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Corrective Action Plans

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Finding 299 (2022-002)
Significant Deficiency 2022
City of Parlier
CA
Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties
The city staff managing the business loan will receive training on the job duties, with oversight from the Sr. Revenue Manager. The city is monitoring each loan to ensure that we’re up-to-date with information, and remain in compliance with all necessary requirements of the loan program.
The city staff managing the business loan will receive training on the job duties, with oversight from the Sr. Revenue Manager. The city is monitoring each loan to ensure that we’re up-to-date with information, and remain in compliance with all necessary requirements of the loan program.
View Audit 552 Questioned Costs: $1
Finding 230 (2022-007)
Significant Deficiency 2022
Puerto Rico College of Physicians-Surgeons
PR
Questioned Costs Procurement, Suspension & Debarment
Hire a person with legal knowledge of federal grant regulations to report any situations directly to the attention of the Governing Board of PR College. Also, knowledge in accounting and auditing procedures. In addition, must have experience in federal compliance and that can monitor an execute the ...
Hire a person with legal knowledge of federal grant regulations to report any situations directly to the attention of the Governing Board of PR College. Also, knowledge in accounting and auditing procedures. In addition, must have experience in federal compliance and that can monitor an execute the college policies.
View Audit 475 Questioned Costs: $1
Finding 229 (2022-006)
Significant Deficiency 2022
Puerto Rico College of Physicians-Surgeons
PR
Questioned Costs Procurement, Suspension & Debarment Reporting
Hire a person with legal knowledge of federal grant regulations to report any situations directly to the attention of the Governing Board of PR College. Knowledge in accounting and auditing procedures. In addition, must have experience in federal compliance that can monitor an execute the college po...
Hire a person with legal knowledge of federal grant regulations to report any situations directly to the attention of the Governing Board of PR College. Knowledge in accounting and auditing procedures. In addition, must have experience in federal compliance that can monitor an execute the college policies.
View Audit 475 Questioned Costs: $1
Finding 227 (2022-004)
Significant Deficiency 2022
Puerto Rico College of Physicians-Surgeons
PR
Questioned Costs
The College must insist in Hiring an external person as an advisor with legal knowledge of federal grant regulations to report any situations directly to the attention of the Governing Board of PR College, plus must train current staff appropriately including but not limited to knowledge in grant ag...
The College must insist in Hiring an external person as an advisor with legal knowledge of federal grant regulations to report any situations directly to the attention of the Governing Board of PR College, plus must train current staff appropriately including but not limited to knowledge in grant agreements and Uniform Guidance compliance. Establish internal staff to be direct supervisors in the management of funds to maintain effective controls including the internal purchase process of the college.
View Audit 475 Questioned Costs: $1
Finding 226 (2022-003)
Significant Deficiency 2022
Puerto Rico College of Physicians-Surgeons
PR
Questioned Costs
First, the College must hire an external person as an advisor with legal knowledge of federal grant regulations to report any situations directly to the attention of the Governing Board of PR College. The Governing Board of Puerto Rico College of Physicians and Surgeons will require adequately train...
First, the College must hire an external person as an advisor with legal knowledge of federal grant regulations to report any situations directly to the attention of the Governing Board of PR College. The Governing Board of Puerto Rico College of Physicians and Surgeons will require adequately trained personnel to ensure the compliance of internal controls, policies, and grant agreements.
View Audit 475 Questioned Costs: $1
Finding 223 (2022-003)
Significant Deficiency 2022
Five Towns Community Center INC
NY
Questioned Costs Allowable Costs / Cost Principles
FTCC concurs with this finding and will make every attempt to create time studies to support salary allocations in the future.
FTCC concurs with this finding and will make every attempt to create time studies to support salary allocations in the future.
View Audit 465 Questioned Costs: $1
Finding 164 (2022-102)
Material Weakness 2022
Santa Cruz County
AZ
Questioned Costs Cash Management Eligibility § 200.303
The County is in the final stages of implementing grant policies, which will cover reimbursement procedures for all departmental grants. The County will work with the pass-through grantor to repay the amounts the County received in excess. The County will work with the Health Department director a...
The County is in the final stages of implementing grant policies, which will cover reimbursement procedures for all departmental grants. The County will work with the pass-through grantor to repay the amounts the County received in excess. The County will work with the Health Department director and staff to review grant policies and procedures.
View Audit 240 Questioned Costs: $1
Finding 161 (2022-101)
Material Weakness 2022
Santa Cruz County
AZ
Questioned Costs Matching / Level of Effort / Earmarking § 200.303
To assist the County, meet the WIOA 75% earmarking requirement for out-of-school youth program, the County will develop written policies and procedures for its WIOA Youth Activities program. The County will provide eligible out-of-school youth the opportunity of paid work experiences (WEX). The Co...
To assist the County, meet the WIOA 75% earmarking requirement for out-of-school youth program, the County will develop written policies and procedures for its WIOA Youth Activities program. The County will provide eligible out-of-school youth the opportunity of paid work experiences (WEX). The County will also work with the pass-through grantor to develop an effective strategy to recruit and retain eligible out-of-school youth. The County will monitor the out-of-school services spending throughout the fiscal year and award period.
View Audit 240 Questioned Costs: $1
Health Services Management, INC
TN
Questioned Costs Reporting
FINDING 2022-001 PROVIDER RELIEF FUND REPORTING Condition: During the audit, we noted that management did not complete the reporting portion on the Provider Relief Fund Reporting Portal for one of the facilities that received PRF money during 2021. RESPONSE AND CORRECTIVE ACTION PLAN PREPARED BY: Sc...
FINDING 2022-001 PROVIDER RELIEF FUND REPORTING Condition: During the audit, we noted that management did not complete the reporting portion on the Provider Relief Fund Reporting Portal for one of the facilities that received PRF money during 2021. RESPONSE AND CORRECTIVE ACTION PLAN PREPARED BY: Scott Fisher PERSON RESPONSIBLE FOR IMPLEMENTING THE CORRECTIVE ACTION: Scott Fisher ANTICIPATED COMPLETION DATE OF CORRECTIVE ACTION: December 31, 2023 PLANNED CORRECTIVE ACTION: Management will review all the EINs associated with each facility to ensure the PRF funding received has been accounted for and properly reported in the Provider Relief Fund Reporting Portal.
View Audit 82 Questioned Costs: $1
Finding 66 (2022-001)
Material Weakness 2022
County of Madera
CA
Questioned Costs Subrecipient Monitoring HUD Housing Programs
The Community and Economic Development Planning Division has implemented the following procedures for the fiscal year ending June 30, 2023. For non-compliant loans that do not provide responses to annual residency and request for home insurance three letters will be sent by mail to grant recipient....
The Community and Economic Development Planning Division has implemented the following procedures for the fiscal year ending June 30, 2023. For non-compliant loans that do not provide responses to annual residency and request for home insurance three letters will be sent by mail to grant recipient. If a response is not received a certified letter will be sent with the request for information followed by a phone call to the number on file. The final step is to send a certified letter stating the loan is out of compliance and will become due and payable in full. For Economic Development loans an annual audit will be conducted June to ensure that the requirements of the grant are met. If audit finds any non-compliance issues are found three letters will be sent by mail to grant recipient. If a response is not received a certified letter will be sent with the request for information followed by a phone call to the number on file. The final step is to send a certified letter stating the loan is out of compliance and will become due and payable in full. We will update our loan receivables listing to include a compliance check box which indicate that the loan is complying and actually a receivable at the end of the year.
View Audit 61 Questioned Costs: $1
Finding 1164243 (2021-007)
Material Weakness 2021
Portsmouth Redevelopment and Housing Authority
VA
Questioned Costs HUD Housing Programs Significant Deficiency
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its controls over reasonable rent determinations to ensure that they are performed timely, files are maintained, and the approved rent is properly carried forward to the HUD-50058. Explan...
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its controls over reasonable rent determinations to ensure that they are performed timely, files are maintained, and the approved rent is properly carried forward to the HUD-50058. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority has reinforced internal controls and accountability procedures to ensure that reasonable rent determinations are consistently performed and properly documented in compliance with HUD regulations. The HCV Director has assumed responsibility for reviewing and approving all reasonable rent determinations and will continue to monitor compliance until the Compliance Manager is hired in January 2026. Name(s) of the contact person(s) responsible for corrective action Keva Newsome, Director of Housing Choice Voucher Program Planned completion date for corrective action plan: 12/1/25
View Audit 373527 Questioned Costs: $1
Finding 1164241 (2021-005)
Material Weakness 2021
Portsmouth Redevelopment and Housing Authority
VA
Questioned Costs HUD Housing Programs Special Tests & Provisions
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority: - Review and revise its eligibility determination procedures to ensure full compliance with HUD regulations. - Train staff on proper documentation and verification protocols for income, citizen...
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority: - Review and revise its eligibility determination procedures to ensure full compliance with HUD regulations. - Train staff on proper documentation and verification protocols for income, citizenship/immigration status, Social Security numbers, and student eligibility. - Conduct a file audit to identify and correct any improperly admitted tenants. - Update its Administrative Plan to reflect accurate eligibility screening procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Due to the high level of staff turnover, all HCV personnel will be retrained on verification requirements, eligibility documentation standards, and proper file maintenance. PRHA is also strengthening long-term compliance monitoring and accountability measures. The Authority will hire a Compliance staff person for the HCV Program in January 2026 to provide dedicated oversight of eligibility determinations, quality control, and ongoing staff training. Name(s) of the contact person(s) responsible for corrective action: Keva Newsome, Director of Housing Choice Voucher Program Planned completion date for corrective action plan: 1/31/26
View Audit 373527 Questioned Costs: $1
Finding 1164240 (2021-004)
Material Weakness 2021
Portsmouth Redevelopment and Housing Authority
VA
Questioned Costs Allowable Costs / Cost Principles Significant Deficiency
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its internal controls over allowable costs to ensure all documentation is maintained at the time expenses are paid. Explanation of disagreement with audit finding: There is no disagreemen...
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its internal controls over allowable costs to ensure all documentation is maintained at the time expenses are paid. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority is prioritizing completion of outstanding audits to ensure records can be located promptly when requested. All invoices will continue to require proper approval signatures prior to payment, and payment authorization will serve as an additional layer of verification to confirm compliance with internal control procedures. This instance involved only one of forty (40) accounts payable items that was not available in the document imaging system at the time of review so it needed to be recreated by printing off the invoice and it was paid online. The payment would have had to be pre-approved by CFO prior to payment. Name(s) of the contact person(s) responsible for corrective action: Shannon Sterling, CFO Planned completion date for corrective action plan: 12/1/25
View Audit 373527 Questioned Costs: $1
Finding 1164238 (2021-002)
Material Weakness 2021
Portsmouth Redevelopment and Housing Authority
VA
Questioned Costs HUD Housing Programs Significant Deficiency
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its controls over HQS inspections and abatements to ensure the controls are properly implemented. Explanation of disagreement with audit finding: There is no disagreement with the audit f...
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its controls over HQS inspections and abatements to ensure the controls are properly implemented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A new HCV Director has been appointed and will perform monthly compliance reviews of failed inspections to ensure timely abatement enforcement and documentation accuracy. Name(s) of the contact person(s) responsible for corrective action: Keva Newsome, Director of Housing Choice Voucher Program Planned completion date for corrective action plan: 12/1/2025
View Audit 373527 Questioned Costs: $1
Finding 1163012 (2021-005)
Material Weakness 2021
Ruth Ellis Center, Inc.
MI
Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303
View of Responsible Officials and Corrective Action Plan – The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check payment from approved by the Grant...
View of Responsible Officials and Corrective Action Plan – The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check payment from approved by the Grant Program Director and CEO/Executive Director, or by the CFO, along with the invoice for the expenditure, and explanation of reason for the change to the specific grant.
View Audit 372604 Questioned Costs: $1
Finding 1162248 (2021-004)
Material Weakness 2021
Stephens Memorial Hospital
TX
Questioned Costs Allowable Costs / Cost Principles Reporting
Corrective Action Plan for Finding 2021-004, Reporting and Activities Allowed/Unallowed and Allowable Costs/Cost Principles We are in receipt of the findings required to be reported by the single audit for Period 1 reporting for payments received from the Provider Relief Fund (PRF), specifically, re...
Corrective Action Plan for Finding 2021-004, Reporting and Activities Allowed/Unallowed and Allowable Costs/Cost Principles We are in receipt of the findings required to be reported by the single audit for Period 1 reporting for payments received from the Provider Relief Fund (PRF), specifically, regarding discrepancies in the reporting requirements and auditing for the above period for the PRF. Management does not dispute the finding. The District will work to develop policies over financial reporting for future periods for PRF reporting and auditing. The District will perform detailed analysis of the reporting requirements in accordance with the guidelines set forth by HRSA. The District CEO, Gena Speer, will oversee this to ensure that this is accomplished. The District had enough expenditures for Period 1 and 4 funding received to cover any disqualified lost revenues that were utilized as a basis for the funds received. The Corrective Action Plan will be implemented by September 30, 2025.
View Audit 372059 Questioned Costs: $1
Finding 1162247 (2021-003)
Material Weakness 2021
Stephens Memorial Hospital
TX
Questioned Costs Allowable Costs / Cost Principles Reporting
Corrective Action Plan for Finding 2021-003, Reporting and Activities Allowed/Unallowed and Allowable Costs/Cost Principles We are in receipt of the findings required to be reported by the single audit for Period 1 reporting for payments received from the Provider Relief Fund (PRF), specifically, re...
Corrective Action Plan for Finding 2021-003, Reporting and Activities Allowed/Unallowed and Allowable Costs/Cost Principles We are in receipt of the findings required to be reported by the single audit for Period 1 reporting for payments received from the Provider Relief Fund (PRF), specifically, regarding discrepancies in the reporting requirements and auditing for the above period for the PRF. Management does not dispute the finding. The District will work to develop policies over financial reporting for future periods for PRF reporting and auditing. The District will perform detailed analysis of the reporting requirements in accordance with the guidelines set forth by HRSA. The District CEO, Gena Speer, will oversee this to ensure that this is accomplished. The Corrective Action Plan will be implemented by September 30, 2025.
View Audit 372059 Questioned Costs: $1
Finding 1162227 (2021-004)
Material Weakness 2021
Stonewall County Hospital District
TX
Questioned Costs Allowable Costs / Cost Principles Eligibility
Corrective Action Plan for Finding 2021-004 We are in receipt of the finding required to be reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting and Activities Allowed or Unallowed and Allowable Costs/Cost Principles Reporting. Management agrees with the ...
Corrective Action Plan for Finding 2021-004 We are in receipt of the finding required to be reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting and Activities Allowed or Unallowed and Allowable Costs/Cost Principles Reporting. Management agrees with the finding. Policies and procedures over federal grant reporting will be modified to ensure reports are prepared using complete and accurate information. We will increase compensating controls for introducing additional oversight and review for future federal funding reporting. Lewis Robbins, CFO, will be responsible to ensure this is accomplished. The District had enough lost revenues related to Period 1, as reported in the Period 4 reporting submission, that the error determined in Finding 2021-003 will not result in a conflict with funding received. The Corrective Action Plan will be implemented by September 30, 2025.
View Audit 372037 Questioned Costs: $1
Finding 1162226 (2021-003)
Material Weakness 2021
Stonewall County Hospital District
TX
Questioned Costs Allowable Costs / Cost Principles Cash Management
Corrective Action Plan for Finding 2021-003 We are in receipt of the finding required to be reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting and Activities Allowed or Unallowed and Allowable Costs/Cost Principles Reporting. Management agrees with the ...
Corrective Action Plan for Finding 2021-003 We are in receipt of the finding required to be reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting and Activities Allowed or Unallowed and Allowable Costs/Cost Principles Reporting. Management agrees with the finding. Policies and procedures over federal grant reporting will be modified to ensure reports are prepared using complete and accurate information. We will increase compensating controls for introducing additional oversight and review for future federal funding reporting. Lewis Robbins, CFO, will be responsible to ensure this is accomplished. The District had enough lost revenues related to Period 1, as reported in the Period 4 reporting submission, that the error determined in Finding 2021-003 will not result in a conflict with funding received. The Corrective Action Plan will be implemented by September 30, 2025.
View Audit 372037 Questioned Costs: $1
Finding 1161064 (2021-004)
Material Weakness 2021
Coal County Healthcare Authority
OK
Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles
Condition - Expenditures reported to HRSA were not in accordance with Pub. L. No. 116-136, 134 Stat. 563 Plan of Corrective Action Much research was performed by the Authority's leadership to identify guidance from HRSA including reviewing FAQs, Fact Sheets, consulting attorneys, auditors, consultan...
Condition - Expenditures reported to HRSA were not in accordance with Pub. L. No. 116-136, 134 Stat. 563 Plan of Corrective Action Much research was performed by the Authority's leadership to identify guidance from HRSA including reviewing FAQs, Fact Sheets, consulting attorneys, auditors, consultants and other parties. The complexity of the reporting requirements, including changing FAQ's and our inability to gain a definite approval of the use of our funds, resulted in the Authority filing the its submission based on the best available information at the time. The Authority's position is that the Provider Relief Funds were appropriately expensed using additional expenses and lost revenues not initially submitted to the portal. The Authority will continue to monitor the guidance for use of funds provided by HRSA and will strive to appropriately utilize all funds in the future. The Authority will review the most recently distributed Provider Relief Fund FAQ's which provide details on requirements related to the program Contact person: Chris Martin, CEO cmartin@ccghospital.com (580)927-2327 Expected implementation:2024 - 2025
View Audit 371035 Questioned Costs: $1
Finding 1159783 (2021-008)
Material Weakness 2021
Program of Academic Exchange
NY
Questioned Costs Allowable Costs / Cost Principles § 200.430
In a previous period and by previous auditors, PAX was told that because we were using a percentage of effort calculation in budgeting that time sheets were no longer needed for this purpose. At that time, we abandoned the time sheet process (which was arduous). Based upon current auditor’s advice, ...
In a previous period and by previous auditors, PAX was told that because we were using a percentage of effort calculation in budgeting that time sheets were no longer needed for this purpose. At that time, we abandoned the time sheet process (which was arduous). Based upon current auditor’s advice, PAX will, going forward, establish an effort verification reporting system. This system will accurately capture the effort spent by each employee on specific grants, ensuring proper allocation of wages and salaries to the respective federal awards. Dije Kucana, Comptroller, effective immediately
View Audit 370334 Questioned Costs: $1
Finding 1155786 (2021-005)
Material Weakness 2021
Medstar, Inc.
MI
Questioned Costs Allowable Costs / Cost Principles Material Weakness
Condition: The Organization was unable to provide supporting documentation to substantiate the allowability and accuracy of the expenses and lost revenue submitted in the portal. Planned Corrective Action: Company is an emergency services (ambulance, first responder, and was instrumental in the admi...
Condition: The Organization was unable to provide supporting documentation to substantiate the allowability and accuracy of the expenses and lost revenue submitted in the portal. Planned Corrective Action: Company is an emergency services (ambulance, first responder, and was instrumental in the administration of the monoclonal antibodies) - healthcare company and was during the pandemic. Company was able to provide general ledger information by personnel classification in aggregate monthly with percentages related to the Covid pandemic, Company changed payroll companies in June, 2022 from Trion to DM Payroll -where we were unable to access the payroll registers by personnel name. Medstar has full access to payroll registers through DM Payroll. Contact person responsible for corrective action: Lalainia Budyznowski Anticipated Completion Date: 06/30/2022 - Completed
View Audit 368173 Questioned Costs: $1
Finding 576262 (2021-010)
Material Weakness 2021
Community Homeless Solutions
CA
Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment
The agency will implement a policy of attaching or associating supporting documentation for classification for appropriate natural General Ledger and Expense Account
The agency will implement a policy of attaching or associating supporting documentation for classification for appropriate natural General Ledger and Expense Account
View Audit 366162 Questioned Costs: $1
Finding 576256 (2021-009)
Material Weakness 2021
Community Homeless Solutions
CA
Questioned Costs Allowable Costs / Cost Principles Material Weakness
The agency will implement a formal voucher and approval system to correctly record grant expenses
The agency will implement a formal voucher and approval system to correctly record grant expenses
View Audit 366162 Questioned Costs: $1
Finding 576250 (2021-008)
Material Weakness 2021
Community Homeless Solutions
CA
Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties
The agency will improve the time keeping system to properly reflect after the fact work effort
The agency will improve the time keeping system to properly reflect after the fact work effort
View Audit 366162 Questioned Costs: $1
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