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Corrective Action Plans

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Finding 400914 (2023-002)
Significant Deficiency 2023
Api Chaya
WA
Questioned Costs Allowable Costs / Cost Principles
Finding Number 2023-002 Federal Agency: U.S. Department of Justice Federal Program Name: Crime Victim Assistance Assistance Listing Number: 16.575 Pass-Through Agency: Washington State Department of Commerce Pass-Through Numbers: F21-31219-201, F22-31219-815 Award Period: July 1, 2023 – June 30, 202...
Finding Number 2023-002 Federal Agency: U.S. Department of Justice Federal Program Name: Crime Victim Assistance Assistance Listing Number: 16.575 Pass-Through Agency: Washington State Department of Commerce Pass-Through Numbers: F21-31219-201, F22-31219-815 Award Period: July 1, 2023 – June 30, 2026, October 1, 2023 – June 30, 2025. Type of Finding Significant Deficiency in Internal Control over Compliance –Period of Performance. Other Matter – Noncompliance with Period of Performance Requirements. Corrective Action to be Taken API Chaya implements controls to ensure expenditures are recorded in the correct Federal grant year, paying particular attention to quarterly invoices and expenditures. Completion of Action Corrective Action was completed April 24, 2024. Controls in place. Agency Response There is no disagreement with the finding. Agency Contact Responsible for Corrective Action Tina Masuda-Draughon at tina@apichaya.org
View Audit 308948
Regional School Unit #56
ME
Questioned Costs
Management response/corrective action plan: We will attempt to include this information on construction contracts moving forward.
Management response/corrective action plan: We will attempt to include this information on construction contracts moving forward.
View Audit 308925
Finding 400882 (2023-001)
Significant Deficiency 2023
City of Brighton
CO
Questioned Costs Subrecipient Monitoring Reporting § 200.301
The City agrees with the finding. The City will improve internal controls over the Performance and Expenditure report review process and ensure this review addresses all aspects of the reports and is completed prior to submission. Corrective action was taken in spring of 2024 when the issue was iden...
The City agrees with the finding. The City will improve internal controls over the Performance and Expenditure report review process and ensure this review addresses all aspects of the reports and is completed prior to submission. Corrective action was taken in spring of 2024 when the issue was identified during the 2023 audit. Responsible Official: Catrina Asher, Finance Director Planned completion date for corrective action plan: March 31, 2024.
View Audit 308914
Sustainable Northwest
OR
Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.318 § 200.327
Finding # 2023-002 Assistance Listing: 10.937 Partnerships for Climate-Smart Commodities Immaterial noncompliance over procurement The Organization’s fiscal policies and procedures does not meet the required federal standards for procurement. Corrective Action: The Organization agrees with and i...
Finding # 2023-002 Assistance Listing: 10.937 Partnerships for Climate-Smart Commodities Immaterial noncompliance over procurement The Organization’s fiscal policies and procedures does not meet the required federal standards for procurement. Corrective Action: The Organization agrees with and independently identified this issue and proactively procured services of a national non-profit focused CPA firm and has begun methodically rewriting all financial policies to ensure compliance with the Uniform Guidance. The procurement policy was updated and compliant with all Uniform Guidance requirements as of January 2024, all other policies will be updated by the end of 2024. Anticipated Completion Date: January 2024
View Audit 308903
Finding 400870 (2023-001)
Significant Deficiency 2023
Shasta Community Health Center, Inc.
CA
Questioned Costs Special Tests & Provisions
Description of Finding: Sliding fee discounts were given to three of the 40 patients tested that were inconsistent with the Health Center’s sliding fee discount policy. Statement of Concurrence: Shasta Community Health Center (SCHC) management agrees with the finding related to sliding fee discount...
Description of Finding: Sliding fee discounts were given to three of the 40 patients tested that were inconsistent with the Health Center’s sliding fee discount policy. Statement of Concurrence: Shasta Community Health Center (SCHC) management agrees with the finding related to sliding fee discounts being provided to a small number of patients inconsistent with the Health Center’s sliding fee discount policy. The finding suggests that staff miscalculated which discount these patients would qualify for based on the income documented on the sliding fee forms. This miscalculation caused incorrect sliding fee discounts to be provided. Corrective Action: Miscalculations seem to be the leading cause of the errors noted by the auditors. Ongoing training/internal audits needs to be more robust to ensure staff understand and accurately calculate which discount the patient qualifies for. Center Managers shall review the slide audits to determine which employees are making errors and provide re-training or corrective action as applicable and document/monitor for improvement. In addition, SCHC is in the process of launching a computer-based patient form completion system, which will calculate the slide fee automatically, removing much of the human element, and thereby greatly reducing the likelihood of miscalculation. We will continue to perform audits on the new process to ensure we see an improvement in our administration of the sliding fee discount program. Individual Primarily Responsible for Corrective Action: Chief Operations Officer Projected Completion Date: Center Managers will begin documenting retraining/corrective action taken based on sliding fee audit starting June 2024. SCHC is in the process of creating the electronic forms needed to launch the computer-based registration and income verification. We expect the forms to be ready to go live late Fall, early Winter.
View Audit 308896
Finding 400860 (2023-001)
Material Weakness 2023
The Development Corporation of Orchard Knob, Inc.
GA
Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties
In accordance with HUD regulations, entities should have sufficient fidelity bond insurance coverage. The Project did not have sufficient coveraget as of 12/31/23. The Project is noncompliant with the HUD regulatory agreement. Housing Resource Center, Inc. (management agent) will expedite the proces...
In accordance with HUD regulations, entities should have sufficient fidelity bond insurance coverage. The Project did not have sufficient coveraget as of 12/31/23. The Project is noncompliant with the HUD regulatory agreement. Housing Resource Center, Inc. (management agent) will expedite the process of increasing the policy coverage amount.
View Audit 308887
Finding 400858 (2023-001)
Significant Deficiency 2023
Alice Williams Towers, Inc.
GA
Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs
In accordance with HUD regulations, entities should not make unauthorized distributions of Project. The Project paid expenses for an adjacent project. The Corporation paid non-project expenses from Project funds. The Project is noncompliant with HUD regulatory agreement. Management is in agreement w...
In accordance with HUD regulations, entities should not make unauthorized distributions of Project. The Project paid expenses for an adjacent project. The Corporation paid non-project expenses from Project funds. The Project is noncompliant with HUD regulatory agreement. Management is in agreement with the finding, amounts were paid for non-project expenses.
View Audit 308886 Questioned Costs: $1
Finding 400847 (2023-003)
Significant Deficiency 2023
Louisiana Delta Service Corps
LA
Special Tests & Provisions Questioned Costs Subrecipient Monitoring
2023-003 Compliance of Special Tests and Provisions – National Service Criminal History Checks: Management Response: Management will ensure an individual who does not perform the adjudication will review and document whether information was entered correctly and whether the adjudications are proper ...
2023-003 Compliance of Special Tests and Provisions – National Service Criminal History Checks: Management Response: Management will ensure an individual who does not perform the adjudication will review and document whether information was entered correctly and whether the adjudications are proper and documented prior to a member’s start date. Responsible Person: Lisa Moore, Executive Director Anticipated Remediation Date: Fiscal year ending August 31, 2024
View Audit 308865
Finding 400846 (2023-002)
Significant Deficiency 2023
Louisiana Delta Service Corps
LA
Questioned Costs Allowable Costs / Cost Principles Reporting § 200.303 § 200.404
2023-002 Approval of Living Allowance Payments: Management Response: Management will include others on correspondence regarding approval of payroll, which will help detect when an approval of payroll is not made timely. If payroll is not approved before paid, then Management will perform a documente...
2023-002 Approval of Living Allowance Payments: Management Response: Management will include others on correspondence regarding approval of payroll, which will help detect when an approval of payroll is not made timely. If payroll is not approved before paid, then Management will perform a documented review to ensure payroll payments are proper. Management will also develop a policy to stop living allowance payments timely when a member will not meet their service hour obligation. Responsible Person: Lisa Moore, Executive Director Anticipated Remediation Date: Fiscal year ending August 31, 2024
View Audit 308865
Finding 400845 (2023-001)
Material Weakness 2023
Louisiana Delta Service Corps
LA
Internal Control / Segregation of Duties Questioned Costs Cash Management § 200.303
2023-001 Segregation of Duties: Management Response: Due to the size of LDSC’s administrative staff, complete segregation of duties is not economically feasible. However, during the 2023 fiscal year, LDSC created a financial policies handbook that outlines controls and responsibilities in the financ...
2023-001 Segregation of Duties: Management Response: Due to the size of LDSC’s administrative staff, complete segregation of duties is not economically feasible. However, during the 2023 fiscal year, LDSC created a financial policies handbook that outlines controls and responsibilities in the financial reporting cycle. We will ensure the areas recommended above are added to our current policy to the extent it is economically feasible. Responsible Person: Lisa Moore, Executive Director Anticipated Remediation Date: Fiscal year ending August 31, 2024
View Audit 308865
Finding 400843 (2023-033)
Significant Deficiency 2023
City of Grand Prairie Texas
TX
Questioned Costs Reporting Significant Deficiency
Planned Corrective Action: ARPA Grant Funds are now being approved by the Controller before submitting to the Treasury Website. Responsible officials: Luis Barrera, Controller, will be responsible for approvals before submitting the expenditures Planned completion date: The approval process was impl...
Planned Corrective Action: ARPA Grant Funds are now being approved by the Controller before submitting to the Treasury Website. Responsible officials: Luis Barrera, Controller, will be responsible for approvals before submitting the expenditures Planned completion date: The approval process was implemented on October 31, 2023
View Audit 308851
Finding 400840 (2023-001)
Significant Deficiency 2023
Mountain View School District
AR
Allowable Costs / Cost Principles Questioned Costs Internal Control / Segregation of Duties
The district will contact the Arkansas Division of Elementaiy and Secondary Education for guidance on returning the funds and the district will take care to make sure all unallowable expenditures are not included in the calcu lation for indirect cost taken in the future on all federal funds.
The district will contact the Arkansas Division of Elementaiy and Secondary Education for guidance on returning the funds and the district will take care to make sure all unallowable expenditures are not included in the calcu lation for indirect cost taken in the future on all federal funds.
View Audit 308847 Questioned Costs: $1
Finding 400838 (2023-001)
Significant Deficiency 2023
Comunidades Latinas Unidas En Servicio INC
MN
Reporting Questioned Costs Allowable Costs / Cost Principles
Management Response: CLUES’ financial management detected an oversight in billing a specific unallowable cost to certain grants that fund our Behavioral Health (“BH”) clinics. The oversight was promptly investigated, and we immediately remedied the situation with the affected funders. CLUES has take...
Management Response: CLUES’ financial management detected an oversight in billing a specific unallowable cost to certain grants that fund our Behavioral Health (“BH”) clinics. The oversight was promptly investigated, and we immediately remedied the situation with the affected funders. CLUES has taken action to prevent similar potential errors in the future. Two of our grants account for the majority of the improper billing total. The funders agreed that we can charge other billable expenses not previously covered. CLUES expended all funds with the funder’s approval. This matter was resolved and reported to the funder’s satisfaction. Action taken in response to finding: Management immediately identified the scope of the billing discrepancy, contacted the funders to resolve it, and have incorporated training and monitoring procedures internally to ensure we do not inadvertently bill such unallowable costs again. Proper review processes have been implemented to detect and prevent similar findings in the future. Name of the contact person responsible for corrective action: Ryan Robinson (VP of Finance & Administration) Planned completion date for corrective action plan: This matter was resolved in May 2024.
View Audit 308846
Finding 400830 (2023-005)
Material Weakness 2023
Firstfollowers
IL
Allowable Costs / Cost Principles Questioned Costs Procurement, Suspension & Debarment § 200.303
It is the policy that either Marlon Mitchell or James Kilgore approves expenditures of the programs. FirstFollowers is not in the habit of initialing the invoices, so we will purchase a stamp to provide physical evidence that the invoice requests and/or receipts have completed the review steps. Eith...
It is the policy that either Marlon Mitchell or James Kilgore approves expenditures of the programs. FirstFollowers is not in the habit of initialing the invoices, so we will purchase a stamp to provide physical evidence that the invoice requests and/or receipts have completed the review steps. Either Marlon or James will date/initial with the approval stamp. All the contractors and employees have a yearly review of their salary and/or hourly rates. Those contracts are written and kept in the files of FirstFollowers and were provided to CliftonLarsonAllen upon request. We will continue to update these contracts each fiscal year and ensure that the contracts are reviewed by the Board of Directors and noted in the minutes.
View Audit 308844
Finding 400812 (2023-001)
Significant Deficiency 2023
Orchard Hospital and Affiliate
CA
Reporting Significant Deficiency Questioned Costs
Management acknowledges the delay in completing the FYE 2023 audit and filing the Data Collection Form (SF-SAC) on time. We have since completed the audit and submitted the required documentation to the Federal Audit Clearinghouse. To prevent recurrence of this issue the following corrective actio...
Management acknowledges the delay in completing the FYE 2023 audit and filing the Data Collection Form (SF-SAC) on time. We have since completed the audit and submitted the required documentation to the Federal Audit Clearinghouse. To prevent recurrence of this issue the following corrective actions will be implemented: -Establish a detailed timeline for the audit process, including key milestones and deadlines -Conduct regular progress review to ensure adherence to the timeline -Allocate additional resources to the finance departments as needed during critical periods to ensure timely completion of tasks -Improve communication between the audit team and mangement to promptly address any issues that may cause delays. Responsible Party: Ed Gonzalez, CFO, will be responsible for overseeing the implementation and execution of this corrective action plan. Estimated Completion Date: The corrective actions outlined above are expected to be fully implemented by May 31, 2024. We are committed to ensuring compliance with all financial reporting obligations and will take the necessary steps to prevent future occurrences of such delays.
View Audit 308835
Cal-Pep
CA
Procurement, Suspension & Debarment Reporting Questioned Costs
Late Filing of Required Reporting of Federal Awards/Grant. CAL-PEP Inc.’s Data Collection Form and Reporting Package was not submitted to the Federal Clearinghouse within extended due date. Corrective Action Plan: Policy and Procedures on the submittal of Data Collection Form and Reporting Package t...
Late Filing of Required Reporting of Federal Awards/Grant. CAL-PEP Inc.’s Data Collection Form and Reporting Package was not submitted to the Federal Clearinghouse within extended due date. Corrective Action Plan: Policy and Procedures on the submittal of Data Collection Form and Reporting Package to the Federal Clearing House within extended due date had been established. Policy is shown below: The reporting package for the Federal clearing house must be submitted 30 days after receipt of auditor's report, or 9 months after end of the fiscal year whichever comes first, (February). In order to meet the deadline, a request to start the company audit will be arrange at the earliest, by August every year. In case an Audit Report is expected not to be receive within 9 months after fiscal year, a written extension must be submitted by the Finance Manager.
View Audit 308830
Finding 400747 (2023-008)
Material Weakness 2023
School District U-46
IL
Questioned Costs Allowable Costs / Cost Principles Reporting
Finding 2023-008: Compliance with Federal Wage Requirements Finding: The District did not include federal wage rate requirements in construction contracts which were partially funded with federal grant funds. Additionally, the District did not require the contractors in those agreements to submit we...
Finding 2023-008: Compliance with Federal Wage Requirements Finding: The District did not include federal wage rate requirements in construction contracts which were partially funded with federal grant funds. Additionally, the District did not require the contractors in those agreements to submit weekly certified payrolls. Corrective Actions Planned: The District will update the language used for construction contracts and develop an internal process for the collection and retention of the required weekly certified payrolls. Expected Implementation Date: June 30, 2024 Contact Person: Dr. Frank Williams
View Audit 308771 Questioned Costs: $1
Finding 400689 (2023-003)
Material Weakness 2023
Pr Health Corporation D/b/a First Care Health Center
ND
Special Tests & Provisions Questioned Costs Material Weakness § 200.303
Finding 2023‐003 Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the reserve funds for ...
Finding 2023‐003 Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the reserve funds for the federal program. Responsible Individuals: Marcus Lewis, CEO, and Nina Hollingsworth, CFO Status: We will implement additional control processes to ensure the reserve fund reconciliation has a secondary review and approval that is documented. Anticipated Completion Date: 6/30/2024
View Audit 308769
Family Service Association of San Antonio, Inc.
TX
Allowable Costs / Cost Principles Reporting Questioned Costs § 200.328
Finding #2023-001: Type of Finding: Questioned Cost and Other Noncompliance Responsible Person Hector P. Luevano – Controller Richard Davidson – Chief Operating Officer Implementation Date January 1, 2024 Views of responsible officials and planned corrective actions Management agrees and will more c...
Finding #2023-001: Type of Finding: Questioned Cost and Other Noncompliance Responsible Person Hector P. Luevano – Controller Richard Davidson – Chief Operating Officer Implementation Date January 1, 2024 Views of responsible officials and planned corrective actions Management agrees and will more closely monitor obligated and incurred expenditures near the end of reporting periods to ensure they are completed within 120 days after the close of the grant year. Future planned expenditures are to be tracked separately and not reported as expenditures until an expense is obligated or incurred by the program. Family Service will be elevating the responsibility of monitoring the execution of projects with their scheduled expenses to the Chief Operations Officer and Controller, to avoid future gaps between obligated and/or future planned expenditures, project completion and payments.
View Audit 308759 Questioned Costs: $1
Finding 400674 (2023-007)
Significant Deficiency 2023
San Francisco Unified School District
CA
Questioned Costs Allowable Costs / Cost Principles
2023-007 ALLOWABLE COSTS/COST PRINCIPLES - TIME AND EFFORT REPORTING (50000) • Time Certification Schedules: Implement semi-annual time certifications for employees funded by a single federal source and monthly certifications for employees funded by multiple sources.
2023-007 ALLOWABLE COSTS/COST PRINCIPLES - TIME AND EFFORT REPORTING (50000) • Time Certification Schedules: Implement semi-annual time certifications for employees funded by a single federal source and monthly certifications for employees funded by multiple sources.
View Audit 308733 Questioned Costs: $1
Finding 400670 (2023-002)
Material Weakness 2023
Casa De Amparo
CA
Allowable Costs / Cost Principles Questioned Costs Reporting
Management agrees with the assessment and has implemented steps at the beginning of the fiscal year 2023-2024 to address this issue. The organization has transitioned its accounting software to QuickBooks Online to enhance efficiency and streamline processes within the accounting department. Additio...
Management agrees with the assessment and has implemented steps at the beginning of the fiscal year 2023-2024 to address this issue. The organization has transitioned its accounting software to QuickBooks Online to enhance efficiency and streamline processes within the accounting department. Additionally, a thorough review of procedures has been conducted, and measures have been implemented to mitigate the previous impact of employee turnover. These strategic initiatives are expected to rectify the identified deficiency and contribute to improved effectiveness and efficiency within the accounting department.
View Audit 308725
Town of Southbridge, Massachusetts
MA
Questioned Costs Reporting Program Income § 200.328
Finding 2023-001 Condition: As of the March 31, 2023, reporting date, the Town understated its expenditures by approximately $1,132,000 and did not report any obligations for contracted amounts not spent. Corrective Action Planned: Update the expenditures to reflect the inclusion of prior repor...
Finding 2023-001 Condition: As of the March 31, 2023, reporting date, the Town understated its expenditures by approximately $1,132,000 and did not report any obligations for contracted amounts not spent. Corrective Action Planned: Update the expenditures to reflect the inclusion of prior reported expenditures for an accurate cumulative spending. Existing obligations will also be updated accordingly. A review of all obligations will be completed to ensure all necessary contracts are in place prior to 12/31/2024. Anticipated Completion Date: Expenditure and obligation reporting corrected with submission due by 4/30/2024. Contracted obligations to be in place prior to October 31, 2024. Contact: Kristine Russell, Town Accountant
View Audit 308710
Finding 400653 (2023-002)
Significant Deficiency 2023
Forsyth County, North Carolina
NC
Allowable Costs / Cost Principles Questioned Costs Cash Management § 200.303
Finding 2023-002, Significant Deficiency – Allowable Costs Corrective Action Plan: Goal: To ensure that duplicative expenses are not drawn down in state funding. Plan: The County identified the duplicate transaction of $20,740 reported for drawdown for Project AA 362 was due to an issue with the rep...
Finding 2023-002, Significant Deficiency – Allowable Costs Corrective Action Plan: Goal: To ensure that duplicative expenses are not drawn down in state funding. Plan: The County identified the duplicate transaction of $20,740 reported for drawdown for Project AA 362 was due to an issue with the reporting mechanism. Specifically, the report used to extract project costing details included a commitment number column, which inadvertently resulted in the creation of duplicate records for each commitment associated with a single invoice. Performance Improvement Strategies: To address this issue and prevent its recurrence in the future, immediate steps have already been taken. County Finance has amended the report to exclude the commitment number parameter, thereby eliminating the possibility of duplicate records being generated. Responsible Parties: Nursing Supervisor Brooke Hamby and Assistant Health Directors Nicole Priddy & Marie Stephens Timeframes: Brooke Hamby will reach out to the Division of Public Health, Women & Children’s Health/Children & Youth section, no later than June 15, 2024, to inform them of the Audit finding of this duplicate expense and request what the process is for returning the funds.
View Audit 308707 Questioned Costs: $1
Finding 400647 (2023-001)
Significant Deficiency 2023
Casa De Primavera Apts, LLC - Dba Casa De Primavera 123-11222
AZ
Questioned Costs HUD Housing Programs
Comments on the Finding and Each Recommendation: As of June 30, 2023, deposits to the reserve for replacements totaling $768 had not been made. Pursuant to Section 10 of the Regulatory Agreement, the Company shall deposit a monthly amount into the reserve for replacements account. The amount of t...
Comments on the Finding and Each Recommendation: As of June 30, 2023, deposits to the reserve for replacements totaling $768 had not been made. Pursuant to Section 10 of the Regulatory Agreement, the Company shall deposit a monthly amount into the reserve for replacements account. The amount of the monthly deposit may be increased or decreased from time to time at the written direction of HUD. Effective April 1, 2023, HUD increased the monthly deposit from $8,012 to $8,396. Management inadvertently did not increase the monthly deposit until June 2023. As a result, the Company was not in compliance with the terms of the Regulatory Agreement. The reserve for replacements was underfunded by $768 as of June 30, 2023. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation and transferred $768 to the reserve for replacements on August 11, 2023. No further action is required.
View Audit 308702 Questioned Costs: $1
Finding 400643 (2023-004)
Significant Deficiency 2023
Fairbanks Community Homes 176-Hd-021
AK
Questioned Costs HUD Housing Programs Reporting
Failure to submit REAC report Name of Contact:Kendrick D. Blais, President Management's view:Management agrees with the finding. Corrective Action: Management will transfer surplus cash to the...
Failure to submit REAC report Name of Contact:Kendrick D. Blais, President Management's view:Management agrees with the finding. Corrective Action: Management will transfer surplus cash to the residual receipts account. Proposed Completion Date: June 30, 2024
View Audit 308683
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