Corrective Action Plans

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FINDING 2023-001: SEGREGATION OF DUTIES Classes of financial transactions have been segregated to the extent possible among the existing employees. However, because of the limited number of employees involved in the accounting and bookkeeping functions, a corrective action plan to remedy the lack of...
FINDING 2023-001: SEGREGATION OF DUTIES Classes of financial transactions have been segregated to the extent possible among the existing employees. However, because of the limited number of employees involved in the accounting and bookkeeping functions, a corrective action plan to remedy the lack of segregation of duties is not cost justified. Rather, each level of management, the Board of Directors and Administrator, are aware of the concept of "segregation of duties" and are also aware of potential problems that may occur when accounting and bookkeeping duties cannot be segregated. Because there is awareness, each level of management is charged with the responsibility to follow-up on any circumstances or transactions that they perceive to be unusual. Contact person: Tim Nichols Anticipated completion date: Unknown
Condition: The Authority did not utilize federal procurement requirements cited above for the tele-health services and SUD Peer Recovery Service contracted service providers utilized for the Certified Community Behavioral Health Clinics project. (no documentation for sole source, no proof that it wa...
Condition: The Authority did not utilize federal procurement requirements cited above for the tele-health services and SUD Peer Recovery Service contracted service providers utilized for the Certified Community Behavioral Health Clinics project. (no documentation for sole source, no proof that it was advertised, google search was provided from 7/24/24 is not sufficient, board cannot waive federal requirement). Recommendation: The Authority follow federal procurement as required in 2 CFR 200.319(d) for all contracts reimbursed with federal funds. Planned Corrective Action: Going forward the Authority will follow federal procurement as required in 2 CFR 200.319(d) for all contracts reimbursed with federal funds. Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2024
View Audit 329033 Questioned Costs: $1
Condition: Accrued PTO time was adjusted as of September 30, 2023, however certain employees were transferred over to the grant program that had accrued PTO as of September 30, 2022 that was not taken into account. As a result, the grant was charged PTO time for amounts that had been accrued in prio...
Condition: Accrued PTO time was adjusted as of September 30, 2023, however certain employees were transferred over to the grant program that had accrued PTO as of September 30, 2022 that was not taken into account. As a result, the grant was charged PTO time for amounts that had been accrued in prior years in other programs and activities. Recommendation: Schedule should be revised to take into account the PTO time employees have prior to being transferred into the grant activities Planned Corrective Action: A new schedule has been created that will calculate only the increase in PTO cost year over year per individual and used to accrue PTO cost at year end. Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2024
View Audit 329033 Questioned Costs: $1
Condition: The Authority allocated wages and fringe benefits to the program based on the grant budget, with no adjustment made to actual time spent. Recommendation: Implement a review process to ensure the amount charged to a federal award is based on the time the employees spend on providing the se...
Condition: The Authority allocated wages and fringe benefits to the program based on the grant budget, with no adjustment made to actual time spent. Recommendation: Implement a review process to ensure the amount charged to a federal award is based on the time the employees spend on providing the services. Planned Corrective Action: This process has been corrected and only timesheet hours will be used to allocate cost going forward. Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2024
View Audit 329033 Questioned Costs: $1
The Authority did not realize quarterly reports were required and was never asked by USDA for these. USDA was contacted and the Authority has been informed that a quarterly Balance Sheet and Profit and Loss Statement will fulfill this requirement. The past due reports will be sent to USDA this mon...
The Authority did not realize quarterly reports were required and was never asked by USDA for these. USDA was contacted and the Authority has been informed that a quarterly Balance Sheet and Profit and Loss Statement will fulfill this requirement. The past due reports will be sent to USDA this month and going forward, quarterly reports will be forwarded to USDA within 30 days of the end of each quarter.
Finding 508392 (2023-002)
Significant Deficiency 2023
Views of Responsible Officials: In 2024, Think of Us took steps to address this issue by appointing new executive leadership, including a President and Fractional CFO and engaging a proven accounting firm with demonstrated expertise in nonprofit accounting.
Views of Responsible Officials: In 2024, Think of Us took steps to address this issue by appointing new executive leadership, including a President and Fractional CFO and engaging a proven accounting firm with demonstrated expertise in nonprofit accounting.
Corrective action planned: Effective 06/2023, One Health transitioned EDR systems to better integrate with the EMR. Intention of the new system is to automate the slide process and reduce manual entry by staff. In conjunction with the EDR transition, One Health has expanded their staffing and train...
Corrective action planned: Effective 06/2023, One Health transitioned EDR systems to better integrate with the EMR. Intention of the new system is to automate the slide process and reduce manual entry by staff. In conjunction with the EDR transition, One Health has expanded their staffing and training regarding slide applications. Patient Financial Services staff review and support slide applications, working directly with patients to obtain needed documents. Additionally, One Health has added a supervisory role within this department in order to prioritize slide application internal audits on an ongoing basis. Anticipated completion date: 12/31/2023 Contact person responsible for corrective action: Emily Faricy, Associate Vice President - Finance
The Coronavirus State and Local Fiscal Recovery Funds Report was filed in April of 2023, including expenditures related to the Centerville Widening Project and Payroll. After the report was filed, the determination was made to remove Centerville related expenditures. Due to this determination the re...
The Coronavirus State and Local Fiscal Recovery Funds Report was filed in April of 2023, including expenditures related to the Centerville Widening Project and Payroll. After the report was filed, the determination was made to remove Centerville related expenditures. Due to this determination the report was no longer accurate. As the 2023 report cannot be amended, this change will be recorded with the filing of the 2024 report.
2023-002: 2023-001 – Grant Project Payroll Tracking Reports Contact Person: Christian Strohmaier, cstrohmaier@chesco.org, 610-455-1370 Condition: Per review of the District’s internal payroll tracking reports, it was noted that while employees keep a detailed list of time worked each day, no specif...
2023-002: 2023-001 – Grant Project Payroll Tracking Reports Contact Person: Christian Strohmaier, cstrohmaier@chesco.org, 610-455-1370 Condition: Per review of the District’s internal payroll tracking reports, it was noted that while employees keep a detailed list of time worked each day, no specific documentation was maintained within the tracking reports of which projects relate to the ACAP grant program to support the hours being charged to the program each quarter. Corrective Action: Increased programmatic responsibilities make it necessary for all staff to accurately record their completed activities and the time spent upon them. Technical staff historically have reported this way, with activity stated, hours spent, and which program the activity relates to recorded. Each technical staff employe has an individual report maintained in Excel that is updated daily. This model will be used for administrative staff as well for their time spent in support of these programs. Proposed Completion Date: December 1, 2024
Name of auditee: St. Clare Apartments Housing Development Fund Company, Inc. TIN: 16-1524084 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2023 - December 31, 2023 CAP prepared by: Kyle Lyskawa klyskawa@christopher-community.org Finding 2023-003 The Company will work...
Name of auditee: St. Clare Apartments Housing Development Fund Company, Inc. TIN: 16-1524084 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2023 - December 31, 2023 CAP prepared by: Kyle Lyskawa klyskawa@christopher-community.org Finding 2023-003 The Company will work to engage its auditors to perform the December 31, 2024 audit in March of 2025 and complete the data collection form to the Federal Clearinghouse by the required due date. The current year data collection form will be completed and filed upon completion of this audit.
Name of auditee: St. Clare Apartments Housing Development Fund Company, Inc. TIN: 16-1524084 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2023 - December 31, 2023 CAP prepared by: Kyle Lyskawa klyskawa@christopher-community.org Finding 2023-002 The Company will work...
Name of auditee: St. Clare Apartments Housing Development Fund Company, Inc. TIN: 16-1524084 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2023 - December 31, 2023 CAP prepared by: Kyle Lyskawa klyskawa@christopher-community.org Finding 2023-002 The Company will work to engage its auditors to perform the December 31, 2024 audit in March of 2025 and complete the audited submission within 90 days after the end of the fiscal year. The current year audited submission will be complete and filed upon completion of this audit.
Name of auditee: St. Clare Apartments Housing Development Fund Company, Inc. TIN: 16-1524084 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2023 - December 31, 2023 CAP prepared by: Kyle Lyskawa klyskawa@christopher-community.org Finding 2023-001 Management understand...
Name of auditee: St. Clare Apartments Housing Development Fund Company, Inc. TIN: 16-1524084 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2023 - December 31, 2023 CAP prepared by: Kyle Lyskawa klyskawa@christopher-community.org Finding 2023-001 Management understands HUD’s reserve for replacements required deposit requirements and will deposit the $8,400 by December 31, 2024.
Finding 508278 (2023-002)
Significant Deficiency 2023
Recommendation: It is recommended County management add an additional control review over the eligibility of casefile reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to designate a...
Recommendation: It is recommended County management add an additional control review over the eligibility of casefile reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to designate an internal reviewer to continually review the casefile eligibility determinations throughout the year. Name of the contact person responsible for corrective action plan: Jill Frisell, Finance Director Planned completion date for corrective action plan: December 31, 2024
#1 - 1 case continued to receive monthly benefits during 2023 when records indicated that the case should have closed in 2022. Consolidated Report Listing FB021 will be reviewed by supervisor to ensure WFNJ cases are redetermined appropriately. #2 and #3 - 1 case was incorrectly coded as being exe...
#1 - 1 case continued to receive monthly benefits during 2023 when records indicated that the case should have closed in 2022. Consolidated Report Listing FB021 will be reviewed by supervisor to ensure WFNJ cases are redetermined appropriately. #2 and #3 - 1 case was incorrectly coded as being exempted from lifetime limit. 1 case was coded as being exempted from lifetime limit; however, the GCDSS cannot locate supporting documentation. Share Data Warehouse (SDW) ‘TANF and GA Clock’ report & SDW ‘WFNJ Clock’ report will be reviewed by supervisor to ensure correct exemption coding. #2 and #3 Staff will receive refresher DIMs case separator training. All clerical DIMs staff will receive refresher DIMs procedure and indexing training. In-house QC spot checks by Supervisors.
View Audit 328808 Questioned Costs: $1
The County Clerk and County Treasurer watched the live informational Zoom meeting to learn how to fill out the SLFRF Project and Expenditures Report correctly. For entities who received less than $10 million in SLFRF, the entity was allowed to report the total amount as a loss in revenue. The slide ...
The County Clerk and County Treasurer watched the live informational Zoom meeting to learn how to fill out the SLFRF Project and Expenditures Report correctly. For entities who received less than $10 million in SLFRF, the entity was allowed to report the total amount as a loss in revenue. The slide show was difficult to understand and follow, but we mistakenly thought we were supposed to put $0 on that part of the report. After the auditors discussed this error with me, I went to the reporting website to correct the error; however, the website would not allow changes to the report after a certain period of time. In the future we will report the difference in total expenditures between the two reporting periods. McDonald County is of the opinion that the U.S. Department of Treasury has changed reporting requirements, information, and acceptable expenditures so many times, they have made the reporting requirements difficult to understand or follow. We will do our best to not have an error in the next report.
Views of Responsible Officials and Planned Corrective Actions: USTTI formalized a procurement policy be in compliance with 2 CFR 200 subsequent to December 31, 2023. USTTI management has distributed and communicated the policy with all USTTI employees. USTTI management will ensure the policy is prop...
Views of Responsible Officials and Planned Corrective Actions: USTTI formalized a procurement policy be in compliance with 2 CFR 200 subsequent to December 31, 2023. USTTI management has distributed and communicated the policy with all USTTI employees. USTTI management will ensure the policy is properly enforced and that all procurement actions are documents in writing in vendor and contractor files.
Finding 2023 001 - Reasonable Rental Rates Auditee's Response and Planned Corrective Action Hudson River Housing's action moving forward is that the Director of Resident Services, Vinny Darrow, will ensure that each tenant file under this program contain a signed rent reasonableness determination w...
Finding 2023 001 - Reasonable Rental Rates Auditee's Response and Planned Corrective Action Hudson River Housing's action moving forward is that the Director of Resident Services, Vinny Darrow, will ensure that each tenant file under this program contain a signed rent reasonableness determination worksheet ensuring that the rent being charged does not exceed the annual HUD published Fair Market Rent for that unit. In the event that the rent does exceed FMR, the determination will document how the rent was arrived at and that it has been determined reasonable as per HUD guidelines in comparison to other rents in the area. Planned Implementation Date of Corrective Action: November 6, 2024 Person Responsible for Corrective Action: Christa Hines, CEO
Finding ref number: 2023-002 Finding caption: The District’s internal controls were inadequate for ensuring compliance with federal procurement requirements. Name, address, and telephone of District contact person: Tom Laufmann, Executive Director of Business Services 1601 Ave D Snohomish, WA 98...
Finding ref number: 2023-002 Finding caption: The District’s internal controls were inadequate for ensuring compliance with federal procurement requirements. Name, address, and telephone of District contact person: Tom Laufmann, Executive Director of Business Services 1601 Ave D Snohomish, WA 98290 360-563-7239 Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). For future contracts, the district will make sure to follow all policies and procedures. In particular, the district will ensure that multiple quotes will be obtained before entering any contract and that all staff involved in contract awards are re-educated and aware of this requirement. Anticipated date to complete the corrective action: 8/31/24
View Audit 328694 Questioned Costs: $1
Finding ref number: 2023-001 Finding caption: The District charged unallowable costs to the Supply Chain Assistance award of the Child Nutrition Cluster. Name, address, and telephone of District contact person: Tom Laufmann, Executive Director of Business Services 1601 Ave D Snohomish, WA 98290 3...
Finding ref number: 2023-001 Finding caption: The District charged unallowable costs to the Supply Chain Assistance award of the Child Nutrition Cluster. Name, address, and telephone of District contact person: Tom Laufmann, Executive Director of Business Services 1601 Ave D Snohomish, WA 98290 360-563-7239 Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). The district is making multiple checks for processed vs unprocessed foods claimed in the Supply Chain Assistance award. This includes multiple staff reviewing the claimed items and cross-checking against the 2022-23 claim. All items deemed processed are removed from the claim. Anticipated date to complete the corrective action: 8/31/2024
View Audit 328694 Questioned Costs: $1
2023-003: Deficiency in Internal Controls and Compliance Finding -COVID-19 – Education Stabilization Fund – ALN 84.425: Two final financial reports due during the prior fiscal years were not submitted. (Questioned Costs: None) The Town of Clinton/School Department will follow grants closeout proced...
2023-003: Deficiency in Internal Controls and Compliance Finding -COVID-19 – Education Stabilization Fund – ALN 84.425: Two final financial reports due during the prior fiscal years were not submitted. (Questioned Costs: None) The Town of Clinton/School Department will follow grants closeout procedures, consequently, the district will monitor closely all grants spending throughout each grant cycle. For both state-administered and direct grants, regardless of the period of availability, the District must liquidate all obligations incurred under the award Reports not later than 90 days after the end of the funding period unless an extension is authorized. These procedures have been updated in the Financial Procedures Manual (pages 226-230 under Section G— Timely Obligation of Funds)
Finding 508041 (2023-002)
Significant Deficiency 2023
2023-002: Significant Deficiency in Internal Controls and Compliance Finding -Child Nutrition Cluster ALN (10.553, 10.555,10.559): The District’s school lunch office-maintained production records and manual count sheets for the elementary school and high school instead of using the point-of-sale sys...
2023-002: Significant Deficiency in Internal Controls and Compliance Finding -Child Nutrition Cluster ALN (10.553, 10.555,10.559): The District’s school lunch office-maintained production records and manual count sheets for the elementary school and high school instead of using the point-of-sale system for tracking student meal counts. (Questioned Costs: None) The Town of Clinton/School Department will utilize and maintain the point-of-sale system consistently in all district school buildings to track student meals counts. Already implemented at the start of FY25 school year.
Finding 508037 (2023-001)
Significant Deficiency 2023
2023-001: Significant Deficiency in Internal Controls and Compliance Finding -Child Nutrition Cluster ALN (10.553, 10.555,10.559): A competitive procurement process, which includes suspension and debarment certifications, was not properly performed by the Town for the purchase of school lunch food p...
2023-001: Significant Deficiency in Internal Controls and Compliance Finding -Child Nutrition Cluster ALN (10.553, 10.555,10.559): A competitive procurement process, which includes suspension and debarment certifications, was not properly performed by the Town for the purchase of school lunch food product. (Questioned Costs: $453,359) The Town of Clinton/School Department will maintain proper procurement procedures in compliance with Local, State and Federal laws and regulations. State procurement laws (MGL Chapter 30B for Goods and Services and MGL Chapter 149 Construction) are followed however the district is aware of the federal requirements. When there are exemptions from state procurement laws, or when federal regulations are stricter the district will use the strictest rules, under 2 CFR 200.318-327. These procedures have been updated in the Financial Procedures Manual (pages 231-240, under Section II Procurement System). The Town of Clinton/School Department has expanded membership with French River Education Center – Purchasing Cooperative to include several school lunch food products. The Town of Clinton/School Department will utilize two methods to determine if a potential vendor has been suspended or disbarred. Prior to approving a requisition for a contracted service in excess of $25,000 funded by a Federal grant, district will verify Sam.gov and will require the vendor to sign a Vendor Compliance Certification.
View Audit 328582 Questioned Costs: $1
2023-004 ACTIVITIES ALLOWED OR UNALLOWED Program: Education Stabilization Fund Federal Assistance Listing Number: 84.425 Federal Agency: U.S. Department of Education Pass-Through Agency: Arizona Department of Education Grantor Number: 21FESSII-111175-01A and 21FESIII-111175-01A Questioned Costs: $13...
2023-004 ACTIVITIES ALLOWED OR UNALLOWED Program: Education Stabilization Fund Federal Assistance Listing Number: 84.425 Federal Agency: U.S. Department of Education Pass-Through Agency: Arizona Department of Education Grantor Number: 21FESSII-111175-01A and 21FESIII-111175-01A Questioned Costs: $133,105 Type of Finding: Noncompliance (Other Matter), significant deficiency in internal control Compliance Requirement: A. Activities Allowed or Unallowed Condition/Context: During our testing of expenditures, it was noted that eleven expenditures with a total of $133,105 were not included within the Education Stabilization Fund budget as approved by the Arizona Department of Education. Corrective Action: The District will ensure all expenditures are approved by the SEA before purchase. Planned completion date for corrective action plan: For the period ending June 30, 2024. Name of the contact person responsible for corrective action: Dorene Mudrow, Superintendent
View Audit 328565 Questioned Costs: $1
2023-003 Twenty-First Century Community Learning Centers - Assistance Listing No. 84.287 Material Weakness in Internal Control Over Compliance and Noncompliance - A. Activities Allowed or Unallowed and B. Allowable Costs/Cost Principles Recommendation: The Auditor recommends that the Organization es...
2023-003 Twenty-First Century Community Learning Centers - Assistance Listing No. 84.287 Material Weakness in Internal Control Over Compliance and Noncompliance - A. Activities Allowed or Unallowed and B. Allowable Costs/Cost Principles Recommendation: The Auditor recommends that the Organization establish a formal documentation process to ensure personnel costs are adequately reviewed and allocated to the federal award. Planned Corrective Action: We agree with the recommendation and plan to have the corrective action implemented by December 31, 2024. An updated timesheet policy with the correct wording will be created by the Finance Board Subcommittee at the October meeting, presented to the full Board of Directors at the November Board meeting and voted on at the December 2024 Board meeting.
View Audit 328454 Questioned Costs: $1
Misapplication of the Sliding Fee Scale The department responsible for gathering and recording patient income data, and applying sliding fee discounts, experienced high attrition rates due to the role being entry-level. Recognizing these challenges, the Organization is in the process of revising th...
Misapplication of the Sliding Fee Scale The department responsible for gathering and recording patient income data, and applying sliding fee discounts, experienced high attrition rates due to the role being entry-level. Recognizing these challenges, the Organization is in the process of revising the training plan for this department and establishing a quality assurance process for monitoring. Additionally, the Organization will review and revise the sliding fee policy to enhance clarity of the process for application of discounts and proof of income documentation. Responsible Parties: Mark Groeller, Compliance Director, Lisa DeMallie, Associate Vice President of Patient Experience, and Melissa Darko, Revenue Cycle Director Estimated Completion Date: December 31, 2024
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