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Corrective Action Plans

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Finding 6417 (2023-004)
Material Weakness 2023
Wagner Community Memorial Hospital
SD
Questioned Costs Subrecipient Monitoring Material Weakness § 200.303
Finding 2023-004 Federal Agency Name: Department of Agriculture Federal Financial Assistance Listing #10.766 Program Name: Community Facilities Loans and Grants Cluster Compliance Requirement: Special Test and Provisions Finding Summary: The Hospital's reserve account is fully funded per the requir...
Finding 2023-004 Federal Agency Name: Department of Agriculture Federal Financial Assistance Listing #10.766 Program Name: Community Facilities Loans and Grants Cluster Compliance Requirement: Special Test and Provisions Finding Summary: The Hospital's reserve account is fully funded per the requirements in the loan resolution agreement. However, there is no documented secondary monitoring of the account balance as compared to the required minimum balance. Responsible Individuals: Lisa Weisser, Director of Finance Corrective Action Plan: A qualifying statement will be added to the bi-monthly board report which will qualify the minimum USDA-RD required reserve balance for the board of director's review and oversight. Anticipated Completion Date: January 2024
View Audit 8344
Finding 6401 (2023-003)
Material Weakness 2023
Open Door Health Services, INC
IN
Questioned Costs Special Tests & Provisions Internal Control / Segregation of Duties
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2023-003: Open Door Health Services, Inc. continues to evaluate controls around monitoring of the sliding fee discounts that are applied. Open Door Health Services, Inc. will actively re...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2023-003: Open Door Health Services, Inc. continues to evaluate controls around monitoring of the sliding fee discounts that are applied. Open Door Health Services, Inc. will actively review past and current discounts to ensure errors are corrected in a timelier manner.
View Audit 8323
Finding 6392 (2023-004)
Material Weakness 2023
Family Medical Center of Michigan, Inc.
MI
Questioned Costs Allowable Costs / Cost Principles Material Weakness
2023-004 - Material weakness and Material Noncompliance - Missing Timesheets FMC Comment: FMC was in the process of converting for a one payroll system to another system during the Audit year. The conversion process was time consuming and involved files being transferred from one system to another ...
2023-004 - Material weakness and Material Noncompliance - Missing Timesheets FMC Comment: FMC was in the process of converting for a one payroll system to another system during the Audit year. The conversion process was time consuming and involved files being transferred from one system to another system. This could have resulted in some timesheets being misplaced as opposed to staff being paid without a timesheet being approved. Corrective Action: FMC has a new timekeeping system - Paylocity- that should prevent the issue of missing timesheets since the system is all electronic. Staff cannot get paid unless within the Paylocity system there is an electronic timesheet. The process is described below: The employee's clock in and out electronically, through a web portal on their phone, desktop or laptop. The supervisor is notified through the Paylocity if there are errors or missed punches. The supervisor works with the employee to correct any errors. The supervisor electronically approves the electronic time card. All approved electronic timecards are locked by payroll, then electronically brought from the time and attendance system to the payroll system. Payroll and HR will review all timecards to ensure all hours are correct and the vacation, sick and personal time are within appropriate parameters. Any additional corrections are made electronically with the supervisor and employee's input. Once all the electronic records are approved, Payroll submits the payroll for processing by Paylocity. The electronic timesheet record is printed on one document and kept with the payroll register for each pay period.
View Audit 8310
Finding 6388 (2023-003)
Material Weakness 2023
Family Medical Center of Michigan, Inc.
MI
Questioned Costs Material Weakness Special Tests & Provisions
2023-003 - Material Weakness and Material Noncompliance - Special Tests FMC Comment: Family Medical Center's Patient Accounts department has had significant turnover over the past three years as well as implementation of a new software. FMC hired several temporary staff to support that led to more ...
2023-003 - Material Weakness and Material Noncompliance - Special Tests FMC Comment: Family Medical Center's Patient Accounts department has had significant turnover over the past three years as well as implementation of a new software. FMC hired several temporary staff to support that led to more turnover and a lack of consistency in personnel. Many of the issues are due to improper documentation or manual error inputting the patients' slide scale into the system. Corrective Action: Family Medical Center will have management or assigned staff to review all current sliding fee patients and ensure that the Center has an updated sliding fee application for each. FMC will provide additional training to front desk staff at each site and require them to obtain the proper application and documentation. Patient Accounts will review the current application to ensure that the current patients are charged the proper sliding fee scale. Management will develop a training module with Human Resources to have each staff complete in addition to hiring additional staff. This corrective action is expected to be completed by March 31, 2024.
View Audit 8310
Finding 6386 (2023-002)
Significant Deficiency 2023
Pontiac Housing Commission
MI
HUD Housing Programs Internal Control / Segregation of Duties Questioned Costs
2023-002 Condition: Questionable Use of Federal Funds Steps to Resolve: We concur with this finding and the Auditor's recommendation. We will establish internal financial control procedures over the budget process to ensure that each program operates within its means and in accordance with HUD re...
2023-002 Condition: Questionable Use of Federal Funds Steps to Resolve: We concur with this finding and the Auditor's recommendation. We will establish internal financial control procedures over the budget process to ensure that each program operates within its means and in accordance with HUD regulations. We have already taken steps to reduce expenses in the COCC and will generate revenue from grants and other business activity to offset the COCC expenses. Management will take corrective action to close this finding in connection with the FY 2024 audit report. Timeframe: By the fiscal year end for March 31, 2024 Individual responsible for correction: Mr. Ahmad Taylor, Executive Director
View Audit 8287
Henry County R-I School District
MO
Questioned Costs Cash Management
December 8, 2023 U.S. Department of Education Henry County R-I School District respectfully submits the following Corrective Action Plan for the year ended June 30, 2023. Contact information for the individual responsible for the corrective action: Brad Hunter, Superintendent Henry County R-I School...
December 8, 2023 U.S. Department of Education Henry County R-I School District respectfully submits the following Corrective Action Plan for the year ended June 30, 2023. Contact information for the individual responsible for the corrective action: Brad Hunter, Superintendent Henry County R-I School District Independent Public Accounting Firm: Gerding, Korte & Chitwood, P.C., 723 Main Street, Boonville, MO 65233 Audit Period: Year ended June 30, 2023 The findings from the June 30, 2023, Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Significant Deficiency 2023-002 ARP ESSER III Recommendation: The District must ensure that they have proper documentation and have actually spent the federal funds prior to seeking reimbursement. Action Taken: The District will ensure that expenditures are properly supported prior to requesting reimbursement. Completion Date: June 30, 2024 Sincerely, Brad Hunter, Superintendent Henry County R-I School District
View Audit 8258 Questioned Costs: $1
King's College
PA
Special Tests & Provisions Questioned Costs Student Financial Aid
Views of Responsible Officials and Planned Corrective Actions: The College agrees with the finding. The Associate Director of Financial Aid is responsible for calculating Return of Title IV (R2T4) refunds for all students who withdraw from the College within the first 60% of the payment period using...
Views of Responsible Officials and Planned Corrective Actions: The College agrees with the finding. The Associate Director of Financial Aid is responsible for calculating Return of Title IV (R2T4) refunds for all students who withdraw from the College within the first 60% of the payment period using the Colleague software R2T4 module for calculating refunds. The Director of Financial Aid will provide a secondary review of all calculated R2T4 refunds before funds are returned to the Common Origination and Disbursement system. Names of Contact Persons Responsible for Corrective Action: Barbara Schmitt, Director of Financial Aid Anticipated Completion Date: Changes were effective for the fall 2023 semester
View Audit 8234
Finding 6234 (2023-001)
Significant Deficiency 2023
Charleston-Kanawha Housing Authority
WV
Questioned Costs Eligibility Significant Deficiency
CKHA will implement an internal quality control function which will review the income calculations for one hundred (100) percent of all move-ins and ten (10) percent of monthly recertifications by site to determine that incomes are correctly included int he Family Reports in accordance with the ACOP...
CKHA will implement an internal quality control function which will review the income calculations for one hundred (100) percent of all move-ins and ten (10) percent of monthly recertifications by site to determine that incomes are correctly included int he Family Reports in accordance with the ACOP and 24 CFR 960.259. Moving forward, Tammy Edelman, Director of Housing Management, will be responsible for assuring this function is completed in an accurate and timely manner. Anticipated Completion Date: This new function with be implemented January 1, 2024, and this will be an on-going function.
View Audit 8188 Questioned Costs: $1
Zion-Benton Township High School District No. 126
IL
Questioned Costs
Condition: Data submitted on the LEA Data Collection Form showed some key line-item expenditures categorized differently from previously filed expenditure reports. Plan: Management will implement procedures including reconciling amounts between underlying data, quarterly expenditure reports, and...
Condition: Data submitted on the LEA Data Collection Form showed some key line-item expenditures categorized differently from previously filed expenditure reports. Plan: Management will implement procedures including reconciling amounts between underlying data, quarterly expenditure reports, and annual data collection reports. Additionally, reports and supporting documentation will be reviewed by a second person. Anticipated Date of Completion: 06/30/2024 Name of Contact Person: Mathew Wilkinson, Ed. D., CSBO Management Response: N/A
View Audit 8135
Finding 6172 (2023-001)
Significant Deficiency 2023
Housing Authority of the City of New Smyrna Beach
FL
Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties
2023-001 Condition: Deficiencies Noted in SEMAP Compliance Steps to Resolve: We concur with this finding and the Auditor’s recommendation. We will adjust our procedures to ensure that all new leases and rent increases have a determination of rent reasonableness and the documentation is retained i...
2023-001 Condition: Deficiencies Noted in SEMAP Compliance Steps to Resolve: We concur with this finding and the Auditor’s recommendation. We will adjust our procedures to ensure that all new leases and rent increases have a determination of rent reasonableness and the documentation is retained in the files for review. Management will implement procedures to clear this finding in FY 2024. Timeframe: By the fiscal year end for March 31, 2024 Individual responsible for correction: Ms. Teresa Pope, Executive Director
View Audit 8104
Finding 6156 (2023-003)
Significant Deficiency 2023
Cedar County Memorial Hospital
MO
Questioned Costs Reporting Significant Deficiency
U.S. Department of Health and Human Services Cedar County Memorial Hospital (“Organization”) respectfully submits the following corrective action plan for the year ended January 31, 2023. Audit period: February 1, 2022 – January 31, 2023 The findings from the schedule of findings and questioned cos...
U.S. Department of Health and Human Services Cedar County Memorial Hospital (“Organization”) respectfully submits the following corrective action plan for the year ended January 31, 2023. Audit period: February 1, 2022 – January 31, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS— FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL PROGRAMS DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023 – 003 COVID-19 Provider Relief Funding and American Rescue Plan Rural Distribution Recommendation: We recommend the Hospital design controls to ensure that reporting is completing in accordance with latest HHS guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management misunderstood the input of the information to be on fiscal vs. calendar year end. Name of the contact person responsible for corrective action: Carla Gilbert, CFO. Planned completion date for corrective action plan: November 1, 2023 If the Department of Health and Human Services has questions regarding this plan, please call Carla Gilbert, CFO at (417) 876-3097.
View Audit 8022
Isd# 2167 Lakeview
MN
Procurement, Suspension & Debarment Equipment & Real Property Management Questioned Costs
Lack of Approval for School Food Authority Equipment Purchase Auditor Recommendation We recommend that the District review requirements of the school food authorities for the purchase of capital expenditures. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is...
Lack of Approval for School Food Authority Equipment Purchase Auditor Recommendation We recommend that the District review requirements of the school food authorities for the purchase of capital expenditures. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding Chris Fenske (Superintendent) will review requirements prior to purchases of capital expenditures being coded to food service. 3. Official Responsible for Insuring CAP Chris Fenske is the official responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP This plan has been and will continue to be implemented during the 2023-2024 fiscal year. 5. Plan to Monitor Completion of CAP Chris Fenske and the School Board will be monitoring this corrective action plan.
View Audit 8014
Isd# 2167 Lakeview
MN
Procurement, Suspension & Debarment Questioned Costs
Procurement Policy Auditor Recommendation We recommend that the District continue to follow the written procurement policy adopted on October 17, 2022, to ensure that the federal program compliance requirements are being followed. Corrective Action Plan (CAP) 1. Explanation of Disagreement with...
Procurement Policy Auditor Recommendation We recommend that the District continue to follow the written procurement policy adopted on October 17, 2022, to ensure that the federal program compliance requirements are being followed. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding Chris Fenske (Superintendent) ensured the adoption of a written procurement policy on October 17, 2022, to ensure that the federal program compliance requirements are being followed. 3. Official Responsible for Insuring CAP Chris Fenske is the official responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP This plan was implemented on October 17, 2022. 5. Plan to Monitor Completion of CAP Chris Fenske monitored this plan.
View Audit 8014
Finding 6146 (2023-005)
Material Weakness 2023
Isd# 2167 Lakeview
MN
Procurement, Suspension & Debarment Equipment & Real Property Management Internal Control / Segregation of Duties
Controls over Compliance of Federal Programs Auditor Recommendation We recommend that the District establish appropriate controls to ensure compliance in regard to the compliance requirements of federal programs. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding T...
Controls over Compliance of Federal Programs Auditor Recommendation We recommend that the District establish appropriate controls to ensure compliance in regard to the compliance requirements of federal programs. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding Chris Fenske (Superintendent) will ensure the establishment of appropriate controls to ensure compliance regarding federal program compliance requirements. 3. Official Responsible for Insuring CAP Chris Fenske is the official responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP This plan will be implemented immediately. 5. Plan to Monitor Completion of CAP Chris Fenske and the School Board will be monitoring this corrective action plan.
View Audit 8014
Finding 6134 (2023-002)
Significant Deficiency 2023
Union County Board of Education
KY
Internal Control / Segregation of Duties Questioned Costs
The District agrees with the auditor recommendation and has actively implemented a system that requires a substitute teaching certificate on file prior to initiating active substitute status within the payroll system. The District also agrees with the recommendation to appropriately utilize recomme...
The District agrees with the auditor recommendation and has actively implemented a system that requires a substitute teaching certificate on file prior to initiating active substitute status within the payroll system. The District also agrees with the recommendation to appropriately utilize recommendation forms to identify non-certified substitute teachers participating in EPSB’s Emergency Non-Certified School Personnel Program prior to the assignment of a pay classification included on the approved salary schedule. The District also has established a unique salary table for the non-certified substitute teacher job classification.
View Audit 7998
Central Pines Regional Council
NC
Questioned Costs Allowable Costs / Cost Principles Cash Management
2023-001 Name of Contact Person: Hope Tally Corrective Action: Management recognizes a systematic error occurred to create an immaterial allocation overage. Management is taking steps to correct the system setup to prevent errors and creating new processes to catch any system overages in a timely an...
2023-001 Name of Contact Person: Hope Tally Corrective Action: Management recognizes a systematic error occurred to create an immaterial allocation overage. Management is taking steps to correct the system setup to prevent errors and creating new processes to catch any system overages in a timely and consistent manner. Proposed Completion Date: 6/30/2024
View Audit 7976 Questioned Costs: $1
Finding 6095 (2023-001)
Significant Deficiency 2023
Columbia International University and Subsidiaries
SC
Questioned Costs Subrecipient Monitoring Significant Deficiency
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: 1. The security program documentation will be updated to reflect actions required by the June 2023 GLBA legislative changes. 2. The information and technology risk management activities logged and captured in supplemental docume...
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: 1. The security program documentation will be updated to reflect actions required by the June 2023 GLBA legislative changes. 2. The information and technology risk management activities logged and captured in supplemental documentation will be included in the master security program documentation going forward. 3. Active technology projects and roadmap initiatives that impact GLBA compliance will be expedited. Person Responsible for Corrective Action Plan: Tirrell Howell, Vice President of Information Technology Anticipated Date of Completion: May 31, 2024
View Audit 7973
Housing Authority of Savannah
GA
Questioned Costs HUD Housing Programs Procurement, Suspension & Debarment
Management has implemented, and is in the process of implementing, specific corrective actions to address each of HUD’s Findings. The Authority’s Deputy Director, Kenneth Clark has assumed the responsibility of implementing the specific corrective actions and anticipates complete implementation by ...
Management has implemented, and is in the process of implementing, specific corrective actions to address each of HUD’s Findings. The Authority’s Deputy Director, Kenneth Clark has assumed the responsibility of implementing the specific corrective actions and anticipates complete implementation by March 31, 2024.
View Audit 7953 Questioned Costs: $1
Finding 6050 (2023-001)
Significant Deficiency 2023
The Meadows
MN
Questioned Costs Reporting Internal Control / Segregation of Duties
Finding 2023-001 Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Tak...
Finding 2023-001 Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned completion date: Not Applicable.
View Audit 7926
Finding 6045 (2023-005)
Significant Deficiency 2023
Orchard View Schools
MI
Special Tests & Provisions Questioned Costs Cash Management
Finding 2023-005: Child Nutrition Cluster Federal Reimbursement Receipting Procedures U.S. Department of Agriculture Pass-through agency: Michigan Department of Education Assistance Listing Numbers: 10.553, 10.555, and 10.559 Award numbers: 221970, 231970, 220910, 221960, 231960, 220900 and ...
Finding 2023-005: Child Nutrition Cluster Federal Reimbursement Receipting Procedures U.S. Department of Agriculture Pass-through agency: Michigan Department of Education Assistance Listing Numbers: 10.553, 10.555, and 10.559 Award numbers: 221970, 231970, 220910, 221960, 231960, 220900 and 230900 Award year ends: June 30, 2023 and September 30, 2023 Recommendation: The School District should provide training to accounting department personnel of the requirements for non-profit school food service accounts under Uniform Grant Guidance, and the School District should require payments to be timely receipted and credited to the proper food service accounts. Action Taken: The financial services staff will reconcile and record monthly transactions timely in the accounting records. We also will cross train staff and build familiarity with the process, focusing on improving our procedures during the year to streamline receipting processes. Additionally, the Superintendent and accounting department have temporarily contracted an additional accounting professional to assist the business manager in this process. Responsible Person and Anticipated Completion Date: Director of Finance, November 2023. If the Michigan Department of Education has questions regarding this plan, please call Jim Nielsen at (231) 760-1309.
View Audit 7910
Finding 6001 (2023-001)
Significant Deficiency 2023
Ascent Academies of Utah
UT
Questioned Costs Reporting Significant Deficiency
Finding Summary: Ascent Academies of Utah is required to submit an annual performance report to the State of Utah detailing GEER and ESSER expenditures by subgrant fund, expenditure category, object code, number of specific positions supported with GEER and ESSER funds, allocation of GEER and ESSER ...
Finding Summary: Ascent Academies of Utah is required to submit an annual performance report to the State of Utah detailing GEER and ESSER expenditures by subgrant fund, expenditure category, object code, number of specific positions supported with GEER and ESSER funds, allocation of GEER and ESSER funds and criteria used and number of full-time equivalent positions for all GEER & ESSER funds received from the USBE during the period of July 1, 2021 to June 30, 2022. Ascent Academies of Utah reported ESSER II expenditures incorrectly. Responsible Individuals: Accountant and Lead Director Corrective Action Plan: Management has communicated with the State of Utah regarding what they believe to be deficiencies in the reporting mechanism that was provided by the State to report annual GEER and ESSER expenditures. These deficiencies include the absence of adequate means for management to prevent and detect typographical errors, and the absence of documentation for the submitted report. The reporting error has been corrected and management will use mitigating controls to prevent future errors. Anticipated Completion Date: The Corrective Action Plan has been implemented.
View Audit 7889
Simpson University
CO
Questioned Costs Student Financial Aid
Inaccurate Pell Calculations Planned Corrective Action: The University recognized that this was an isolated concern based on the late notification from the Department of Education on Pell Grant Awards for the 2022-23 award year. System updates and 20 hours of system training have been scheduled and/...
Inaccurate Pell Calculations Planned Corrective Action: The University recognized that this was an isolated concern based on the late notification from the Department of Education on Pell Grant Awards for the 2022-23 award year. System updates and 20 hours of system training have been scheduled and/or implemented to prevent this from reoccurring. Person Responsible for Corrective Action Plan: Shondra Dickson, Director of Financial Aid Anticipated Date of Completion: April 2024
View Audit 7877
Finding 5784 (2023-002)
Significant Deficiency 2023
Simpson University
CO
Questioned Costs Student Financial Aid Allowable Costs / Cost Principles
Need Analysis Planned Corrective Action: The University recognizes the federal regulations regarding over‐awarding and has implemented the use of a delivered report through the Student Information System to address this concern. Person Responsible for Corrective Action Plan: Shondra Dickson, Direc...
Need Analysis Planned Corrective Action: The University recognizes the federal regulations regarding over‐awarding and has implemented the use of a delivered report through the Student Information System to address this concern. Person Responsible for Corrective Action Plan: Shondra Dickson, Director of Financial Aid Anticipated Date of Completion: Implemented
View Audit 7877
Finding 5777 (2023-006)
Significant Deficiency 2023
Minnesota Valley Action Council, Inc.
MN
Questioned Costs Allowable Costs / Cost Principles Significant Deficiency
2023-006 Special Tests and Provisions Recommendation: We recommend that management implements journal entry review process for Workforce Council Executive Director indirect cost allocations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action pl...
2023-006 Special Tests and Provisions Recommendation: We recommend that management implements journal entry review process for Workforce Council Executive Director indirect cost allocations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: MVACs executive director will review WFCs executive director timesheet for approval. Name of the contact person responsible for corrective action: Amanda Mackie Planned completion date for corrective action plan: We plan to implement by the 12.01.2023 payroll.
View Audit 7859
Finding 5773 (2023-001)
Significant Deficiency 2023
Minnesota Valley Action Council, Inc.
MN
Questioned Costs Significant Deficiency Internal Control / Segregation of Duties
2023-001 Activities Allowed or Unallowed Recommendation: We recommend obtaining documentation of approval for all invoices. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Staff will be retrained to ensu...
2023-001 Activities Allowed or Unallowed Recommendation: We recommend obtaining documentation of approval for all invoices. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Staff will be retrained to ensure they are following procedures and collecting the appropriate signatures and documentation prior to dispersing funds. Name of the contact person responsible for corrective action: Amanda Mackie Planned completion date for corrective action plan: This has been completed.
View Audit 7859
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