Corrective Action Plans

Finding 554472 (2022-009)

Significant Deficiency 2022

OH

Eligibility Significant Deficiency Matching / Level of Effort / Earmarking

Views of Responsible Officials and Planned Corrective Action: To address the issue, the management will develop and document a clear policy for obtaining and retaining eligibility documentation. This policy should outline the specific types of documentation required and the procedures for collectin...

Views of Responsible Officials and Planned Corrective Action: To address the issue, the management will develop and document a clear policy for obtaining and retaining eligibility documentation. This policy should outline the specific types of documentation required and the procedures for collecting and storing them. Set up a monitoring and reporting system to track the status of eligibility documentation. Regularly review reports to ensure that all required documentation is up-to-date and complete. Anticipated Date of Completion: Ongoing analysis; expected to be completed by December 1, 2025.

View Audit 353100

Finding 553994 (2022-007)

Significant Deficiency 2022

California Fire Safe Council, Inc.

CA

Subrecipient Monitoring Reporting Significant Deficiency § 200.328 § 200.329

Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jacy Hyde, Executive Director Joel Rusco, Chief Financial and Administrative Officer Jessica Martinez, Deputy Director Contact Person: Jessica Martinez, Deputy Director Co...

Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jacy Hyde, Executive Director Joel Rusco, Chief Financial and Administrative Officer Jessica Martinez, Deputy Director Contact Person: Jessica Martinez, Deputy Director Corrective Action Plan: In response to the FY21 Corrective Action Plan, CFSC implemented an updated Reporting Policy in June 2024 to ensure compliance with timely and accurate reporting to funders. This policy includes defined responsibilities for grant reporting and procedures for tracking report deadlines. To further strengthen compliance and eliminate late submissions, CFSC will implement the following corrective actions: 1.Report Deadline Tracking: CFSC will enhance its report tracking to flag upcoming report due dates and set reminder alerts for responsible staff. 2.Late Submission Justification: Any delays in submission (whether approved by funder or not) must be documented in the grant file. 3.Quarterly Compliance Audits on Reporting: CFSC will conduct quarterly internal audits to review: a.Timeliness of report submissions (ensuring they met funder deadlines) b.Accuracy & completeness of reports filed in the Master Grant File. c.Corrective actions for any delayed or missing reports. Anticipated Completion Date: These corrective actions will be fully implemented by the end of Quarter 2 of FY25.

View Audit 352633

Finding 553982 (2022-005)

Significant Deficiency 2022

Ka Mana O Na Helu

HI

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

Corrective Action Responsible Party: Executive Director Finding has reoccurred as the finding was issued and corrective action plan was implemented after the time period of the single audit for time period ending December 31, 2022.The single audit requirement was new to KMNH as a result of ESG CV fu...

Corrective Action Responsible Party: Executive Director Finding has reoccurred as the finding was issued and corrective action plan was implemented after the time period of the single audit for time period ending December 31, 2022.The single audit requirement was new to KMNH as a result of ESG CV funding. KMNH has updated internal controls to carefully monitor the $1,000,000 federal dollar threshold which requires organizations to comply with the Uniform Guidance with respect to the submission deadline on single audit reports.

View Audit 352631

Finding 553979 (2022-004)

Significant Deficiency 2022

Ka Mana O Na Helu

HI

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking

Corrective Action Responsible Party: Director of Operations Finding has reoccurred as the finding was issued and corrective action plan was implemented after the time period of the single audit for time period ending December 31, 2022. KMNH has updated procurement policies and procedures to incorp...

Corrective Action Responsible Party: Director of Operations Finding has reoccurred as the finding was issued and corrective action plan was implemented after the time period of the single audit for time period ending December 31, 2022. KMNH has updated procurement policies and procedures to incorporate §200.318 through §200.327 of the Uniform Guidance procurement standards to ensure compliance with Federal standards. The policies and procedures were approved by the KMNH BOD on April 26, 2024.

View Audit 352631

Finding 553843 (2022-004)

Material Weakness 2022

So Consortium

OH

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.414 § 200.502 § 200.510

Consortium’s Fiscal Agent will ensure that supporting documentation will be maintained for all expenditures to ensure that each expenditure charged to the program is for an allowable activity/cost. In addition, Fiscal Agent will complete corrective action for 2022-005 & 2022-006

View Audit 352548

Finding 544475 (2022-010)

Material Weakness 2022

Marian High School

IN

Questioned Costs Allowable Costs / Cost Principles Cash Management

Management agrees with the finding and has established a monthly meeting between the Business Manager and the Cafeteria Director in order to review the monthly budget and ascertain that all appropriate expenses are disbursed only for the federally funded department. The Business Manager has impleme...

Management agrees with the finding and has established a monthly meeting between the Business Manager and the Cafeteria Director in order to review the monthly budget and ascertain that all appropriate expenses are disbursed only for the federally funded department. The Business Manager has implemented these accounting changes as of September 2022.

View Audit 351152 Questioned Costs: $1

Finding 544472 (2022-009)

Material Weakness 2022

Marian High School

IN

Eligibility Reporting School Nutrition Programs

Management agrees with the finding and has developed a set of policies and documented them. The Business Manager has implemented the changes as of June 2023.

View Audit 351152

Finding 540863 (2022-108)

Significant Deficiency 2022

Pancare of Florida, INC

FL

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.328

2021-108 Lack of Documentation Related to Reporting Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance ...

2021-108 Lack of Documentation Related to Reporting Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. Source documentation for grant reporting is retained and maintained in grant folders on the shared drive for future reference. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer Anticipated Completion Date: Implemented

View Audit 350520

Finding 540862 (2022-105)

Material Weakness 2022

Pancare of Florida, INC

FL

Cash Management Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional support...

Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to include only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer Anticipated Completion Date: Implemented

View Audit 350520

Finding 540860 (2022-101)

Material Weakness 2022

Pancare of Florida, INC

FL

Subrecipient Monitoring Special Tests & Provisions Matching / Level of Effort / Earmarking § 200.303

2022-101 Lack of Internal Controls over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale ...

2022-101 Lack of Internal Controls over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization’s policies for the sliding fee scale were recently updated during fiscal year 2022, by management, based on findings during the monitoring by HRSA performed in 2022, but management will consider discussing potential improvements to their policy with the grantor to potentially update it to allow for certain exceptions. The Billing and Collections Policy will be updated to waive co-pays for students in the School-Based Program. The Billing Department will audit and implement periodic feedback & training sessions for the Operations Department for training and compliance for the Sliding Fee Discount Program. The Organization expects to have the corrective action implemented by May 1, 2025. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer Anticipated Completion Date: May 1, 2025

View Audit 350520

Finding 537925 (2022-003)

Material Weakness 2022

Municipality of Camuy

PR

Reporting Material Weakness Matching / Level of Effort / Earmarking

Management concurs with the finding. We will monitor our internal control activities directly related to the financial accounting of state funds and federal funds. We will implement procedures for improving information communica-tion between the accounting finance office and the office of compliance...

Management concurs with the finding. We will monitor our internal control activities directly related to the financial accounting of state funds and federal funds. We will implement procedures for improving information communica-tion between the accounting finance office and the office of compliance so rec-ords are reconciled and are available on time for audit financial statements, including Single Audit.

View Audit 348980

Finding 530121 (2022-005)

Material Weakness 2022

Healthsource Saginaw, Inc.

MI

Material Weakness Reporting Matching / Level of Effort / Earmarking

Finding Number: 2022-005 Condition: HealthSource's controls in place for reporting submissions did not identify that guidelines were not followed related to the lost revenue calculations. Planned Corrective Action: All future submissions will be reviewed with CEO and President for accuracy and thoro...

Finding Number: 2022-005 Condition: HealthSource's controls in place for reporting submissions did not identify that guidelines were not followed related to the lost revenue calculations. Planned Corrective Action: All future submissions will be reviewed with CEO and President for accuracy and thoroughness prior to submission upload. Contact person responsible for corrective action: Sonja Martinez, Chief Financial Officer Anticipated Completion Date: 12/31/2024

View Audit 348199

Finding 530120 (2022-004)

Material Weakness 2022

Healthsource Saginaw, Inc.

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

Corrective Action Plans

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