1205859 (2024-003)
Material Weakness 2024
Juneau Housing First Collaborative
AK
Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Special Tests & Provisions § 200.326
2024-003 – Significant Deficiency in Internal Control over Compliance and Other Matters – Special Tests and Provisions Name of Contact Person: Mariya Lovishchuk, Development Director Corrective Action: This was a clerical error issue. Davis Bacon Wages were paid throughout the entire project and cer...
2024-003 – Significant Deficiency in Internal Control over Compliance and Other Matters – Special Tests and Provisions Name of Contact Person: Mariya Lovishchuk, Development Director Corrective Action: This was a clerical error issue. Davis Bacon Wages were paid throughout the entire project and certified payroll was provided. However, the original construction contract did not include the correct prevailing wage language. Prevailing wages requirement was discussed and agreed upon prior to issuance of contract, but wrong language was inserted by mistake. Upon discovery of the wrong language, contract amendment was immediately issued to rectify. Proposed Completion Date: Already complete
View Audit 397618
Finding 1205811 (2024-004)
Material Weakness 2024
City of Tower, Minnesota
MN
Internal Control / Segregation of Duties
Management will research and clean up the old outstanding items, create a new general ledger account and reconcile all accounts on a monthly basis.
Management will research and clean up the old outstanding items, create a new general ledger account and reconcile all accounts on a monthly basis.
View Audit 397558
Finding 1205810 (2024-003)
Material Weakness 2024
City of Tower, Minnesota
MN
Reporting Internal Control / Segregation of Duties
Management will evaluate the cost benefit of making cash to accrual adjusting entries on an annual basis.
Management will evaluate the cost benefit of making cash to accrual adjusting entries on an annual basis.
View Audit 397558
Finding 1205809 (2024-002)
Material Weakness 2024
City of Tower, Minnesota
MN
Internal Control / Segregation of Duties
Management is aware of the finding and has concluded that it is not economically feasible to correct this finding. Management will rely on oversight by the Mayor and City Council to monitor this condition.
Management is aware of the finding and has concluded that it is not economically feasible to correct this finding. Management will rely on oversight by the Mayor and City Council to monitor this condition.
View Audit 397558
Finding 1205808 (2024-001)
Material Weakness 2024
City of Tower, Minnesota
MN
Internal Control / Segregation of Duties
For now, the City accepts the degree of risk associated with this condition and thoroughly reviews a draft of the financial statements, footnote disclosures, and supplementary information prior to issuance. Management will engage the audit firm to prepare drafts of its annual financial statements an...
For now, the City accepts the degree of risk associated with this condition and thoroughly reviews a draft of the financial statements, footnote disclosures, and supplementary information prior to issuance. Management will engage the audit firm to prepare drafts of its annual financial statements and related footnote disclosures in accordance with the regulatory basis of accounting.
View Audit 397558
Finding 1205800 (2024-001)
Material Weakness 2024
Town of Akron
CO
Material Weakness Internal Control / Segregation of Duties
The Town has implemented a process whereas the Town Manager and Board of Trustees review all federal or state grant agreements to verify whether the grant agreement outlines a CFDA number in determining whether the funds are related to federal awards.
The Town has implemented a process whereas the Town Manager and Board of Trustees review all federal or state grant agreements to verify whether the grant agreement outlines a CFDA number in determining whether the funds are related to federal awards.
View Audit 397536
Finding 1205742 (2024-005)
Material Weakness 2024
Excelsior Springs Hospital
MO
Reporting Internal Control / Segregation of Duties
Corrective Action Plan: The Hospital is currently working on a plan to file all audit reports for the subsequent fiscal year ended September 30, 2025, before their required reporting due date of June 30, 2026.
Corrective Action Plan: The Hospital is currently working on a plan to file all audit reports for the subsequent fiscal year ended September 30, 2025, before their required reporting due date of June 30, 2026.
View Audit 397466
Finding 1205047 (2024-001)
Material Weakness 2024
Detroit Police Athletic League, Inc.
MI
Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties
Finding: The Organization did not have adequate and effective controls over compliance in place as it relates to activities allowed or unallowed and allowable costs. We noted Instances where payroll and non-payroll related expenditures did not have documentation of review. Corrective Response: Manag...
Finding: The Organization did not have adequate and effective controls over compliance in place as it relates to activities allowed or unallowed and allowable costs. We noted Instances where payroll and non-payroll related expenditures did not have documentation of review. Corrective Response: Management is committed to strengthening how we track and allocate hours to grant-funded projects to ensure full compliance with 2 CFR 200.430. Going forward, the organization will implement a time study approach to support the allocation of personnel costs to federal grants. Employees working across multiple funding sources will participate in periodic time studies designed to reasonably estimate the distribution of their time based on actual activities performed. The results of these time studies will be used as the basis for allocating payroll costs to the appropriate grants, and will be supported by documentation and supervisory review. We will also implement consistent tools and processes to ensure allocations are applied systematically across all funding sources. On a monthly basis, the finance team will review and reconcile payroll allocations to ensure they align with the established methodology. In addition, we will provide training and ongoing oversight to reinforce compliance and prevent similar Issues In the future.
View Audit 396692
Finding 1205007 (2024-002)
Material Weakness 2024
Innovative Health Solutions
CA
Significant Deficiency Internal Control / Segregation of Duties
Finding 2024-02 Internal Control Over Compliance: Written Compliance Policies and Procedures. Management concurs with the finding. In June 2025, IHS completed revising its Fiscal Policy Manual to incorporate key Uniform Grant Guidance compliance requirements
Finding 2024-02 Internal Control Over Compliance: Written Compliance Policies and Procedures. Management concurs with the finding. In June 2025, IHS completed revising its Fiscal Policy Manual to incorporate key Uniform Grant Guidance compliance requirements
View Audit 396668
Finding 1205006 (2024-001)
Material Weakness 2024
Innovative Health Solutions
CA
Material Weakness Reporting Internal Control / Segregation of Duties
Finding 2024-01 Internal Control Over Financial Reporting: Revenue Recognition. Management concurs with the finding. Innovative Health Solutions (IHS) began full implementation of GAAP reporting in FY2024/25. The Fiscal Policy Manual was updated during FY2024/25 to incorporate GAAP revenue recogniti...
Finding 2024-01 Internal Control Over Financial Reporting: Revenue Recognition. Management concurs with the finding. Innovative Health Solutions (IHS) began full implementation of GAAP reporting in FY2024/25. The Fiscal Policy Manual was updated during FY2024/25 to incorporate GAAP revenue recognition criteria for various revenue streams. IHS will continue to review and refine its accounting policies and procedures as it transitions some of its financial reporting and audit support functions to a new outside CPA firm specializing in nonprofit services beginning July 1, 2025.
View Audit 396668
Finding 1205000 (2024-010)
Material Weakness 2024
The City of Frederick, Maryland
MD
Special Tests & Provisions Material Weakness Internal Control / Segregation of Duties
Finding reference: 2024-010 - 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Special Tests and Provisions Recommendation: All elements required for the sliding fee discount should be properly maintained in Allscripts. Employees should be properly trained on t...
Finding reference: 2024-010 - 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Special Tests and Provisions Recommendation: All elements required for the sliding fee discount should be properly maintained in Allscripts. Employees should be properly trained on the software, and a user manual should be created related to patient intake so patient records are consistent and documented appropriately. Action taken: All elements required for the sliding fee discount are being properly maintained. All employees have been properly trained in software.
View Audit 396662
Finding 1204855 (2024-004)
Material Weakness 2024
Mountain State Centers for Independent Living, Inc.
WV
Internal Control / Segregation of Duties
Indirect cost proposal. MSCIL acknowledges the need to maintain compliance wi th fed eral reporting requirements and has taken steps to ensure timely submission going forward. Management will complete and submit the indirect cost proposal immediately upon finalization of the audited financial statem...
Indirect cost proposal. MSCIL acknowledges the need to maintain compliance wi th fed eral reporting requirements and has taken steps to ensure timely submission going forward. Management will complete and submit the indirect cost proposal immediately upon finalization of the audited financial statements. Responsibility for preparing future proposals will be assigned to a designated staff member, with oversight from the President/CEO to ensure deadlines are met. MSCIL is also refining its reporting schedule and review procedures to support timely and accurate filings in future years. The Fyffe Jones Group will assist with filing needs as necessary to support compliance and ensure accuracy of submissions. These steps will help e nsure tha t indirect cost proposals are submitted timely in accordance with federal requirements.
View Audit 396485
Finding 1203053 (2024-001)
Material Weakness 2024
Incorporated Village of Ocean Beach
NY
Procurement, Suspension & Debarment Cash Management Matching / Level of Effort / Earmarking § 200.303
United States Environmental Protection Agency Capitalization Grants for Clean Water Revolving Funds ALN: 66.458 Condition: The Village has not updated its existing policies and written procedures to conform to Uniform Guidance requirements. Planned Corrective Action: The Village’s Treasurer will wor...
United States Environmental Protection Agency Capitalization Grants for Clean Water Revolving Funds ALN: 66.458 Condition: The Village has not updated its existing policies and written procedures to conform to Uniform Guidance requirements. Planned Corrective Action: The Village’s Treasurer will work on updating all policies and procedures relating to the U.S. Office of Management and Budget Uniform Guidance to ensure the Village policies are in compliance with these guidelines. Responsible Contact Person: Linda M. Morrisey Village Treasurer Village of Ocean Beach Bay & Cottage Walks, P.O. Box 457 Ocean Beach, NY 11770 Anticipation completion date: March 31, 2026
View Audit 396283
Finding 1191626 (2024-001)
Material Weakness 2024
Hawkeye Properties and Workforce Innovation, Inc.
CA
Reporting Internal Control / Segregation of Duties § 200.510 § 200.512
Management has taken steps to contract an audit firm and is currently working with the auditors to perform the single audit for the fiscal year ended June 30, 2025, with anticipation of completion before the deadline of March 31, 2026. Management has also prepared a Schedule of Expenditures of Feder...
Management has taken steps to contract an audit firm and is currently working with the auditors to perform the single audit for the fiscal year ended June 30, 2025, with anticipation of completion before the deadline of March 31, 2026. Management has also prepared a Schedule of Expenditures of Federal Awards for the fiscal year ended June 30, 2025.
View Audit 395484
Finding 1191602 (2024-003)
Material Weakness 2024
First Nations Community Healthsource, Inc.
NM
Reporting Internal Control / Segregation of Duties § 200.512
Recommendation We recommend that management enhance its internal control structure, including financial close and reporting, to ensure timely filing of future Single Audit reporting packages. Management Response Corrective Action FNCH recognizes the critical importance of establishing robust interna...
Recommendation We recommend that management enhance its internal control structure, including financial close and reporting, to ensure timely filing of future Single Audit reporting packages. Management Response Corrective Action FNCH recognizes the critical importance of establishing robust internal controls to guarantee the timely preparation and accurate submission of reports and records for audit purposes, particularly in alignment with the requirements outlined in 2 CFR 200.512. To effectively implement these internal controls, management will enforce procedures for the timely preparation of all necessary reports and records, including the Schedule of Expenditures of Federal Awards (SEFA). This will not only facilitate smoother audit processes but also ensure adherence to the 2 CFR 200.512. Management will train staff and establish timelines and responsibilities for report preparation and documentation to enhance compliance and streamline overall operations. Expected Outcome: • On‑time Single Audit filings in compliance with federal rules. • Clear visibility and accountability for deadlines. • Reduced risk of penalties and funding delays. • Greater confidence from agencies and stakeholders. Due Date of Completion: 3 days following issuance of the audit report Responsible Party(ies): CEO, CFO
View Audit 395458
Finding 1191113 (2024-002)
Material Weakness 2024
Keams Canyon Elementary School
AZ
Internal Control / Segregation of Duties
The School has hired a consultant for training.
The School has hired a consultant for training.
View Audit 395263
Finding 1191112 (2024-001)
Material Weakness 2024
Keams Canyon Elementary School
AZ
Reporting Internal Control / Segregation of Duties
The School has hired a consultant to train and assist school personnel in internal controls and processing transactions. The School has hired a Business Manager and Human Resource Manager.
The School has hired a consultant to train and assist school personnel in internal controls and processing transactions. The School has hired a Business Manager and Human Resource Manager.
View Audit 395263
Finding 1190872 (2024-001)
Material Weakness 2024
St. John's Lutheran Home of Albert Lea
MN
Material Weakness Reporting Internal Control / Segregation of Duties
St. John’s Lutheran Home of Albert Lea submits the following corrective action plan for the year ended September 30, 2024. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: October 1, 2023 – September 30, 2...
St. John’s Lutheran Home of Albert Lea submits the following corrective action plan for the year ended September 30, 2024. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: October 1, 2023 – September 30, 2024 The findings from the September 30, 2024 schedule of findings, questioned costs and recommendations. FINDINGS - FINANCIAL STATEMENT AUDIT Finding 2024-001 - Auditor Preparation of the Financial Statements Material Weakness Finding Summary: The Organization does not have an internal control system designed to provide for the preparation of the complete consolidated financial statements, including the accompanying footnotes, as required by GAAP. We were also requested to draft the financial statements and accompanying notes to the financial statements. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of financial statements and accompanying notes. We requested that our auditors Lethert, Skwira, Schultz & Co. LLP, prepare the financial statements and the accompanying notes to the financial statements as a part of their annual audit. We have designated a member of management to review the drafted financial statements and accompanying notes. Responsible Individuals: Heather King, Director of Finance, 507-473-1066 Anticipated Completion Date: Ongoing
View Audit 395160
Finding 1182298 (2024-005)
Material Weakness 2024
The Order of Fishermen Ministry Head Start Program, Inc.
MI
Subrecipient Monitoring Reporting Significant Deficiency § 200.303
TOFMHS concurs with the finding. The Agency filed both semi annual and annual financial reports for three grants during the fiscal year on a timely basis. The one semi-annual report was inadvertently filed late. However, upon notice by the Payment Management System of it being overdue, it was immedi...
TOFMHS concurs with the finding. The Agency filed both semi annual and annual financial reports for three grants during the fiscal year on a timely basis. The one semi-annual report was inadvertently filed late. However, upon notice by the Payment Management System of it being overdue, it was immediately filed. The Agency will prepare a checklist of required federal reports by the finance department, which will be monitored by the Program Director. Responsible Person: Fiscal Officer/Program Director Completion Date: January 1, 2025
View Audit 393724
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