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Corrective Action Plans

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Finding 479413 (2023-003)
Material Weakness 2023
Southeast Iowa Regional Medical Center
IA
Internal Control / Segregation of Duties Questioned Costs Allowable Costs / Cost Principles
U.S. Department of Health and Human Services Great River Health System, Inc. and Subsidiaries respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 – June 30, 2023 The finding from the schedule of findings and questioned costs is discu...
U.S. Department of Health and Human Services Great River Health System, Inc. and Subsidiaries respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 – June 30, 2023 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING—FEDERAL AWARD PROGRAMS AUDITS MATERIAL WEAKNESS U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-003 Provider Relief Fund – Assistance Listing No. 93.498 Recommendation: We recommend the Organization put in place controls over compliance that mitigate the risk of errors in reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We added an additional management review for future submissions prior to filing and submission. Name(s) of the contact person(s) responsible for corrective action: Jeremy Alexander, CFO Planned completion date for corrective action plan: 7/01/2024 If the Department of Health and Human Services has questions regarding this plan, please call Jeremy Alexander at 319-768-3280.
View Audit 315911 Questioned Costs: $1
Finding 479412 (2023-001)
Significant Deficiency 2023
Child Guidance & Family Solutions
OH
Questioned Costs Allowable Costs / Cost Principles Cash Management
Management will review all draw down requests and tracking of overall payroll costs billed to the program to ensure employees are not billed more than once for the same period. The overpayment finding is being refunded to the funder.
Management will review all draw down requests and tracking of overall payroll costs billed to the program to ensure employees are not billed more than once for the same period. The overpayment finding is being refunded to the funder.
View Audit 315906 Questioned Costs: $1
Finding 479405 (2022-003)
Significant Deficiency 2023
Meadows Mental Health Policy Institute for Texas
TX
Questioned Costs Allowable Costs / Cost Principles Cash Management
Maintain detailed documentation of the review process, including any findings or discrepancies identified during the review of drawdowns. Establish clear review procedures for the drawdowns prepared by the Assistant Controller. Continuously monitor the effectiveness of the review process and identif...
Maintain detailed documentation of the review process, including any findings or discrepancies identified during the review of drawdowns. Establish clear review procedures for the drawdowns prepared by the Assistant Controller. Continuously monitor the effectiveness of the review process and identify areas for improvement. Implement any necessary changes or enhancements to the review procedures to ensure thorough compliance with grant requirements.
View Audit 315903
Finding 479403 (2023-003)
Significant Deficiency 2023
City of Green Bay
WI
Questioned Costs Reporting Significant Deficiency
Condition The Quarter 2 and 4 Project and Expenditure Reports were tested. The Quarter 4 (Q4) report had a typo that resulted in the Q4 expenditures to be understated by $1,007,000 for project 2-6-001, but the cumulative expenditures were input correctly. Additionally, project 12-6-201 was understat...
Condition The Quarter 2 and 4 Project and Expenditure Reports were tested. The Quarter 4 (Q4) report had a typo that resulted in the Q4 expenditures to be understated by $1,007,000 for project 2-6-001, but the cumulative expenditures were input correctly. Additionally, project 12-6-201 was understated by $18,515 for the Q4 and cumulative expenditures due to excluding a transaction. Corrective Action Plan Corrective Action Planned: SLFRF Compliance reports will be reviewed and approved by the Grant Administrator, Assistant Finance Director and Finance Director. Query reports are now in place to capture all accounts and ensure accuracy. Name(s) of Contact Person(s) Responsible for Corrective Action: Susan House, Grant Administrator; Linda Chosa, Assistant Finance Director; Diana Ellenbecker, Finance Director Anticipated Completion Date: July 31, 2024
View Audit 315900
Finding 479402 (2023-002)
Significant Deficiency 2023
Mercer County
IL
Questioned Costs Reporting
County management and County Board will ensure that ARPA interim reports are completed in a timely manner.
County management and County Board will ensure that ARPA interim reports are completed in a timely manner.
View Audit 315899
Finding 479401 (2023-001)
Significant Deficiency 2023
Mercer County
IL
Questioned Costs
County management will review employee timesheets.
County management will review employee timesheets.
View Audit 315899
Finding 479373 (2023-001)
Material Weakness 2023
Spyglass Ridge
OR
Questioned Costs Allowable Costs / Cost Principles Material Weakness
Views of Responsible Officials and Planned Corrective Actions We agree with this finding. NWCH was successful in adding needed staff in 2023, but was unable to hire a degreed accountant or controller, or to contract with an accounting firm for oversight of the accounting function. Bookkeeper trainin...
Views of Responsible Officials and Planned Corrective Actions We agree with this finding. NWCH was successful in adding needed staff in 2023, but was unable to hire a degreed accountant or controller, or to contract with an accounting firm for oversight of the accounting function. Bookkeeper training was provided from Shelter Resources Financial Manager in February 2023. NWCH is researching CPA firms in order to contract a qualified controller with expertise in real estate holdings relevant to NWCH. NWCH has been actively searching for a qualified CPA to hire or contract with since 2021, however, due to capacity constraints and overwhelmed CPA firms, NWCH has been unsuccessful. Efforts to hire experienced accounting personnel continues.
View Audit 315878
Finding 479363 (2023-001)
Significant Deficiency 2023
Regional Food Bank of Northeastern New York, Inc.
NY
Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles
Finding, Reference Number: 2023-001 Federal Agency: Department of Agriculture (USDA) Description of Finding: Criteria: 7 CFR Section 250.1 9(a) identifies requirements related to record keeping for this major program. It is important to note the Food Bank appeared to maintain the appropriate suppo...
Finding, Reference Number: 2023-001 Federal Agency: Department of Agriculture (USDA) Description of Finding: Criteria: 7 CFR Section 250.1 9(a) identifies requirements related to record keeping for this major program. It is important to note the Food Bank appeared to maintain the appropriate supporting documents and required components, this finding relates to one component regarding the lack of a signoff not lack of documentation. Condition: During audit testing, we noted the following; the invoices created as a result of USDA orders being made were not consistently signed off on by the recipient agency representative upon pick up or delivery of the commodities. Statement of Concurrence or Nonconcurrence: The Food Bank agrees with this finding. Corrective Action: The Food Bank places a strong emphasis on ensuring accountability in the pickup process for agencies by requiring them to sign invoices upon receiving their orders. This practice is crucial for maintaining accurate records and verifying the receipt of products and other items. To strengthen this procedure, we will be reinforcing with our staff the absolute requirement for agencies to sign for their orders at the time of pickup. As of July 8, 2024 we will implement a new procedure mandating dual sign-offs on all orders by both the agency representative and a Food Bank staff member. Our Programs team will also conduct educational marketing raising awareness among the agencies about the importance of signing their invoices. These steps will not only enhance our operational efficiency but also uphold our commitment to transparency and accountability in distributing food resources to those in need. Name of Contact Person: Nicholas Pisani, Chief Operating Officer; phone number 518-786-3691 ext. 241; email NickP@Regionalfoodbank.net Projected completion date: July 8, 2024
View Audit 315870
Finding 479339 (2023-002)
Material Weakness 2023
1260 Housing Development Corporation
PA
Questioned Costs HUD Housing Programs Matching / Level of Effort / Earmarking
Finding 2023-002: Special Tests and Provisions The Corporation has three properties secured by CDBG loans. The properties are known as Mid-City, AppleTree Housing, Inc. (“ATH”), and Center West. The Corporation was unable to support that at least fifty-one percent (51%) of the tenants at the ATH pro...
Finding 2023-002: Special Tests and Provisions The Corporation has three properties secured by CDBG loans. The properties are known as Mid-City, AppleTree Housing, Inc. (“ATH”), and Center West. The Corporation was unable to support that at least fifty-one percent (51%) of the tenants at the ATH property were leased to and occupied by low or very low-income persons as determined by the Federal “Section 8” Income Standards with completed tenant certifications and recertifications. At ATH, 6 of 6 occupied unit’s certifications were not completed during the year ended June 30, 2023. This was an initial finding during the year ended June 30, 2020. Planned Corrective Action: It is the goal of the Corporation to maintain compliance with regulatory requirements. Where hardships are encountered the Corporation remains in ongoing communication with respective regulatory agencies to promote transparency and mitigate risk of loss in fundings or default. Mark Deitcher, CFO, is responsible for the corrective action plan. If the U.S Department of Housing and Urban Development has questions regarding this plan, please call Mark Deitcher at 1-215-557-8414.
View Audit 315836
Finding 479338 (2023-004)
Significant Deficiency 2023
Upper Great Lakes Family Health Center
MI
Questioned Costs Matching / Level of Effort / Earmarking
Contact Person Responsible for Correction: Chief Financial Officer- Trevor Hodges Corrective Action Planned: Bond secured for an effective date of 7/1/2024. Anticipated Date of Completion: 6/13/2024
Contact Person Responsible for Correction: Chief Financial Officer- Trevor Hodges Corrective Action Planned: Bond secured for an effective date of 7/1/2024. Anticipated Date of Completion: 6/13/2024
View Audit 315834
Finding 479337 (2023-003)
Significant Deficiency 2023
Upper Great Lakes Family Health Center
MI
Questioned Costs Matching / Level of Effort / Earmarking
Contact Person Responsible for Correction: Chief Financial Officer- Trevor Hodges Corrective Action Planned: Established account and fully funded the account as required in the US Department Agricultural (USDA) funding approval letter. Anticipated Date of Completion: 5/28/2024
Contact Person Responsible for Correction: Chief Financial Officer- Trevor Hodges Corrective Action Planned: Established account and fully funded the account as required in the US Department Agricultural (USDA) funding approval letter. Anticipated Date of Completion: 5/28/2024
View Audit 315834
Finding 479336 (2023-002)
Significant Deficiency 2023
Upper Great Lakes Family Health Center
MI
Questioned Costs Matching / Level of Effort / Earmarking
Contact Person Responsible for Correction: Chief Financial Officer- Trevor Hodges Corrective Action Planned: Establish separate account as required. Anticipated Date of Completion: 7/1/2024
Contact Person Responsible for Correction: Chief Financial Officer- Trevor Hodges Corrective Action Planned: Establish separate account as required. Anticipated Date of Completion: 7/1/2024
View Audit 315834
Finding 479335 (2023-001)
Significant Deficiency 2023
Upper Great Lakes Family Health Center
MI
Questioned Costs
Contact Person Responsible for Correction: Chief Financial Officer- Trevor Hodges Corrective Action Planned: Additional training provided to grant compliance staff and review by CFO/CEO to ensure completion by due date. Anticipated Date of Completion: May 31, 2024
Contact Person Responsible for Correction: Chief Financial Officer- Trevor Hodges Corrective Action Planned: Additional training provided to grant compliance staff and review by CFO/CEO to ensure completion by due date. Anticipated Date of Completion: May 31, 2024
View Audit 315834
Finding 479334 (2023-001)
Significant Deficiency 2023
Gravette School District
AR
Allowable Costs / Cost Principles Questioned Costs Internal Control / Segregation of Duties
The District has instituted an internal control that requires the preparation, review and retention of documentation as evidence that coding changes have not only been made but also made in a timely manner. The District will ensure that a contract is executed for every full-time employee included in...
The District has instituted an internal control that requires the preparation, review and retention of documentation as evidence that coding changes have not only been made but also made in a timely manner. The District will ensure that a contract is executed for every full-time employee included in the human resources module in eFinance by reconciling employee and contract counts.
View Audit 315830 Questioned Costs: $1
Finding 479333 (2023-002)
Significant Deficiency 2023
Gravette School District
AR
Allowable Costs / Cost Principles Questioned Costs Internal Control / Segregation of Duties
In our test of disbursements, we identified unallowable costs totaling $4,458 for football kicking lessons ($2,250) and student t-shirts to be worn at sporting events ($2,208) were paid from Education Stabilization Funds.
In our test of disbursements, we identified unallowable costs totaling $4,458 for football kicking lessons ($2,250) and student t-shirts to be worn at sporting events ($2,208) were paid from Education Stabilization Funds.
View Audit 315830 Questioned Costs: $1
Finding 479328 (2023-010)
Significant Deficiency 2023
Colorado Legal Services, INC
CO
Questioned Costs Cash Management Reporting § 200.303
COIVD-19: Coronavirus State and Local Fiscal Recovery – Assistance Listing No. 21.027 Recommendation: We recommend that the Organization consider implementing a process that documents review and approval of submitted indirect cost claims by someone other than the preparer of such claims. Documentat...
COIVD-19: Coronavirus State and Local Fiscal Recovery – Assistance Listing No. 21.027 Recommendation: We recommend that the Organization consider implementing a process that documents review and approval of submitted indirect cost claims by someone other than the preparer of such claims. Documentation of contemporaneous review should also be maintained. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The organization will review this finding and current methodology and propose corrections as part of a broader review of its technologies. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025
View Audit 315826
Finding 479327 (2023-009)
Material Weakness 2023
Colorado Legal Services, INC
CO
Allowable Costs / Cost Principles Questioned Costs Material Weakness § 200.403
COIVD-19: Coronavirus State and Local Fiscal Recovery – Assistance Listing No. 21.027 Recommendation: We recommend that the Organization consider updating its salaries, wages, and employee benefit cost allocation methodology and process to reduce the frequency of manual adjustments based on review ...
COIVD-19: Coronavirus State and Local Fiscal Recovery – Assistance Listing No. 21.027 Recommendation: We recommend that the Organization consider updating its salaries, wages, and employee benefit cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual time records and expense data and maximize the use of automated allocations based on employees’ time and effort records, effective compensation during work periods, and that are calculated in a consistent manner. We also recommend that the Organization maintain contemporaneous documentation supporting all cost allocations. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization is updating the segregation of duties in order to improve the preparation, review and sign steps of the process. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025
View Audit 315826 Questioned Costs: $1
Finding 479314 (2023-008)
Material Weakness 2023
Colorado Legal Services, INC
CO
Matching / Level of Effort / Earmarking Questioned Costs Material Weakness
Aging Cluster – Special Programs for the Aging, Title III, Part B – Assistance Listing No. 93.004 Recommendation: We recommend that the Organization implement a control process to ensure that it meets its matching requirements within the grant period. Explanation of disagreement with audit finding...
Aging Cluster – Special Programs for the Aging, Title III, Part B – Assistance Listing No. 93.004 Recommendation: We recommend that the Organization implement a control process to ensure that it meets its matching requirements within the grant period. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization is updating the segregation of duties in order to improve the preparation, review and sign steps of the process. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025
View Audit 315826
Finding 479298 (2023-007)
Material Weakness 2023
Colorado Legal Services, INC
CO
Questioned Costs Allowable Costs / Cost Principles Material Weakness
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization update its derivative income allocation method, policy and procedures to reflect the method described in the federal regulations. Explanation of disagreement with audit finding: ...
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization update its derivative income allocation method, policy and procedures to reflect the method described in the federal regulations. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization will reach out to LSC to understand if our current method is acceptable. If not, the Organization will implement corrections to comply with applicable standards. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025
View Audit 315826
Finding 479297 (2023-006)
Material Weakness 2023
Colorado Legal Services, INC
CO
Allowable Costs / Cost Principles Questioned Costs Material Weakness
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization consider updating its salaries, wages, and employee benefit cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual tim...
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization consider updating its salaries, wages, and employee benefit cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual time records and expense data and maximize the use of automated allocations based on employees’ time and effort records, effective compensation during work periods, and that are calculated in a consistent manner. We also recommend that the Organization maintain contemporaneous documentation supporting all cost allocations. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization will review this finding and current methodology and propose corrections as part of a broader review of its technologies. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025
View Audit 315826 Questioned Costs: $1
Finding 479296 (2023-005)
Significant Deficiency 2023
Colorado Legal Services, INC
CO
Questioned Costs Significant Deficiency Internal Control / Segregation of Duties
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization review its case file review internal controls to ensure that they are designed in a manner to detect and prevent noncompliance with this requirement. Explanation of disagreement ...
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization review its case file review internal controls to ensure that they are designed in a manner to detect and prevent noncompliance with this requirement. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization has robust training for case handlers around when a retainer is required. The Organization will keep these measures in place and also plan to provide additional training for all case handlers on our case handler standards, which we will make sure also covers retainer agreements and managers’ review of case files. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025
View Audit 315826
Finding 479294 (2023-003)
Material Weakness 2023
Colorado Legal Services, INC
CO
Allowable Costs / Cost Principles Questioned Costs Material Weakness § 200.430
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization consider updating its salaries and wages cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual time records and expen...
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization consider updating its salaries and wages cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual time records and expense data and maximize the use of automated allocations based on employees’ time and effort records. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization will review this finding and current methodology and propose corrections as part of a broader review of its technologies. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025
View Audit 315826 Questioned Costs: $1
Finding 479282 (2023-006)
Material Weakness 2023
Puerto Rico Safe Drinking Water Treatment Revolving Loan Fund
PR
Reporting Questioned Costs Matching / Level of Effort / Earmarking
Finding 2023-006 All Federal Agencies in the SEFA Reporting Financial, Internal Control Weakness and Noncompliance PRDOH accepts the finding, due to a misinterpretation on the waiver given by the FAC with regard to Hurricane Fiona, the PRDOH incurred in a delay for the contracting ...
Finding 2023-006 All Federal Agencies in the SEFA Reporting Financial, Internal Control Weakness and Noncompliance PRDOH accepts the finding, due to a misinterpretation on the waiver given by the FAC with regard to Hurricane Fiona, the PRDOH incurred in a delay for the contracting for the 2023 single audit. At this time the Department has accelerated the hiring process of the auditors for 2023 and 2024. The 2023 report is in the final stages of revision. On the other hand, the 2024 report is in the process for the renewal of the contract which is expected to start at the end of August 2024. Responsible Official Hector Stewart Torres Director Federal Programs Division 787-765-2929 Ext.4871 Velmary Martinez Yace Finance Department Director 787-765-2929 Ext.3291 Estimated Completion Date Implementation is expected to be completed on or before the end of March 2025.
View Audit 315825
Finding 479279 (2023-005)
Material Weakness 2023
Puerto Rico Safe Drinking Water Treatment Revolving Loan Fund
PR
Questioned Costs Internal Control / Segregation of Duties
Finding 2023-005 Medical Assistance Program Special Test and Provisions- ADP Risk Analysis and System Security Review Material Weakness and Noncompliance The DOH disagrees with this finding as they believe the MCO should have received a SOC 1 Type 1 and Type 2 Report. The DOH has requested this ...
Finding 2023-005 Medical Assistance Program Special Test and Provisions- ADP Risk Analysis and System Security Review Material Weakness and Noncompliance The DOH disagrees with this finding as they believe the MCO should have received a SOC 1 Type 1 and Type 2 Report. The DOH has requested this information from the MCO however it has not been provided yet due to the short time frame for gathering the requested information. Responsible Officials Dinorah Collazo Ortiz Executive Director 787-765-2929 ext. 3402 Felmarie Cruz Morales Fiscal Director 787-765-2929 ext. 6721 Marcia Berrios De La Torre Financial Advisor 787-765-2929 ext. 6746 Estimated Completion Date Implementation is expected to be completed on or before the end of the year 2025.
View Audit 315825
Finding 479278 (2023-004)
Material Weakness 2023
Puerto Rico Safe Drinking Water Treatment Revolving Loan Fund
PR
Matching / Level of Effort / Earmarking Questioned Costs Reporting
Finding 2023-004 Maternal and Child Health Services Block Grants to the States Earmarking Material Weakness in Internal Control over Compliance The PRDOH agrees with the finding. PRDOH has fixed the segregation of financial records, we have systems in place within our system People Soft 8.4 in wh...
Finding 2023-004 Maternal and Child Health Services Block Grants to the States Earmarking Material Weakness in Internal Control over Compliance The PRDOH agrees with the finding. PRDOH has fixed the segregation of financial records, we have systems in place within our system People Soft 8.4 in which permit the tracing of funds to a level of the expenditures that will be adequate. PRDOH will implement this system for the proposal of 2024. Also, the same system will be used in the new ERP system by the treasury Department that should be starting by July 2025. Responsible Officials Dr. Manuel Vargas Bernier Program Director 787-765-2929 ext. 4583 Mrs. Diana Ferrer Rivera Senior Accountant 787-765-2929 ext. 4551 Estimate Date of Completion Implementation is expected to be completed on or before the end of October 2024.
View Audit 315825
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