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Corrective Action Plans

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Finding 11575 (2023-003)
Material Weakness 2023
Outpatient Medical Center, Inc.
LA
Allowable Costs / Cost Principles Material Weakness Reporting
2023-003 Reporting Corrective action planned: OMC will work with the new accounting software vendor so that financial information needed for the annual UDS report (specifically personnel related data) can be extracted based on data in the financial system. All reports used to gather information for ...
2023-003 Reporting Corrective action planned: OMC will work with the new accounting software vendor so that financial information needed for the annual UDS report (specifically personnel related data) can be extracted based on data in the financial system. All reports used to gather information for the UDS report will be retained and filed electronically in the designated folder. Anticipated completion date: April 2024 Contact person responsible for corrective action: Kathy Barroso, Financial Consultant
View Audit 15387
Finding 11564 (2023-002)
Material Weakness 2023
Eventide
MN
Material Weakness Reporting Internal Control / Segregation of Duties § 200.33
Finding 2023-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA #93.498 Finding Summary: The Organization had a resident revenue calculation error of $269,085 on the HHS special report w...
Finding 2023-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA #93.498 Finding Summary: The Organization had a resident revenue calculation error of $269,085 on the HHS special report with no impact to the actual lost revenues calculated (i.e. lost revenues reported were accurate on the HHS special report but key line items were misstated). Responsible Individuals: Darin Ohe, CFO Corrective Action Plan: Eventide will enhance internal control policies to ensure the HHS special report is supported by accurate revenue calculations. The resident revenue numbers will be updated to the correct numbers on the next HHS special report, if applicable. Anticipated Completion Date: 9/30/23
View Audit 15370
Finding 11552 (2023-004)
Material Weakness 2023
Vista Homes Housing Corporation
NY
Eligibility HUD Housing Programs Material Weakness
The Organization will enhance its controls to ensure all tenant files are maintained in accordance with the HUD Handbook.
The Organization will enhance its controls to ensure all tenant files are maintained in accordance with the HUD Handbook.
View Audit 15369
Finding 11551 (2023-003)
Material Weakness 2023
Vista Homes Housing Corporation
NY
Procurement, Suspension & Debarment Allowable Costs / Cost Principles HUD Housing Programs
The Organization will enhance its controls to ensure bidding is obtained when needed, expenses are captured in the correct fiscal period and that at year-end there is a final review of the transactions to ensure completeness, accuracy and proper classification.
The Organization will enhance its controls to ensure bidding is obtained when needed, expenses are captured in the correct fiscal period and that at year-end there is a final review of the transactions to ensure completeness, accuracy and proper classification.
View Audit 15369
Finding 11550 (2023-002)
Material Weakness 2023
Vista Homes Housing Corporation
NY
Reporting Internal Control / Segregation of Duties Material Weakness
The Organization will enhance its controls and procedures to ensure financial reporting is complete, accurate, and timely.
The Organization will enhance its controls and procedures to ensure financial reporting is complete, accurate, and timely.
View Audit 15369
Finding 11549 (2023-001)
Material Weakness 2023
Vista Homes Housing Corporation
NY
HUD Housing Programs Special Tests & Provisions Cash Management
The Organization has opened a new residual receipts account and has enhanced its controls to ensure that the calculated surplus cash balance is deposited into the account, if applicable, annually.
The Organization has opened a new residual receipts account and has enhanced its controls to ensure that the calculated surplus cash balance is deposited into the account, if applicable, annually.
View Audit 15369
Finding 11546 (2023-004)
Material Weakness 2023
Housing for the Multi-Handicapped Blind
NY
Eligibility HUD Housing Programs Material Weakness
The Organization will enhance its controls to ensure all tenant files are maintained in accordance with the HUD Handbook.
The Organization will enhance its controls to ensure all tenant files are maintained in accordance with the HUD Handbook.
View Audit 15367
Finding 11545 (2023-003)
Material Weakness 2023
Housing for the Multi-Handicapped Blind
NY
Allowable Costs / Cost Principles HUD Housing Programs Material Weakness
The Organization will enhance its controls to ensure expenses are captured in the correct fiscal period and that at year-end there is a final review of the transactions to ensure completeness, accuracy and proper classification.
The Organization will enhance its controls to ensure expenses are captured in the correct fiscal period and that at year-end there is a final review of the transactions to ensure completeness, accuracy and proper classification.
View Audit 15367
Finding 11544 (2023-002)
Material Weakness 2023
Housing for the Multi-Handicapped Blind
NY
Reporting Internal Control / Segregation of Duties Material Weakness
The Organization will enhance its controls and procedures to ensure financial reporting is complete, accurate, and timely.
The Organization will enhance its controls and procedures to ensure financial reporting is complete, accurate, and timely.
View Audit 15367
Finding 11543 (2023-001)
Material Weakness 2023
Housing for the Multi-Handicapped Blind
NY
HUD Housing Programs Special Tests & Provisions Material Weakness
The Organization has recently established a procedure whereby on the 25th of every month a transfer occurs. Controls to ensure such transfers are appropriate have also been established.
The Organization has recently established a procedure whereby on the 25th of every month a transfer occurs. Controls to ensure such transfers are appropriate have also been established.
View Audit 15367
Finding 11533 (2023-003)
Material Weakness 2023
Great Expectations Housing Corporation
CA
Procurement, Suspension & Debarment Allowable Costs / Cost Principles HUD Housing Programs
The Organization will enhance its controls to ensure bidding is obtained when needed, expenses are captured in the correct fiscal period and that at year-end there is a final review of the transactions to ensure completeness, accuracy and proper classification.
The Organization will enhance its controls to ensure bidding is obtained when needed, expenses are captured in the correct fiscal period and that at year-end there is a final review of the transactions to ensure completeness, accuracy and proper classification.
View Audit 15366
Finding 11532 (2023-002)
Material Weakness 2023
Great Expectations Housing Corporation
CA
Reporting Internal Control / Segregation of Duties Material Weakness
The Organization will enhance its controls and procedures to ensure financial reporting is complete, accurate, and timely.
The Organization will enhance its controls and procedures to ensure financial reporting is complete, accurate, and timely.
View Audit 15366
Finding 11531 (2023-001)
Material Weakness 2023
Great Expectations Housing Corporation
CA
HUD Housing Programs Special Tests & Provisions Cash Management
The Organization has opened a new residual receipts account and has enhanced its controls to ensure that the calculated surplus cash balance is deposited into the account, if applicable, annually.
The Organization has opened a new residual receipts account and has enhanced its controls to ensure that the calculated surplus cash balance is deposited into the account, if applicable, annually.
View Audit 15366
Finding 11523 (2023-003)
Material Weakness 2023
New Visions Housing Corporation
CA
Reporting Internal Control / Segregation of Duties Material Weakness
The Organization will enhance its controls and procedures to ensure financial reporting is complete, accurate, and timely.
The Organization will enhance its controls and procedures to ensure financial reporting is complete, accurate, and timely.
View Audit 15365
Finding 11522 (2023-002)
Material Weakness 2023
New Visions Housing Corporation
CA
Procurement, Suspension & Debarment Allowable Costs / Cost Principles HUD Housing Programs
The Organization will enhance its controls to ensure bidding is obtained when needed, expenses are captured in the correct fiscal period and that at year-end there is a final review of the transactions to ensure completeness, accuracy and proper classification.
The Organization will enhance its controls to ensure bidding is obtained when needed, expenses are captured in the correct fiscal period and that at year-end there is a final review of the transactions to ensure completeness, accuracy and proper classification.
View Audit 15365
Finding 11521 (2023-001)
Material Weakness 2023
New Visions Housing Corporation
CA
HUD Housing Programs Material Weakness Special Tests & Provisions
The Organization is in the process of opening a new residual receipts account. The Organization has recently established a procedure whereby on the 25th of every month a transfer occurs. Controls to ensure such transfers are appropriate have also been established.
The Organization is in the process of opening a new residual receipts account. The Organization has recently established a procedure whereby on the 25th of every month a transfer occurs. Controls to ensure such transfers are appropriate have also been established.
View Audit 15365
Finding 11178 (2023-003)
Material Weakness 2023
Cumberland Memorial Hospital, Inc.
WI
Material Weakness Reporting Internal Control / Segregation of Duties
Recommendation – We recommend that all accounts be reconciled and adjustments be posted to the accounting records on a quarterly basis, at a minimum. Management’s Response – The Hospital will work to establish policies and procedures to reduce the number of adjusting journal entries proposed by the ...
Recommendation – We recommend that all accounts be reconciled and adjustments be posted to the accounting records on a quarterly basis, at a minimum. Management’s Response – The Hospital will work to establish policies and procedures to reduce the number of adjusting journal entries proposed by the auditors.
View Audit 14986
Finding 11176 (2023-001)
Material Weakness 2023
Cumberland Memorial Hospital, Inc.
WI
Internal Control / Segregation of Duties Material Weakness Reporting
Recommendation – We recommend management and those charged with governance continue to evaluate whether to accept the degree of risk associated with this condition because of cost or other considerations. Management’s Response – The Hospital does not have the resources and staff to prepare the finan...
Recommendation – We recommend management and those charged with governance continue to evaluate whether to accept the degree of risk associated with this condition because of cost or other considerations. Management’s Response – The Hospital does not have the resources and staff to prepare the financial statements and notes but will continue to oversee the auditor’s services and review and approve the financial statements and notes.
View Audit 14986
Finding 10980 (2023-002)
Material Weakness 2023
Western Oregon University
OR
Special Tests & Provisions Material Weakness Internal Control / Segregation of Duties
Finding 2023-002 Federal Agency Name: U.S. Department of Education Federal Financial Assistance Listing: 84.063, 84.007, 84.268, 84.033, 84.038, 84.379 Program Name: Student Financial Assistance Cluster Compliance Requirement: Special Tests & Provisions – Gramm-Leach-Bliley Act (GLBA) – Student ...
Finding 2023-002 Federal Agency Name: U.S. Department of Education Federal Financial Assistance Listing: 84.063, 84.007, 84.268, 84.033, 84.038, 84.379 Program Name: Student Financial Assistance Cluster Compliance Requirement: Special Tests & Provisions – Gramm-Leach-Bliley Act (GLBA) – Student Information Security Type of Finding: Material Weakness in Internal Controls Finding Summary: During testing over GLBA compliance, it was noted that the University had not updated the information security program and was missing aspects of the required nine elements. Responsible Individuals: Kella Helyer, Director of Financial Aid (DFA) and Michael Ellis, Assistant Director of University Computing Solutions (AD UCS) Corrective Action Plan: Management agrees with this finding. See the GLBA Draft Corrective Action Plan table below. Anticipated Completion Date: See the attached GLBA Draft Corrective Action Plan table below: GLBA documentation 314.4 Reference What WOU will do Complete by Date Who will do it Completion Date Document full status of 314.4 4/1/24 AD UCS a Complete b Update our CIS18 controls - aka InfoSec Program 7/1/24 AD UCS b.2 Risk assessment for on-prem servers with FinAid* data 4/1/24 AD UCS, Lead Windows Admin, Warehouse Programmer c.1 Document current processes and access controls 4/1/24 AD UCS, DFA c.2 Document current information, including Business Office 12/20/23 Financial Aid Accountant 12/13/23 c.3 Encrypte NetApp volumes, and ensure encryption on DB links 8/1/24 AD UCS, Lead Windows Admin, Warehouse Programmer c.4 Assess warehouse & BannerRPT 7/1/24 AD UCS, Warehouse Programmer, Operating Systems/Security Analyst c.5 Complete c.6 Review PowerFAIDS electronic files for purging Review paper files for purging Have Business Office review files for purging 8/1/24 DFA c.7 Audit FinAid data access upon addition to Warehouse 8/1/24 Warehouse Programmer and/or Operating Systems/Security Analyst c.8 Add access logs to WOU central logging system 8/1/24 AD UCS, Web & Banner Programmer d.2.i Annual pentest by Campus Guard 2/29/24 AD UCS e Complete f Document all 3rd party providers who interact with FinAid data. Audit yearly 8/1/24 DFA, AD UCS g Complete h Complete i Verbal report given in 2023. Anticipated written report to Board on 7/1/24 7/1/24 AD UCS
View Audit 14816
Finding 10974 (2023-001)
Material Weakness 2023
Western Oregon University
OR
Reporting Special Tests & Provisions Student Financial Aid
Finding 2023-001 Federal Agency Name: U.S. Department of Education Federal Financial Assistance Listing: 84.063, 84.007, 84.268, 84.033, 84.038, 84.379 Program Name: Student Financial Assistance Cluster Compliance Requirement: Special Tests & Provisions – Enrollment Reporting Type of Finding: M...
Finding 2023-001 Federal Agency Name: U.S. Department of Education Federal Financial Assistance Listing: 84.063, 84.007, 84.268, 84.033, 84.038, 84.379 Program Name: Student Financial Assistance Cluster Compliance Requirement: Special Tests & Provisions – Enrollment Reporting Type of Finding: Material Weakness in Internal Controls Finding Summary: During the testing of compliance for Enrollment Reporting, there were instances where the National Student Loan Data System (NLSDS) did not reflect accurate or timely reporting of a student’s change in enrollment status. While records were submitted accurately and timely to the National Student Clearinghouse, those records were not reflected in NSLDS. Responsible Individuals: Kella Helyer, Director of Financial Aid and Amy Clark, University Registrar Corrective Action Plan: Management agrees with this finding. The initial response to this request for data did not include the active and inactive enrollment levels for the requested sample students. Initially it appeared that there was a systems issue between the National Student Clearinghouse (NSC) and the National Student Loan Data System (NSLDS); however, upon further investigation and in conversation with NSLDS, the required information was found and subsequently provided to Eide Bailly on December 1, 2023. The resolution of this request for data was resolved but after the final audit report was submitted. Anticipated Completion Date: Completed December 1, 2023
View Audit 14816
Finding 10967 (2023-001)
Material Weakness 2023
Center for Advocacy for the Rights and Interests of the Elderly
PA
Reporting Material Weakness
Center for Advocacy for the Rights and Interests of the Elderly (CARIE) respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: Year ending June 30, 2023 The finding from the schedule of findings and questioned costs is discussed below. The finding...
Center for Advocacy for the Rights and Interests of the Elderly (CARIE) respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: Year ending June 30, 2023 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FINDINGS—SINGLE AUDIT MATERIAL WEAKNESS 2023‐001 Internal Control over Compliance and Compliance (Reporting) Recommendation: We recommend management evaluate their internal controls surrounding the major federal programs to ensure compliance with the reporting requirements of their grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will create a reporting calendar with due dates to be reviewed monthly. The Finance Manager will prepare the reports and the Executive Director will review the reports prior to submission. Names of contact responsible for corrective action: Whitney Lingle, Executive Director. Planned completion date for corrective action plan: June 30, 2024. If the Department of Health and Human Services has questions regarding this plan, please call Whitney Lingle at (267) 546‐3434.
View Audit 14811
Finding 10949 (2023-001)
Material Weakness 2023
Lake County Community College District
OH
Cash Management Subrecipient Monitoring Material Weakness § 200.305
Condition: The College drew down an estimated amount of cash prior to the funds being disbursed to students or used for allowable expenditures. Planned Corrective Action: There is not anymore HEERF or federal stimulus funding to be drawn down moving forward. However, if there is in the future, the C...
Condition: The College drew down an estimated amount of cash prior to the funds being disbursed to students or used for allowable expenditures. Planned Corrective Action: There is not anymore HEERF or federal stimulus funding to be drawn down moving forward. However, if there is in the future, the College will follow the three-day drawdown rules for cash disbursements. Contact person responsible for corrective action: Tom Reynolds College Treasurer Anticipated Completion Date: 12/14/2023 as soon as possible moving forward
View Audit 14778
Finding 10948 (2023-001)
Material Weakness 2023
South Redford School District
MI
Procurement, Suspension & Debarment Subrecipient Monitoring Special Tests & Provisions
Condition: During testing of the grant, we noted the School District utilized funds from the Education Stabilization Funds (ESF) for minor remodeling and renovations of the school buildings. Per the 2023 Compliance Supplement, recipients and subrecipients that use ESF for minor remodeling, renovatio...
Condition: During testing of the grant, we noted the School District utilized funds from the Education Stabilization Funds (ESF) for minor remodeling and renovations of the school buildings. Per the 2023 Compliance Supplement, recipients and subrecipients that use ESF for minor remodeling, renovation, or construction contracts that are over $2,000 and use laborers and mechanics, must meet Davis-Bacon prevailing wage requirements. The School District expended ESSER funds that related to repairs and renovations; however, the prevailing wage requirement was not included in any of the related contracts' language, nor did the School District receive or review the certified payroll reports from any of the contractors. Planned Corrective Action: As it pertains to the use of ANY Federal funds for construction projects in the South Redford School District (SRSD), when said funds will be used to compensate for labor for any construction project: We must stipulate in all RFP’s, Davis-Bacon requirements for prevailing wages as it relates to the use of laborers and mechanics, for all projects over $2,000. All responses to RFP’s must: 1. Acknowledge the Davis Bacon prevailing wage requirement; 2. All bid pricing must reflect prevailing wage requirements; 3. Bid recipients must have a process in place for reporting their compliance to the prevailing wage requirement and submit documentation along with all invoices, be it directly to SRSD or to the construction management firm, who will then include said documentation with their backup and invoices to SRSD. Contact person responsible for corrective action: Linda Earl, Finance Director Anticipated Completion Date: November 1, 2023
View Audit 14775
Finding 10938 (2023-009)
Material Weakness 2023
Caritas Family Solutions and Affiliates
IL
Internal Control / Segregation of Duties Material Weakness Reporting
• Corrective Action Plan: Caritas Family Solutions acknowledges the finding and is committed to establishing and enforcing internal control procedures for compliance with performance reporting requirements. We will work to improve our oversight and compliance in this regard. o A compliance team wil...
• Corrective Action Plan: Caritas Family Solutions acknowledges the finding and is committed to establishing and enforcing internal control procedures for compliance with performance reporting requirements. We will work to improve our oversight and compliance in this regard. o A compliance team will be appointed to ensure that the agency adheres to all compliance requirements. o The compliance team will work closely with the PM to coordinate and delegate tasks to collect the data needed to complete the report. o The compliance team will assist in creating a process for maintaining documentation to support what is reported. o The compliance team will document the level of compliance in which internal controls are followed and report results to program and agency leadership along with recommendations for improvement. Internal audits will be conducted in preparation for external audits. • Anticipated Completion Date: The process will be implemented on January 3, 2024, and will continuously be reviewed and updated to align with best practices.
View Audit 14751
Finding 10934 (2023-005)
Material Weakness 2023
Caritas Family Solutions and Affiliates
IL
Internal Control / Segregation of Duties Allowable Costs / Cost Principles Eligibility
• Corrective Action Plan: This deficiency was also discovered during our internal investigation, and Caritas Family Solutions has implemented a new process to ensure that internal controls are in place. o A SCSEP Employment Specialist will meet with participants to complete the recertification appli...
• Corrective Action Plan: This deficiency was also discovered during our internal investigation, and Caritas Family Solutions has implemented a new process to ensure that internal controls are in place. o A SCSEP Employment Specialist will meet with participants to complete the recertification application and gather the necessary documentation. o The recertification application and documentation will be forwarded to the PM for review and approval. o The PM will review the form, sign, and date it after confirming that all information is accurate and complete. o If there are inaccuracies and/or missing information, the form will be returned to the ES who will follow up with the host site to obtain the missing information or correct the inaccuracy. o Steps 1 and 2 will be repeated. o The QI department will conduct quarterly file reviews to determine if processes are being followed. Re-certification was modified during the pandemic out of an abundance of caution for the participants in the program. Those who had access to the internet were asked to email their documentation, and those who didn’t were asked to mail theirs. A drive through recertification process was implemented when COVID restrictions eased, and participants were asked to remain in their vehicles while SCSEP employment specialists obtained their recertification documentation. Many participants do not have transportation and were not able to participate in the drive through. The most recent, pre-pandemic certification information for participants was used for those who were not able to attend the drive through or virtual recertification processes. CWI did not end COVID protocols until Q4 of PY2022 (April 1, 2023). Alternative recertification methods were used to comply with the protocols. With the end of the COVID protocols and restrictions, we have reinstituted the in-person/face-to-face recertification process required by the funder. • Anticipated Completion Date: Implemented in September 2023, but the process will be ongoing while the program is funded.
View Audit 14751
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