Corrective Action Plans

Finding 520021 (2022-004)

Significant Deficiency 2022

Feeding San Diego

CA

Allowable Costs / Cost Principles Cash Management Reporting

Identification of federal programs 10.558 - Child and Adult Care Food Program (CACFP) Condition The Organization does not retain documentation of review of supper meals and snacks uploaded for reimbursement. Views of Responsible Officials: Management agrees with the finding and observation. Cont...

Identification of federal programs 10.558 - Child and Adult Care Food Program (CACFP) Condition The Organization does not retain documentation of review of supper meals and snacks uploaded for reimbursement. Views of Responsible Officials: Management agrees with the finding and observation. Contact Person: Fendy Wogu, Finance Controller Proposed Completion Date: October 31, 2024

View Audit 339494

Finding 520020 (2022-003)

Significant Deficiency 2022

Feeding San Diego

CA

Allowable Costs / Cost Principles Reporting Questioned Costs

Identification of federal programs 21.027/10.558 - American Rescue Plan Act (ARPA) and Child and Adult Care Food Program (CACFP) Condition The Organization did not have adequate internal controls surrounding reception of food boxes, backpacks, supper meals, or snacks provided as some selections d...

Identification of federal programs 21.027/10.558 - American Rescue Plan Act (ARPA) and Child and Adult Care Food Program (CACFP) Condition The Organization did not have adequate internal controls surrounding reception of food boxes, backpacks, supper meals, or snacks provided as some selections did not have supervisory review of support. Views of Responsible Officials: Management agrees with the finding and observation. Contact Person: Fendy Wogu, Finance Controller Proposed Completion Date: October 31, 2024

View Audit 339494

Finding 520019 (2022-002)

Significant Deficiency 2022

Feeding San Diego

CA

Allowable Costs / Cost Principles Reporting Questioned Costs

Identification of federal programs 10.558 – Child and Adult Care Food Program (CACFP) Condition The Organization could not provide support to evidence the number of meals/snacks provided for a certain site. Views of Responsible Officials: Management agrees with the finding and observation. Cont...

Identification of federal programs 10.558 – Child and Adult Care Food Program (CACFP) Condition The Organization could not provide support to evidence the number of meals/snacks provided for a certain site. Views of Responsible Officials: Management agrees with the finding and observation. Contact Person: Fendy Wogu, Finance Controller Proposed Completion Date: October 31, 2024

View Audit 339494

Finding 520018 (2022-001)

Significant Deficiency 2022

Feeding San Diego

CA

Questioned Costs Eligibility Reporting

Identification of federal programs 10.558 and 21.027 – Child and Adult Care Food Program (CACFP) and Child Care and Development Block Grant (ARPA) Condition The Organization did not retain eligibility documentation for each site noting the control process. Views of Responsible Officials: Manag...

Identification of federal programs 10.558 and 21.027 – Child and Adult Care Food Program (CACFP) and Child Care and Development Block Grant (ARPA) Condition The Organization did not retain eligibility documentation for each site noting the control process. Views of Responsible Officials: Management agrees with the finding and observation. Contact Person: Fendy Wogu, Finance Controller Proposed Completion Date: October 31, 2024

View Audit 339494

Finding 520017 (2022-006)

Significant Deficiency 2022

Feeding San Diego

CA

Allowable Costs / Cost Principles Reporting Questioned Costs

Identification of federal programs 10.558/10.559- Child and Adult Care Food Program (CACFP)and Summer Food Service Program for Children (SFSPC) Condition The Organization did not have personnel with adequate accounting experience as they allowed volunteers to keep track of the grants' tracking an...

Identification of federal programs 10.558/10.559- Child and Adult Care Food Program (CACFP)and Summer Food Service Program for Children (SFSPC) Condition The Organization did not have personnel with adequate accounting experience as they allowed volunteers to keep track of the grants' tracking and accounting. Views of Responsible Officials: Management agrees with the finding and observation. Contact Person: Fendy Wogu, Finance Controller Proposed Completion Date: October 31, 2024

View Audit 339494

Finding 519533 (2022-001)

None 2022

City of Santa Maria

CA

Questioned Costs § 200.512

The Cíty of Santa Maria has contracted with an outside consultant to help catch up on the financials that are overdue. The consultant has been a great help and is engaged through the end of fiscal year 2025. Fiscal year 2024's Single Audit is still scheduled to be completed on time. Planned completi...

The Cíty of Santa Maria has contracted with an outside consultant to help catch up on the financials that are overdue. The consultant has been a great help and is engaged through the end of fiscal year 2025. Fiscal year 2024's Single Audit is still scheduled to be completed on time. Planned completion date: FY23and FY24completed by Mar 31, 2025 and subsequent years delivered on time. If there are any questions regarding this plan, please contact Xenia Bradford, Finance Director, at xbradford@cityofsantamaria.org or 805-925-0951.

View Audit 338539

Finding 519364 (2022-005)

Material Weakness 2022

Confluence Health

WA

Questioned Costs Material Weakness Reporting

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN# 455563741 Finding Summary: The amounts reported for net patient revenue were b...

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN# 455563741 Finding Summary: The amounts reported for net patient revenue were based on gross charges and did not agree to the supporting documentation provided. Corrective Action Plan: Confluence Health during the next pandemic will confirm reporting requirements before submitting reporting data. Confluence developed a Grant Committee to oversee the reporting guidelines before approving grants. This will make the information for reporting requirements clearer to the organization and Financial Reporting Department. The 2023 data was reported at net patient revenue as required by the grant. Responsible Individual: Eric Caldwell, VP of Finance is responsible for this corrective action plan that was put into place after the audit. This process has been put in place and continues monthly during our month-end close meetings to ensure federal grant funds are being reported correctly. The Vice President of Finance, Eric Caldwell, will be the individual responsible for the corrective action plan.

View Audit 338246

Finding 519363 (2022-004)

Material Weakness 2022

Confluence Health

WA

Questioned Costs Material Weakness Reporting

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN# 455563741 Finding Summary: Confluence Health selected option II to calculate l...

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN# 455563741 Finding Summary: Confluence Health selected option II to calculate lost revenue which consists of a comparison of actual results during the period of availability to a budget approved before March 27,2020, for the entire period of availability. The budget used in the calculation of lost revenue was not approved for the entire period of availability. The budget used to cover quarters in 2021 and 2022 was not approved prior to March 27, 2020. Corrective Action Plan: Confluence Health during the next pandemic will issue a budget for the entire period required by the grant. Confluence developed a Grant Committee to oversee the reporting guidelines before approving grants. This will make the information for reporting requirements clearer to the organization and Financial Reporting Department. Responsible Individual: Eric Caldwell, VP of Finance is responsible for this corrective action plan that was put into place after the audit.

View Audit 338246

Finding 519256 (2022-004)

Material Weakness 2022

Wakemed

NC

Questioned Costs Procurement, Suspension & Debarment § 200.318 § 200.327

Finding Number: 2022-004 Condition: WakeMed does not have a written policy in place over procurement methods which covers 2 CFR 200.317 - 200.327, nor did WakeMed follow required procurement guidelines. Planned Corrective Action: WakeMed is in the process of updating their existing procurement poli...

Finding Number: 2022-004 Condition: WakeMed does not have a written policy in place over procurement methods which covers 2 CFR 200.317 - 200.327, nor did WakeMed follow required procurement guidelines. Planned Corrective Action: WakeMed is in the process of updating their existing procurement policy to include the relevant sections from the Code of Federal Regulations and will provide education to the areas involved in procurement and use of federal funds on these requirements. Contact person responsible for corrective action: Lynn Bailey Anticipated Completion Date: 12/5/2024

View Audit 337911 Questioned Costs: $1

Finding 519255 (2022-003)

Material Weakness 2022

Wakemed

NC

Reporting Questioned Costs Material Weakness § 200.502 § 200.508 § 200.510

Finding Number: 2022-003 Condition: Controls in place were not adequate to ensure the schedule of federal expenditures was complete and accurate. Planned Corrective Action: The federal funding was not received until fiscal year 2023 while some expenditures were incurred in fiscal year 2022. The timi...

Finding Number: 2022-003 Condition: Controls in place were not adequate to ensure the schedule of federal expenditures was complete and accurate. Planned Corrective Action: The federal funding was not received until fiscal year 2023 while some expenditures were incurred in fiscal year 2022. The timing of events contributed to the oversight on the 2022 SEFA. WakeMed has reeducated staff on the preparation of the SEFA in order to prevent this error from reoccurring.Contact person responsible for corrective action: Lynn Bailey Anticipated Completion Date: 12/5/2024

View Audit 337911

Finding 519254 (2022-002)

Significant Deficiency 2022

Wakemed

NC

Eligibility Questioned Costs Cash Management

Finding Number: 2022-002 Condition: WakeMed charged costs associated with ineligible individuals to the grant. Planned Corrective Action: WakeMed identified all HRSA patients with other documented insurance within the system. Each claim was reviewed to identify patients with active insurance cover...

Finding Number: 2022-002 Condition: WakeMed charged costs associated with ineligible individuals to the grant. Planned Corrective Action: WakeMed identified all HRSA patients with other documented insurance within the system. Each claim was reviewed to identify patients with active insurance coverage. Patients identified with active insurance coverage were considered ineligible for grant purposes, and the HRSA payments are in the process of being refunded. These costs were removed from the SEFA. In addition, WakeMed has written off all outstanding HRSA claims. Contact person responsible for corrective action: Terry Flynn, Director, Reimbursement Anticipated Completion Date: 06/14/2023

View Audit 337911

Finding 519253 (2022-001)

Significant Deficiency 2022

Wakemed

NC

Reporting Questioned Costs Significant Deficiency

Finding Number: 2022-001 Condition: WakeMed reported duplicate expenditures within the Period 2 portal submission. Planned Corrective Action: WakeMed reviewed the portal submission to determine the impact of the error on the amount of Provider Relief Funds recognized and reported on the SEFA. Wake...

Finding Number: 2022-001 Condition: WakeMed reported duplicate expenditures within the Period 2 portal submission. Planned Corrective Action: WakeMed reviewed the portal submission to determine the impact of the error on the amount of Provider Relief Funds recognized and reported on the SEFA. WakeMed has concluded that there was carried forward lost revenue of $26.4 million that is eligible to be applied to the Period 2 funds of $10.9 million. Therefore, there is no impact on the amounts reported on the SEFA. WakeMed has implemented additional review procedures for grant report submissions to ensure the accuracy of the reports in accordance with granting agency’s reporting requirements. Contact person responsible for corrective action: Terry Flynn, Director, Reimbursement Anticipated Completion Date: 06/14/2023

View Audit 337911

Finding 519125 (2022-007)

Material Weakness 2022

Cleveland County

OK

Questioned Costs Subrecipient Monitoring § 200.208 § 200.332 § 200.339 § 200.501

ALN 21.023 – Lack of Internal Controls and Noncompliance with Subrecipient Monitoring – Emergency Rental Assistance Program (Repeat Finding 2021-013) Cleveland County takes the auditor's findings seriously and has already implemented several improvements in documentation, monitoring, and reporting p...

ALN 21.023 – Lack of Internal Controls and Noncompliance with Subrecipient Monitoring – Emergency Rental Assistance Program (Repeat Finding 2021-013) Cleveland County takes the auditor's findings seriously and has already implemented several improvements in documentation, monitoring, and reporting practices. Cleveland County is working toward improvements for Fiscal Year 2025 and has reconciled billing to align with the contract scope of work. However, we recognize the need for documented internal controls and are committed to addressing all recommendations to ensure compliance and transparency in future programs. The County appreciates the constructive feedback and will continue to refine its processes to better serve its citizens.

View Audit 337659 Questioned Costs: $1

Finding 519000 (2022-002)

Significant Deficiency 2022

The Health Care Authority of the City of Huntsville

AL

Questioned Costs Reporting Internal Control / Segregation of Duties § 200.303 § 200.512

The Authority strives always to meet all regulatory deadlines. This particular deadline for the Single Audit was complicated by the unprecedented nature of the COVID-19 pandemic (which, for many organizations such as ours, triggered a Single Audit requirement for the first time, and overwhelmed the ...

The Authority strives always to meet all regulatory deadlines. This particular deadline for the Single Audit was complicated by the unprecedented nature of the COVID-19 pandemic (which, for many organizations such as ours, triggered a Single Audit requirement for the first time, and overwhelmed the audit profession with a surge of new Single Audits to conduct that did not exist previously). In the Authority’s case, the situation was further complicated by the fact that we were changing external audit firms moving into this particular reporting period. By the time the incumbent audit firm had issued its Single Audit report for Fiscal 2021, and the successor audit firm could therefore begin the Fiscal 2022 Single Audit, it was already beyond the reporting deadline of March 31, 2023. The Authority will have the same finding for the Fiscal 2023 Single Audit, for the same reason. We are hoping to be able to work successfully with the successor audit firm in order to file our Single Audit for Fiscal 2024 timely on or before March 31, 2025 and also have timely filings thereafter.

View Audit 337494

Finding 518977 (2022-003)

Significant Deficiency 2022

House of Hope Community Development Corporation

RI

Questioned Costs Reporting Internal Control / Segregation of Duties § 200.303 § 200.334

FINDING 2022-003: Significant Deficiency in Internal Control Over Financial Documentation Recommendation: Implement enhanced procedures for the systematic maintenance and retrieval of all financial records related to expenditures, including staff training on these protocols. Action Taken: Management...

FINDING 2022-003: Significant Deficiency in Internal Control Over Financial Documentation Recommendation: Implement enhanced procedures for the systematic maintenance and retrieval of all financial records related to expenditures, including staff training on these protocols. Action Taken: Management agrees with the auditor’s finding and recommendation. The newly appointed Deputy Director of Finance will oversee the implementation of these enhanced procedures.

View Audit 337426

Finding 518846 (2024-005)

Significant Deficiency 2022

Somali Community Link INC

OH

Questioned Costs Reporting § 200.302

Management acknowledges the issue and will establish and document reconciliation procedures to ensure reports are consistent with the general ledger and trial balance for all future Federal programs. This includes periodic review and approval by management.

View Audit 337223

Finding 518845 (2024-004)

Material Weakness 2022

Somali Community Link INC

OH

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.303 § 200.308 § 200.344

Management agrees with the findings and has already initiated corrective actions. Moving forward, budget-to-actual comparisons will be prepared monthly, and any discrepancies will be addressed promptly. The organization will work closely with the cognizant agency to arrange for the return of any uno...

Management agrees with the findings and has already initiated corrective actions. Moving forward, budget-to-actual comparisons will be prepared monthly, and any discrepancies will be addressed promptly. The organization will work closely with the cognizant agency to arrange for the return of any unobligated funds or, if applicable, seek authorization to retain the funds for use in other similar programs. This process will ensure proper financial management and compliance.

View Audit 337223 Questioned Costs: $1

Finding 518844 (2024-003)

Significant Deficiency 2022

Somali Community Link INC

OH

Questioned Costs Reporting Program Income § 200.328

Management acknowledges the need to address and enhance this finding. We are committed to implementing new procedures for recording and tracking program income, including documenting its source, amount, and application. These procedures will be put in place within three months, with oversight provid...

Management acknowledges the need to address and enhance this finding. We are committed to implementing new procedures for recording and tracking program income, including documenting its source, amount, and application. These procedures will be put in place within three months, with oversight provided by senior management to ensure proper compliance and effective implementation.

View Audit 337223

Finding 518843 (2024-002)

Material Weakness 2022

Somali Community Link INC

OH

Questioned Costs Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

The organization has already taken steps and will continue to take immediate action to establish a formal risk management framework. This will include conducting a comprehensive fraud risk assessment and integrating fraud detection and prevention processes into the organization’s internal controls. ...

The organization has already taken steps and will continue to take immediate action to establish a formal risk management framework. This will include conducting a comprehensive fraud risk assessment and integrating fraud detection and prevention processes into the organization’s internal controls. A formal risk management policy will be developed and adopted within three months, with regular reviews scheduled thereafter to ensure its continued effectiveness and alignment with industry best practices.

View Audit 337223

Finding 518842 (2024-001)

Significant Deficiency 2022

Somali Community Link INC

OH

Allowable Costs / Cost Principles Questioned Costs § 200.302

The organization has established financial policies and procedures. However, we recognize that these policies do not fully address all areas specific to federal grant requirements. As a relatively new organization, we understand the importance of enhancing these frameworks to ensure full compliance ...

The organization has established financial policies and procedures. However, we recognize that these policies do not fully address all areas specific to federal grant requirements. As a relatively new organization, we understand the importance of enhancing these frameworks to ensure full compliance with federal guidelines and properly manage federal funds. We are committed to addressing this gap and will take immediate action to develop and implement comprehensive policies and procedures that fully comply with all applicable federal grant requirements. We anticipate that this process will be completed within three months, with oversight from senior management to ensure its thoroughness and effectiveness. In addition, key financial processes, including disbursements, payroll, and grants management, will be updated and aligned with these new policies to ensure sound fiscal management and maintain ongoing compliance with federal standards

View Audit 337223

Finding 518469 (2022-005)

Significant Deficiency 2022

Montgomery Area Coalition for the Homeless, Inc.

AL

Significant Deficiency Internal Control / Segregation of Duties Questioned Costs

Corrective Action by MACH: The Mid-Alabama Coalition for the Homeless agrees with this finding. The FY2022 single program audit will be submitted to the Federal Audit Clearinghouse (FAC} by MACH's CPA firm as soon as completed and released by the audit firm. The audit firm will begin the FY2023 sing...

Corrective Action by MACH: The Mid-Alabama Coalition for the Homeless agrees with this finding. The FY2022 single program audit will be submitted to the Federal Audit Clearinghouse (FAC} by MACH's CPA firm as soon as completed and released by the audit firm. The audit firm will begin the FY2023 single program audit shortly after the conclusion of the FY22 audit, with submission to the FAC as soon as completed. MACH will work with the audit firm to assure that all subsequent audits are completed timely.

View Audit 336928

Finding 518468 (2022-004)

Material Weakness 2022

Montgomery Area Coalition for the Homeless, Inc.

AL

Cash Management Material Weakness Matching / Level of Effort / Earmarking § 200.61

Corrective Action by MACH: The Mid-Alabama Coalition for the Homeless agrees with this finding. Since the close of the contract year, MACH's Executive Director, accountant, and CPA firm have established a system for coding, submitting, reconciling, and requesting reimbursement from grant funders. Cu...

Corrective Action by MACH: The Mid-Alabama Coalition for the Homeless agrees with this finding. Since the close of the contract year, MACH's Executive Director, accountant, and CPA firm have established a system for coding, submitting, reconciling, and requesting reimbursement from grant funders. Currently, all grant documentation is assembled as transactions occur, and reimbursement requests are submitted to every grant source each month.

View Audit 336928

Finding 518399 (2022-001)

Material Weakness 2022

Dodge County Board of Education

GA

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.403 § 200.415

FA 2022-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Procurement and Suspension and Debarment Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Dep...

FA 2022-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Procurement and Suspension and Debarment Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund Federal Award Number: S425D210012 (Year: 2021) Questioned Costs: $189,893 Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over expenditures as it relates to the Elementary and Secondary School Emergency Relief Fund program. Corrective Action Plans: Management has implemented internal controls procedures to ensure transactions are properly processed and reported. Additional procedures have been established to review transaction to make they align with the approved budget. Estimated Completion Date: June 30, 2024 Contact Person: Georgette Evans Telephone: 478-374-3783 Email: gevans@dodge.k12.ga.us

View Audit 336767 Questioned Costs: $1

Finding 518330 (2022-003)

Material Weakness 2022

Theatre Under the Stars

TX

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Finding #2022-003 – Material Weakness. Applicable federal program: All federal programs. Condition and context: Same as finding #2022-002. Recommendation: Same as finding #2022-002. Planned corrective action: See finding #2022-002. Responsible officer: Hillary Hart, Executive Director. Est...

Finding #2022-003 – Material Weakness. Applicable federal program: All federal programs. Condition and context: Same as finding #2022-002. Recommendation: Same as finding #2022-002. Planned corrective action: See finding #2022-002. Responsible officer: Hillary Hart, Executive Director. Estimated completion date: December 31, 2024.

View Audit 336687

Finding 518137 (2022-001)

Material Weakness 2022

Nebraska Children's Home Society

NE

Subrecipient Monitoring Questioned Costs Reporting

For Fiscal Year 2023 there was limited time available for any changes to be made or procedures to be put in place as there was a significant staff change over within Finance. The new Finance Director has since implemented a new financial software with proper coding available to track all funding. Th...

For Fiscal Year 2023 there was limited time available for any changes to be made or procedures to be put in place as there was a significant staff change over within Finance. The new Finance Director has since implemented a new financial software with proper coding available to track all funding. There is a new contract and grants management procedure to be managed by the Finance Director and the Contracts and Grants Manager, for proper initial review with quarterly review at a minimum for tracking. All billing and revenue are reviewed monthly with appropriate parties as well. This was fully implemented as of July 1, 2023, the start of FY24.

View Audit 336455

Corrective Action Plans

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