Corrective Action Plans

Finding 530120 (2022-004)

Material Weakness 2022

MI

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

Condition: HealthSource does not have a review process in place related to the lost revenue calculation used to input into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program and not having a review process in place over the fo...

Condition: HealthSource does not have a review process in place related to the lost revenue calculation used to input into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program and not having a review process in place over the forementioned required submissions. Planned Corrective Action: A review of all updates to Covid lost revenue will be performed with the CEO and President as indicated by new activity, and before any submissions are uploaded. Contact person responsible for corrective action: Sonja Martinez, Chief Financial Officer Anticipated Completion Date: 12/31/2024

View Audit 348199

Finding 530092 (2022-005)

Significant Deficiency 2022

South Big Horn Hospital District

WY

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

2022-005 - Reporting Corrective Action Plan: Management agrees with the finding and has committed the resources giving rise to the finding. Person(s) Responsible: M. Michael Garza Timing for Implementation: June 30, 2025

View Audit 348143

Finding 530091 (2022-004)

Significant Deficiency 2022

South Big Horn Hospital District

WY

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

2022-004 - Required debt reserve compliance Corrective Action Plan: Management agrees with the finding and has committed the resources giving rise to the finding. Person(s) Responsible: M. Michael Garza Timing for Implementation: June 30, 20 5

View Audit 348143

Finding 529316 (2022-002)

Material Weakness 2022

City of McKeesport

PA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Reporting § 200.403

CONDITION: During the calendar year 2022, the City did not utilize a formal general ledger system of accounting to track the financial activity (financial position and results of operations) for several ‘Funds’ held at the City. The activity of these funds is either 1) maintained in spreadsheet fash...

CONDITION: During the calendar year 2022, the City did not utilize a formal general ledger system of accounting to track the financial activity (financial position and results of operations) for several ‘Funds’ held at the City. The activity of these funds is either 1) maintained in spreadsheet fashion similar to a checkbook used in personal finances, 2) recorded partially (expenses only with no revenue), or 3) not tracked at all. As these funds are not maintained using the City’s accounting software package, management does not have the ability to efficiently generate financial reports necessary to provide management with the proper fiscal oversight. This condition included the American Rescue Plan Act (ARPA) funding known as the Coronavirus State and Local Fiscal Recovery Fund. However, it should be noted that City personnel were able to prepare spreadsheets to document which expenditures were utilized to prepare the necessary quarterly reporting requirements to the Department of Treasury. This is a repeat finding (2021-002) from the prior year. CRITERIA: Prudent internal control procedures in the areas of general ledger management and financial reporting include maintaining a formal general ledger system of accounting to track the activity of all ‘Funds’ maintained by the City. In specific as it relates to federal programs, Section 2 CFR 200.403(g) of the Uniform Guidance requires that federal costs must be adequately documented which would include the maintaining of a formal general ledger system of accounting for all ‘Funds’ of the City. MANAGEMENT’S CORRECTIVE ACTION PLAN: Management of the City will assess the current workload and expertise of the City’s business office personnel in an effort to determine a feasible timeframe to continue the process of creating a formal general ledger system of accounting for all City ‘Funds’ that are not already entered into the software accounting system. The timeframe for completion of this review will occur during the first nine months of calendar year 2025 with the intention of having the City be in full compliance with Section 2 CFR 200.403(g) of the Uniform Guidance which requires federal costs to be adequately documented which would include the maintaining of a formal general ledger system of accounting for all ‘Funds’ of the City.

View Audit 347342

Finding 528934 (2022-009)

Material Weakness 2022

Iliff School of Theology

CO

Student Financial Aid Matching / Level of Effort / Earmarking Material Weakness

Condition: The Institution does not have evidence that exit counseling was provided to students who withdrew or graduated as required by 34 CFR 682.604. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its stude...

Condition: The Institution does not have evidence that exit counseling was provided to students who withdrew or graduated as required by 34 CFR 682.604. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The school has also ensured that this third-party processor is properly coordinated with the registrar’s office to meet federal requirements for exit counseling when status changes are processed. Contact person responsible for corrective action: Jason Warr, VP for Business, Controller Anticipated Completion Date: May 2024

View Audit 346905

Finding 528933 (2022-008)

Material Weakness 2022

Iliff School of Theology

CO

Material Weakness Matching / Level of Effort / Earmarking Special Tests & Provisions

Condition: The Institution does not have written policies and procedures that incorporate the provisions of 34 CFR 668.51 through 668.61. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid program...

Condition: The Institution does not have written policies and procedures that incorporate the provisions of 34 CFR 668.51 through 668.61. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. All verification procedures are established, and documentation will be maintained to demonstrate compliance. Contact person responsible for corrective action: Jason Warr, VP for Business, Controller Anticipated Completion Date: May 2024

View Audit 346905

Finding 528932 (2022-007)

Material Weakness 2022

Iliff School of Theology

CO

Student Financial Aid Material Weakness Matching / Level of Effort / Earmarking

Condition: The Institution does not have a documented Direct Loan quality assurance program. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The school will coordinate with this third-...

Condition: The Institution does not have a documented Direct Loan quality assurance program. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The school will coordinate with this third-party processor to ensure that there is a documented quality assurance program that is regularly exercised for compliance purposes. All documentation will be maintained. Contact person responsible for corrective action: Jason Warr, VP for Business, Controller Anticipated Completion Date: May 2024

View Audit 346905

Finding 528931 (2022-006)

Material Weakness 2022

Iliff School of Theology

CO

Questioned Costs Student Financial Aid Material Weakness

Condition: Our audit procedures identified an instance where the Institution could not locate evidence that the required R2T4 calculation under federal regulation was completed. The total aid disbursed to this student was $5,125. Planned Corrective Action: The Iliff School of Theology has contracte...

Condition: Our audit procedures identified an instance where the Institution could not locate evidence that the required R2T4 calculation under federal regulation was completed. The total aid disbursed to this student was $5,125. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. This third-party processor is adequately skilled to complete Return of Title IV calculations and includes an established review process for quality control. All documentation will be maintained. Contact person responsible for corrective action: Jason Warr, VP for Business, Controller Anticipated Completion Date: May 2024

View Audit 346905 Questioned Costs: $1

Finding 528930 (2022-005)

Material Weakness 2022

Iliff School of Theology

CO

Student Financial Aid Material Weakness Matching / Level of Effort / Earmarking

Condition: The Institution does not reconcile institutional records with Direct Loan funds received from the Secretary of the U.S. Department of Education and the Direct Loan disbursement records submitted to and accepted by the Secretary of the U.S. Department of Education. Planned Corrective Acti...

Condition: The Institution does not reconcile institutional records with Direct Loan funds received from the Secretary of the U.S. Department of Education and the Direct Loan disbursement records submitted to and accepted by the Secretary of the U.S. Department of Education. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs who will ensure that direct loan reconciliations are conducted on a monthly basis in coordination with the business office. Contact person responsible for corrective action: Jason Warr, VP for Business, Controller Anticipated Completion Date: May 2024

View Audit 346905

Finding 528927 (2022-002)

Material Weakness 2022

Iliff School of Theology

CO

Student Financial Aid Reporting Material Weakness

Condition: Our audit procedures identified instances of inaccurate or untimely reporting of enrollment information to NSLDS. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The school ...

Condition: Our audit procedures identified instances of inaccurate or untimely reporting of enrollment information to NSLDS. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The school has also ensured that this third-party processor is properly coordinated with the registrar’s office to meet federal requirements for NSLDS enrollment reporting. Contact person responsible for corrective action: Jason Warr, VP for Business, Controller Anticipated Completion Date: May 2024

View Audit 346905

Finding 528926 (2022-010)

Significant Deficiency 2022

Iliff School of Theology

CO

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Condition: Our audit procedures identified instances of MPNs not being properly maintained. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The school has also ensured that this third-...

Condition: Our audit procedures identified instances of MPNs not being properly maintained. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The school has also ensured that this third-party processor is properly reviewing MPNs to meet federal requirements. Contact person responsible for corrective action: Jason Warr, VP for Business, Controller Anticipated Completion Date: May 2024

View Audit 346905

Finding 526803 (2022-013)

None 2022

Muskogee County

OK

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

Assistance Listing Number 21.027 Noncompliance Over Reporting - Major Federal Program - Coronavirus State and Local Fiscal Recovery Funds Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will ...

Assistance Listing Number 21.027 Noncompliance Over Reporting - Major Federal Program - Coronavirus State and Local Fiscal Recovery Funds Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to ensure that all grant funds are properly expended and properly reported.

View Audit 345862

Finding 524435 (2022-001)

Significant Deficiency 2022

Anchorage Concert Association

AK

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

Finding 2022-001 Documentation of Approval - Allowable Costs – Significant Deficiency in Internal Control over Compliance Name of Contact Person: Willow Zamos, Business Manager; 907-272-1471 Planned Corrective Action: Anchorage Concert Association will improve procedures to ensure documentation of i...

Finding 2022-001 Documentation of Approval - Allowable Costs – Significant Deficiency in Internal Control over Compliance Name of Contact Person: Willow Zamos, Business Manager; 907-272-1471 Planned Corrective Action: Anchorage Concert Association will improve procedures to ensure documentation of invoice approval is retained in vendor files. Anticipated Completion Date: Already implemented.

View Audit 343739

Finding 524290 (2022-002)

Significant Deficiency 2022

Robonation Inc.

VA

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.333

Views of Responsible Officials and Planned Corrective Actions: Management agrees that improvement is necessary with respect to reconciliation and documentation of credit card expenses. Management is in the process of updated their process surrounding credit cards.

View Audit 343504

Finding 524127 (2022-004)

Significant Deficiency 2022

Papa Ola Lokahi

HI

Internal Control / Segregation of Duties Reporting Matching / Level of Effort / Earmarking § 200.512 § 200.514

The Organization acknowledges that the unexpected resignation of the former independent auditor, and the subsequent domino effect of a delay in securing a new independent auditor, the delay in the new independent auditor’s completion of the final June 30, 2022 audit report, and the issuance of the O...

The Organization acknowledges that the unexpected resignation of the former independent auditor, and the subsequent domino effect of a delay in securing a new independent auditor, the delay in the new independent auditor’s completion of the final June 30, 2022 audit report, and the issuance of the Organization’s single audit report delayed the related Data Collection Form for the year ending June 30, 2022, beyond the nine-month deadline stipulated by the Uniform Guidance. The Organization has established internal compliance controls---the oversight of the process for timely filing with the director of administrative operations, chief executive officer, Board finance sub-committee and full Board.

View Audit 343323

Finding 523087 (2022-002)

Material Weakness 2022

City of Wyandotte, Michigan

MI

Reporting Material Weakness Matching / Level of Effort / Earmarking § 200.502 § 200.508 § 200.510

Condition: The schedule of expenditures of federal awards (SEFA) was not accurate. Planned Corrective Action: The City will review its process for identifying and communicating Federal Grant expenditures to its auditors. Contact person responsible for corrective action: Robert McMahon, City Admini...

Condition: The schedule of expenditures of federal awards (SEFA) was not accurate. Planned Corrective Action: The City will review its process for identifying and communicating Federal Grant expenditures to its auditors. Contact person responsible for corrective action: Robert McMahon, City Administrator Anticipated Completion Date: 09/30/2025

View Audit 342365

Finding 522582 (2022-002)

Significant Deficiency 2022

Clayton County Community Services Authority, Inc.

GA

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

Responsible Persons: Director of Community Support, Executive Director, Case Managers Anticipated Completion Date: February 1, 2025 / On-going Corrective Action: The management of Clayton County Community Services Authority, Inc. has reviewed the above referenced finding and fully agrees with the r...

Responsible Persons: Director of Community Support, Executive Director, Case Managers Anticipated Completion Date: February 1, 2025 / On-going Corrective Action: The management of Clayton County Community Services Authority, Inc. has reviewed the above referenced finding and fully agrees with the recommendation to enhance the design of our control activities to ensure that CSBG participant files are adequately maintained, and to strengthen controls surrounding management review of participant files during intake process. Case Managers are responsible for initiating and developing participant files for the purpose of determining eligibility for the CSBG Program. Once the file has been developed and the participant deemed eligible for assistance, the file is forwarded to the Director of Community Support for additional review and approval. Only after the file has been approved by the Director of Community Support or Executive Director will the payment request/transmittal be submitted to the Fiscal Department for processing of payment. The Fiscal Department will not process any transactions or transmitt als without the required signature approval from the Director of Community Support or Executive Director indicating the participant is eligible for benefits.

View Audit 341807

Finding 522579 (2022-001)

Significant Deficiency 2022

Clayton County Community Services Authority, Inc.

GA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Responsible Persons: Director of Human Resources, Director of Community Support, Chief Financial Officer, Senior Managers, Department Managers Anticipated Completion Date: February 1, 2025 / On-going Corrective Action: The management of Clayton County Community Services Authority, Inc. has reviewed ...

Responsible Persons: Director of Human Resources, Director of Community Support, Chief Financial Officer, Senior Managers, Department Managers Anticipated Completion Date: February 1, 2025 / On-going Corrective Action: The management of Clayton County Community Services Authority, Inc. has reviewed the above referenced finding and fully agrees with the recommendation to enforce the documented policies and procedures as it relates to ensuring payroll cost are properly approved. Management has immediately initiated the process where all timesheets and time and attendance records are reviewed for each pay period and properly approved before being submitted to the payroll department for processing and payment. Each department is responsible for this review and no employee will be paid without proper approval. Signed timesheets are also forwarded to the Human Resources Director and filed for further review. The Human Resources Director has initiated the process of the annual performance appraisal for each employee at the organization starting no later than February 1st of each calendar year. The performance appraisals should be completed by the end of the month in which they begin and will be properly reviewed and signed before filing in the employee's personnel file.

View Audit 341807

Finding 522496 (2022-004)

Significant Deficiency 2022

The Behavioral Wellness Center at Girard

PA

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

Corrective Action: Management agrees with the finding and has subsequently supported other eligible expenses that were not included in the original submission. These amounts exceeded the funding received. Anticipated Completion Date: November 15, 2024 Contact Person: Marco Giordano, Vice President ...

Corrective Action: Management agrees with the finding and has subsequently supported other eligible expenses that were not included in the original submission. These amounts exceeded the funding received. Anticipated Completion Date: November 15, 2024 Contact Person: Marco Giordano, Vice President and Chief Financial Officer

View Audit 341752

Finding 521139 (2022-001)

Significant Deficiency 2022

Children's Defense Fund

DC

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.430

Finding 2022-001 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF hired an Outsourced Grant Manager starting January 2025 to oversee compliance and internal control processes for federal a...

Finding 2022-001 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF hired an Outsourced Grant Manager starting January 2025 to oversee compliance and internal control processes for federal awards, ensuring adherence to 2 CFR Part 200. The Outsourced Grant Manager will implement systems to accurately allocate salaries, wages, and other expenditures. Key actions include:  Payroll Expenditures: Establish procedures to approve payroll allocations based on actual time and effort reporting, requiring supervisor approval and periodic reviews for compliance.  Non-Payroll Expenditures: Develop approval processes for non-payroll expenses, ensuring detailed documentation and implementing checks to verify overhead allocations.  Documentation and Review: Implement a comprehensive filing system for approvals and supporting documents, with regular training for staff.  Ongoing Compliance Monitoring: Conduct periodic internal audits to ensure adherence to internal controls and federal regulations, addressing issues promptly. These measures will strengthen CDF’s internal controls, ensure compliance, and maintain the integrity of federal award management. Anticipated Completion Date: December 31, 2025.

View Audit 341102 Questioned Costs: $1

Finding 521081 (2022-002)

Material Weakness 2022

Avita Health System

OH

Cash Management Material Weakness Matching / Level of Effort / Earmarking

Finding Number: 2022-002 Condition: The System failed to make the monthly debt service reserve fund deposits required by the USDA loan agreement. Planned Corrective Action: Once it was determined that it was necessary to keep the balance of the fund at a prorated amount to the required one year of d...

Finding Number: 2022-002 Condition: The System failed to make the monthly debt service reserve fund deposits required by the USDA loan agreement. Planned Corrective Action: Once it was determined that it was necessary to keep the balance of the fund at a prorated amount to the required one year of debt service by ten years, we began funding it in order to meet that requirement by the end of fiscal year 2023, which we did, and we have maintained the required funding since then. Contact person responsible for corrective action: Eric Draime, CFO Anticipated Completion Date: 6/30/2023

View Audit 341022

Finding 520711 (2022-010)

None 2022

City of Abbeville, Georgia

GA

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.318 § 200.319 § 200.326 § 200.327

The City has identified federal grants subject to the Uniform Guidance and will develop written policies and procedures which include the relevant provisions required by 2 CFR § 200.318 through 2 CFR § 200.326 Contract provisions.

View Audit 340445

Finding 520710 (2022-009)

None 2022

City of Abbeville, Georgia

GA

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.318

The City will develop written standards of conduct in that satisfy the requirements of 2 CFR § 200.318(c)(1).

View Audit 340445

Finding 520709 (2022-008)

None 2022

City of Abbeville, Georgia

GA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.302

The City has identified federal grants subject to the Uniform Guidance and will develop written procedures for determining the allowability of costs in accordance with 2 CFR 200, Subpart E—Cost Principles and the terms and conditions of the Federal award.

View Audit 340445

Finding 520708 (2022-007)

None 2022

City of Abbeville, Georgia

GA

Cash Management Matching / Level of Effort / Earmarking § 200.302 § 200.305

The City has identified federal grants subject to the Uniform Guidance and will develop written procedures to implement the requirements of 2 CFR § 200.305 Payment.

View Audit 340445

Corrective Action Plans

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