Corrective Action Plans

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Item 2021.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this...
Item 2021.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance. • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant’s period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail. • Review these procedures annually to ensure ongoing compliance with the grant’s period of performance.
Item 2021.006 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written proced...
Item 2021.006 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures to document the process for Drawdown requests, including the initial review, documented approval proves, submission to the funding agency, and the recoding of the drawdown in the accounting system immediately after submission. • Maintain detailed records of all drawdown requests, supporting documentation, approvals, and correspondence. • Conduct regular internal reviews of drawdown activities to ensure compliance with procedures and maintain audit trail. • Review drawdown procedures annually to ensure they remain current with funding agency guidelines and best practices.
Item 2021.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this...
Item 2021.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance. • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant’s period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail. • Review these procedures annually to ensure ongoing compliance with the grant’s period of performance.
Item 2021.006 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written proced...
Item 2021.006 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures to document the process for Drawdown requests, including the initial review, documented approval proves, submission to the funding agency, and the recoding of the drawdown in the accounting system immediately after submission. • Maintain detailed records of all drawdown requests, supporting documentation, approvals, and correspondence. • Conduct regular internal reviews of drawdown activities to ensure compliance with procedures and maintain audit trail. • Review drawdown procedures annually to ensure they remain current with funding agency guidelines and best practices.
Audit Finding Reference: Federal Award Findings and Questioned Costs: 2021-03 (Single audit submission) Planned Corrective Action: The Kanawha Valley Collective, Inc. will develop internal policies and procedures designed to ensure a timely annual financial statement closing which will allow the req...
Audit Finding Reference: Federal Award Findings and Questioned Costs: 2021-03 (Single audit submission) Planned Corrective Action: The Kanawha Valley Collective, Inc. will develop internal policies and procedures designed to ensure a timely annual financial statement closing which will allow the required single audit to be completed in a timelier manner. Name of Contact Person: Traci Strickland Anticipated completion date: June 30, 2025
Audit Finding Reference: Federal Award Findings and Questioned Costs: 2021-02 (Reporting) Planned Corrective Action: The Kanawha Valley Collective, Inc. will implement enhanced reconciliation and documentation procedures that timely identify and allow for the correction of differences between the ac...
Audit Finding Reference: Federal Award Findings and Questioned Costs: 2021-02 (Reporting) Planned Corrective Action: The Kanawha Valley Collective, Inc. will implement enhanced reconciliation and documentation procedures that timely identify and allow for the correction of differences between the accounting recordkeeping and the grant reporting documentation. Name of Contact Person: Traci Strickland
Finding Reference Number: MW2021-009 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021: CUAHSI used a single payment gateway for registration on CUAHSI events and was able to accurately ...
Finding Reference Number: MW2021-009 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021: CUAHSI used a single payment gateway for registration on CUAHSI events and was able to accurately document and produce grant-specific totals for audit year 2021 program income. CUAHSI staff missed the NSF filing deadline for declaring federal fiscal year 2021 program income by one day (submitted November 16th, 2021). Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI continues to use a single payment gateway for events and registration fees which supports segregation of payments per event and per grant. Program income has been reported to NSF accurately and on time beginning in 2023 and appropriate staff and policies are in place to ensure future compliance. Name of Contact Person: 􀁸 Maureen S. Ako, Director of Finance 􀁸 Telephone: (339)221-5400 􀁸 Email: msabino@cuahsi.org Projected Completion Date: NA; is complete
Finding Reference Number: MW2021-004 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021 NA Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI is curre...
Finding Reference Number: MW2021-004 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021 NA Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI is currently delinquent on the filing of audits from fiscal years 2021-2023. The organization is treating audit filings as the top priority and is working carefully through the audit backlog with qualified auditors that are currently engaged for audits 2021-2022. The delays in filing will continue into calendar year 2025, at which time it is expected that the audit package for the year ended December 31, 2024, will be filed on time to the Federal Audit Clearinghouse. Changes to CUAHSI’s accounting system, personnel, duties, and processes help ensure future audit preparation and support are streamlined, accurate, and timely. Name of Contact Person: 􀁸 Maureen S. Ako, Director of Finance 􀁸 Telephone: (339)221-5400 􀁸 Email: msabino@cuahsi.org Projected Completion Date: 2025-09-30
Finding 530128 (2021-002)
Material Weakness 2021
Finding Number 2021-002: Reporting - Material Weakness in Internal Control Over Compliance and Instance of Material Noncompliance. Program: U.S. Department of Helath and Human Services - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution. Response and Corrective Action Plan: Mana...
Finding Number 2021-002: Reporting - Material Weakness in Internal Control Over Compliance and Instance of Material Noncompliance. Program: U.S. Department of Helath and Human Services - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution. Response and Corrective Action Plan: Management agress with the finding. The Organization will review and modify policies and procedures over Federal Grant Awards to ensure management implements policies and procedures to ensure there is understanding of the terms and conditions of Federal awards and that reports are prepared and reviewed by separate individuals with evidence of review documented. Anticipated Completion Date: by December 31, 2024. Responsible Person: Matthew Matthiessen, CFO.
Finding 2021-004 Reporting of Lost Revenue Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 1 TIN #910843...
Finding 2021-004 Reporting of Lost Revenue Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 1 TIN #910843135 Compliance Requirement: Reporting Finding Summary: The amounts reported for lost revenue did not agree to the supporting documentation provided. Corrective Action Plan: The District will confirm reporting requirements before submitting reporting data. Reporting data will be reviewed and reconciled to underlying supporting documentation. Responsible Individual: Paul Rogers, Chief Financial Officer
Finding 2021-003 Preparation of Schedule of Expenditures of Federal Awards Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number...
Finding 2021-003 Preparation of Schedule of Expenditures of Federal Awards Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 1 TIN #910843135 Compliance Requirement: Other Finding Summary: The District does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards (schedule) and accompanying notes to the schedule. We were requested to draft the schedule of expenditures of federal awards. Corrective Action Plan: The District will designate a member of the Finance team to be responsible for preparing a schedule of expenditures of federal awards (schedule). Responsible Individual: Paul Rogers, Chief Financial Officer
Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: During the 2021 fiscal year there were superintendent vacancies. The School currently has a superintendent that is knowledgeable of this requirement. Implementation date: June 30, 2025
Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: During the 2021 fiscal year there were superintendent vacancies. The School currently has a superintendent that is knowledgeable of this requirement. Implementation date: June 30, 2025
Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limit...
Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limited to essential staff and activities. Due to the limited staff reports were not always documented or certified. Further, prior to the emergency order key positions in the finance and administration departments were vacant. Currently all finance and administrative positions are staffed. Training will be provided to staff responsible for Federal reporting. Implementation date: June 30, 2025
Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limit...
Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limited to essential activities. The taking of physical inventories was not considered essential. Training relating to the Federal physical inventory requirements will be provided. A physical inventory will be completed in the 2024-2025 fiscal year. Implementation date: June 30, 2025
Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limit...
Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limited to essential staff and activities. Due to the limited staff not all documentation and certifications were obtained. Further, prior to the emergency order key positions in the finance and administration departments were vacant. Currently all finance and administration departments are staffed. The School has implemented electronic procurement and timekeeping systems. These systems provide clarity in the approval process of procurement and timekeeping transactions. The transition from paper to digital formats provides enhanced internal controls to ensure that transactions are documented and approved. Training relating to the Federal and School procurement and timekeeping requirements will be provided. Implementation date: June 30, 2025
Finding 2021-003-Reporting, Non-compliance (Material Weakness) Going forward, the hospital will work with an outside consultant with more in-depth understanding of the reporting requirements prior to additional submissions. We are also catching up on the audit submissions and will remain on task wi...
Finding 2021-003-Reporting, Non-compliance (Material Weakness) Going forward, the hospital will work with an outside consultant with more in-depth understanding of the reporting requirements prior to additional submissions. We are also catching up on the audit submissions and will remain on task with timely submission. Anticipated completion date: 01/31/25.
2021-008- Special Tests and Provisions - Material Weakness Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that tenant eligibility is correctly determined and that the tenant lease files are properly maintained in accordance with the re...
2021-008- Special Tests and Provisions - Material Weakness Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that tenant eligibility is correctly determined and that the tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: Management will establish procedures to ensure that tenant eligibility is correctly determined and that all the tenant lease files are properly maintained in accordance with the requirements of HUD handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs.
2021-007 - Special Tests and Provisions - Material Weakness Recommendation: Management should review the project budget to determine if nonessential costs can be cut or request a loan from the sponsor to ensure that the replacement reserve is funded in accordance with the terms of the regulatory ag...
2021-007 - Special Tests and Provisions - Material Weakness Recommendation: Management should review the project budget to determine if nonessential costs can be cut or request a loan from the sponsor to ensure that the replacement reserve is funded in accordance with the terms of the regulatory agreement. Action Taken: The Managing Agent undertook an agency wide cost reduction beginning in March 2024, reducing project indirect costs by approximately 10-15%. Project direct costs cannot be reduced much further with most required services already being provided by city departments, and designated utility providers. The project has not had a budget increase since 2013, and while the project has a healthy replacement reserve balance in excess of $135k the project operating budget deficit is currently unable to fund those reserves without jeopardizing essential health and safety services. Management has sought and received multiple sponsor loans to address these shortfalls. The Management agent is presently prepared to submit for a required budget increase immediately following completion of all outstanding audits as required to secure the necessary rent increase.
2021-006 - Special Tests and Provisions - Material Weakness Recommendation: Management should obtain a HUD approved AFHMP and add the equal opportunity logo to marketing materials. Action Taken: Although it was believed that a HUD approved AFHMP was in place, documentation of this plan couldnot b...
2021-006 - Special Tests and Provisions - Material Weakness Recommendation: Management should obtain a HUD approved AFHMP and add the equal opportunity logo to marketing materials. Action Taken: Although it was believed that a HUD approved AFHMP was in place, documentation of this plan couldnot be located by all parties. The Managing Agent will take steps to obtain a new HUD approved AFHMP and include the equal opportunity logo to marketing materials.
2021-005 - Reporting - Material Weakness Recommendation: Management should ensure timely completion of a Uniform Guidance audit, as required. Action Taken: Historically, Uniform Guidance Data Collection Form submissions were scheduled by the sponsor. In April 2019, the management agent experienc...
2021-005 - Reporting - Material Weakness Recommendation: Management should ensure timely completion of a Uniform Guidance audit, as required. Action Taken: Historically, Uniform Guidance Data Collection Form submissions were scheduled by the sponsor. In April 2019, the management agent experienced significant staff turnover including the Chief Financial Officer. The Entity's fiscal year fiscal year 2019 closed shortly thereafter. Management Agent Staff were unaware the required fiscal year 2019 and subsequent audit(s) had not been scheduled by the Sponsor; Covid 19 hit shortly thereafter. This issue went unaddressed throughout the pandemic, followed by the resignation of the Management Agent Accounting Manager in 2021, a position that remained vacant for nearly a year. The Management agent engaged with a CPA firm to conduct the 2019, 2020 and 2021 audits.
2021-004 - Reporting - Material Weakness Recommendation: Financial statements should be timely filed to REAC. Action Taken: Historically, REAC submissions were scheduled by the sponsor. In April 2019, the management agent experienced significant staff turnover including the Chief Financial Officer. ...
2021-004 - Reporting - Material Weakness Recommendation: Financial statements should be timely filed to REAC. Action Taken: Historically, REAC submissions were scheduled by the sponsor. In April 2019, the management agent experienced significant staff turnover including the Chief Financial Officer. The Entity's fiscal year fiscal year 2019 closed shortly thereafter. Management Agent Staff were unaware the required fiscal year 2019 and subsequent audit(s) had not been scheduled by the Sponsor; Covid 19 hit shortly thereafter. This issue went unaddressed throughout the pandemic, followed by the resignation of the Management Agent Accounting Manager in 2021, a position that remained vacant for nearly a year. The Management agent engaged with a CPA firm to conduct the 2019, 2020 and 2021 audits.
2021-003 - Special Tests and Provisions - Material Weakness Recommendation: Management should obtain fidelity bond coverage as required by HUD regulations. Action Taken: The Management Agent is not responsible, nor able to obtain fidelity coverage for this property. This is the responsibility of the...
2021-003 - Special Tests and Provisions - Material Weakness Recommendation: Management should obtain fidelity bond coverage as required by HUD regulations. Action Taken: The Management Agent is not responsible, nor able to obtain fidelity coverage for this property. This is the responsibility of the Sponsor. The Management agent will follow up with the sponsor to receive and report documentation when the appropriate coverage is in place.
2021-002 - Allowable Costs/Cost Principles - Material Weakness Recommendation: We recommend that HES develop and implement procedures and controls to ensure management fee payment amounts are in accordance with the management agreement, and we recommend that funds be immediately returned to HES from...
2021-002 - Allowable Costs/Cost Principles - Material Weakness Recommendation: We recommend that HES develop and implement procedures and controls to ensure management fee payment amounts are in accordance with the management agreement, and we recommend that funds be immediately returned to HES from the management agent. Action Taken: This finding resulted from a single mischaracterized sponsor contribution, followed by the subsequent departure of competent accounting staff who could have corrected the issue. Corrective action was taken beginning in fiscal year 2022 when this issue was identified by competent accounting staff during which intercompany balances were reconciled and have been balanced routinely in subsequent fiscal years. The sponsor and management agent are in the process of developing a repayment plan.
View Audit 339373 Questioned Costs: $1
Reference Number: 2021-001 Name of Contact Person: Carlene Moore, CEO Corrective Action: As the 22nd DAA returned to financial stability, management hired and trained a combined 5 full-time employees to fill the needs in human resources and accounting departments. In the future, the 22nd DAA will ...
Reference Number: 2021-001 Name of Contact Person: Carlene Moore, CEO Corrective Action: As the 22nd DAA returned to financial stability, management hired and trained a combined 5 full-time employees to fill the needs in human resources and accounting departments. In the future, the 22nd DAA will engage subject matter experts when pursuing and obtaining any federal grant programs. Proposed Completion Date: December 31, 2022
FINDING 2021-007 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: Material Weakness, Other Matters The County did not have an effective internal control system to ensure compliance with the Reporting compliance requirement. Recipients were...
FINDING 2021-007 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: Material Weakness, Other Matters The County did not have an effective internal control system to ensure compliance with the Reporting compliance requirement. Recipients were required to submit a one-time Interim report to the U.S. Department of the Treasury (Treasury). The County submitted the required interim report during the audit period. The County's process for the completion and submission of the Interim Report was that the County Auditor prepared the Interim Report based on the County's records, without a proper oversight or review process in place prior to submission. The Interim Report was determined to be materially misstated. The County understated the December 31, 2019, Base Year Revenues by $660,302. Contact Person Responsible for Corrective Action: Timothy Stabosz Contact Phone Number and Email Address: 219-326-6808 x2226 tstabosz@laporteco.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct this finding, we will require one person to complete the report and another to review the report prior to submission. The preparer and reviewer will sign/initial to document the review process. Anticipated Completion Date: We will begin requirement a review prior to submission as of November 21, 2024.
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