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Corrective Action Plans

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Finding 409745 (2022-003)
Significant Deficiency 2022
Arrive Ministries
MN
Questioned Costs Reporting Internal Control / Segregation of Duties
Finding 2022-003 - Documentation of Internal Control to Support Federal Program Financial Report Approvals.Recommendation: The Organization implement a process to maintain documentation of the Executive Director?s approval for all reports for federal awards.Corrective Action: We have already impleme...
Finding 2022-003 - Documentation of Internal Control to Support Federal Program Financial Report Approvals.Recommendation: The Organization implement a process to maintain documentation of the Executive Director?s approval for all reports for federal awards.Corrective Action: We have already implemented a process to email initial report to Executive Director, have them review and respond with an email for final approval prior to submitting to the funder.Corrective Action owner: Jennifer Haskett, Senior AccountantCompletion Date: 11/01/2022
View Audit 311939
Finding 409742 (2022-002)
Significant Deficiency 2022
Arrive Ministries
MN
Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties
Finding 2022-002 - Documentation of Internal Control to Support Approvals of Payroll Charged to Federal Program.Recommendation: The Organization implement a process to maintain documentation of the Executive Director?s approval for all pay periods.Corrective Action: We have already implemented a pro...
Finding 2022-002 - Documentation of Internal Control to Support Approvals of Payroll Charged to Federal Program.Recommendation: The Organization implement a process to maintain documentation of the Executive Director?s approval for all pay periods.Corrective Action: We have already implemented a process for retaining the emails approving payroll period time cards by the Director and Executive Director.Corrective Action owner: Jennifer Haskett, Senior AccountantCompletion Date: 11/1/2022
View Audit 311939
Finding 409739 (2022-001)
Material Weakness 2022
Arrive Ministries
MN
Questioned Costs Allowable Costs / Cost Principles Reporting
Finding 2022-001 - Time and Effort ReportingRecommendation: The Organization implement a process to track employee?s time and effort worked on federal programs.Corrective Action: We will implement a process for employees to certify their time charged to federal programs on a monthly basis. We will t...
Finding 2022-001 - Time and Effort ReportingRecommendation: The Organization implement a process to track employee?s time and effort worked on federal programs.Corrective Action: We will implement a process for employees to certify their time charged to federal programs on a monthly basis. We will then adjust the financials as needed.Corrective Action owner: Jennifer Haskett, Senior AccountantCompletion Date: 12/1/2022
View Audit 311939 Questioned Costs: $1
Finding 409733 (2022-001)
Significant Deficiency 2022
The Healthcare Connection INC
OH
Questioned Costs Subrecipient Monitoring HUD Housing Programs
The Healthcare Connection, Inc CORRECTIVE ACTION PLANFor the Year Ended December 31, 2022Finding 2022-001Federal program and specific federal awardU.S. Department of Health and Human Services (HHS)93.224/93.527 Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Car...
The Healthcare Connection, Inc CORRECTIVE ACTION PLANFor the Year Ended December 31, 2022Finding 2022-001Federal program and specific federal awardU.S. Department of Health and Human Services (HHS)93.224/93.527 Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center Program)Specific requirementHealth centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay.ConditionDuring a sample of 25 patient visit encounters, we noted that 1 patient visit from March 2022 did not have the applicable sliding fee application on file and the patient charge was adjusted down to zero.CauseThis was due to an error made by manual entry to adjust the sliding fee without sufficient support on file of the patient?s sliding fee application.Effect or potential effectA patient received a sliding fee to write off the entire charge of $210 that was not supported by a sliding fee application. Subsequent to the discovery of the error during the audit, in April 2023, the Organization was able to obtain an application from the patient to support a sliding fee to a charge of $70.Questioned costsNoneRepeat findingNoRecommendationWe recommend that management continue to work and educate front desk and intake staff on the importance of the required patient application documentation so that the required support is obtained before applying a sliding fee discount to a patient account. In addition, we suggest that management establish a policy to perform regular monitoring of a sample of patient file sliding fee applications, to ensure the sliding fee is applied correctly.Corrective ActionWe agreed with the above comment and will implement a system of monitoring sliding fee applications and continue to educate the front desk and intake staff to ensure all documentation is obtained.
View Audit 311938
Robert Morris University
PA
Student Financial Aid Questioned Costs Matching / Level of Effort / Earmarking
February 24, 2023Audit Response to Federal Grants Audit (A-133) - Enrollment reporting to National Student ClearinghouseAnalysis:Robert Morris University (University) attributes the delay in reporting changes of student enrollment status (withdrawal, graduated, less than half time, etc.) to the Nati...
February 24, 2023Audit Response to Federal Grants Audit (A-133) - Enrollment reporting to National Student ClearinghouseAnalysis:Robert Morris University (University) attributes the delay in reporting changes of student enrollment status (withdrawal, graduated, less than half time, etc.) to the National Student Clearinghouse (NSC) to the implementation of a new student information system conversation (Banner) that occurred in June 2021. Banner replaced a legacy system that the University had used for decades that had reliable processes and reporting controls that accurately reported information to the NSC.The identified exceptions can be categorized into the following two general categories:Off-Cycle GraduationOne group of exceptions related to students who had degrees conferred but the University had not updated their status to "graduated" in the NSC. Upon further review, the University determined extenuating circumstances (i.e. completion of all paperwork, and assignments, incomplete grade(s), etc.) existed for these students' and their graduation date fell outside of the normal graduation date of their peers for that semester cohort. Because of the off-cycle graduation timing, these students were not captured in the new graduate reporting process in Banner at the end of each semester. This resulted in the students not being reported to the NSC.Fall 2021 Status ChangesThe final group of exceptions occurred due to the University's new student information system conversion (Banner) in June 2021. Due to the specific requirements and customized nature of the clearinghouse file, the University's first electronic submission for Fall 2021 was delayed as errors/issues were being resolved in conjunction with the NSC. During that time frame, there were students who had fully withdrawn and/or status changes from the University, but due to the delay and file parameters, they were inadvertently excluded in the first submission and/or their status change wasn't reported in a timely manner.
View Audit 311937
Robert Morris University
PA
Student Financial Aid Questioned Costs
February 24, 2023Audit Response to Federal Grants Audit (A-133) - Return of Title IV Aid (R2T4)Analysis:Robert Morris University ("University") attributes the isolated delay in refunding Title IV funds in excess of the required 45-day window following the student's complete withdrawal to a student i...
February 24, 2023Audit Response to Federal Grants Audit (A-133) - Return of Title IV Aid (R2T4)Analysis:Robert Morris University ("University") attributes the isolated delay in refunding Title IV funds in excess of the required 45-day window following the student's complete withdrawal to a student information system conversation (Banner) that occurred in June 2021. Banner replaced a legacy system that the University had used for decades. Specifically, customized reporting in Banner was needed in order to provide additional visibility so that the University could timely fulfill R2T4 obligations. As a result of the above, the University enacted several measures and safeguards to strengthen controls around the R2T4 process.Response:The University implemented the following control measures:-In September 2022, the University Registrar performed a retraining for all individuals who process complete withdrawals from the University. This training included a detailed walk through of all the steps required to timely and accurately process a complete withdrawal in Banner.-The University's IT department developed custom reports showing complete withdrawals from the University, which are generated and distributed to the Financial Aid office who reviews this report on a weekly basis to make sure withdrawals are completed timely and the appropriate financial aid adjustments are reflected on the students account.-On a monthly basis, the Senior Director of Student Financial Services now performs a double check review of a withdrawal report and alerts Financial Aid of any additional withdrawals that may meet the criteria for a return.Conclusion:The University deems that the control measures in place listed above are adequate and will prevent any future instances of untimely R2T4 funds. Overall, although the refunds were issued in excess of 45 days, the Department of Education did receive all required refunds in full and no amounts were outstanding at the time of the audit procedures.Keith A. RoeperChief Accounting Office and Controller and Assistant Treasurer
View Audit 311937
City of Jersey City
NJ
Reporting Questioned Costs
Corrective Action: The CFO will work with Departmental Fiscal Officers and grant management staff to ensure that SF-425 reports are filed on a timely basis and archived so as to be readily accessible. Implementation Date: Ongoing
Corrective Action: The CFO will work with Departmental Fiscal Officers and grant management staff to ensure that SF-425 reports are filed on a timely basis and archived so as to be readily accessible. Implementation Date: Ongoing
View Audit 311634
City of Jersey City
NJ
Reporting Questioned Costs HUD Housing Programs
Corrective Action: The CFO will work with Departmental Fiscal Officers and grant management staff to ensure that Davis-Bacon reports are filed on a timely basis. Implementation Date: Ongoing
Corrective Action: The CFO will work with Departmental Fiscal Officers and grant management staff to ensure that Davis-Bacon reports are filed on a timely basis. Implementation Date: Ongoing
View Audit 311634
Finding 404700 (2022-001)
Material Weakness 2022
Iliamna Village Council
AK
Questioned Costs § 200.512
MANAGEMENT HAS STARTED WORK ON THEIR 2023 AUDIT PREPARATION AND WILL ENSURE THAT IT IS SUBMITTED TIMELY.
MANAGEMENT HAS STARTED WORK ON THEIR 2023 AUDIT PREPARATION AND WILL ENSURE THAT IT IS SUBMITTED TIMELY.
View Audit 311074
Finding 404506 (2022-005)
Material Weakness 2022
The Salvation Army Northwest Division
WA
Subrecipient Monitoring Questioned Costs Eligibility
The Division will contact each unit distributing TEFAP assistance and communicate the requirement to retain documentation regarding the determination of client eligibility. Anticipated Completion Date: June 2024. Responsible Contact Person: Julie Luft, Northwest Division Social Services Director
The Division will contact each unit distributing TEFAP assistance and communicate the requirement to retain documentation regarding the determination of client eligibility. Anticipated Completion Date: June 2024. Responsible Contact Person: Julie Luft, Northwest Division Social Services Director
View Audit 311047
Finding 404481 (2022-004)
Significant Deficiency 2022
The Salvation Army Northwest Division
WA
Allowable Costs / Cost Principles Questioned Costs
The Division will review allocation and expense workbooks to ensure there are no clerical errors. Anticipated Completion Date: October 2024. Responsible Contact Person: Yohannes Gedlu, Northwest Division Controller & Dani Olsen, Payroll Director
The Division will review allocation and expense workbooks to ensure there are no clerical errors. Anticipated Completion Date: October 2024. Responsible Contact Person: Yohannes Gedlu, Northwest Division Controller & Dani Olsen, Payroll Director
View Audit 311047 Questioned Costs: $1
Finding 404475 (2022-003)
Material Weakness 2022
The Salvation Army Northwest Division
WA
Equipment & Real Property Management Internal Control / Segregation of Duties Questioned Costs
The Division will communicate the importance of timely reporting to granting agencies to program directors and corps officers. Program directors and corps officers will be responsible for identifying agency and grant‐specific reporting requirements and documenting the review and submission of report...
The Division will communicate the importance of timely reporting to granting agencies to program directors and corps officers. Program directors and corps officers will be responsible for identifying agency and grant‐specific reporting requirements and documenting the review and submission of reports to granting agencies. Anticipated Completion Date: October 2024. Responsible Contact Person: Yohannes Gedlu, Northwest Division Controller
View Audit 311047
Finding 404444 (2022-002)
Significant Deficiency 2022
The Salvation Army Northwest Division
WA
Questioned Costs Reporting Significant Deficiency
The Division will enhance controls such that there is segregation of duties between the report preparer and reviewer. Reports will be reviewed prior to submission and the review and submission of reports to granting agencies will be documented. Anticipated Completion Date: October 2024. Responsib...
The Division will enhance controls such that there is segregation of duties between the report preparer and reviewer. Reports will be reviewed prior to submission and the review and submission of reports to granting agencies will be documented. Anticipated Completion Date: October 2024. Responsible Contact Person: Yohannes Gedlu, Northwest Division Controller & Julie Luft, Northwest Division Social Services Director
View Audit 311047
Finding 403909 (2022-009)
Material Weakness 2022
Aerospace MacHinists Joint Training Committee
WA
Questioned Costs Material Weakness Reporting
Corrective Action Plan: AJAC financial reporting policies and procedures will be updated to ensure timely filing of ETA-9130 forms. Monthly reconciliations will help to ensure that all financial information is available for ETA-9130 reports ahead of submission deadlines. Anticipated Completion Date:...
Corrective Action Plan: AJAC financial reporting policies and procedures will be updated to ensure timely filing of ETA-9130 forms. Monthly reconciliations will help to ensure that all financial information is available for ETA-9130 reports ahead of submission deadlines. Anticipated Completion Date: Completed
View Audit 310790
Finding 403908 (2022-008)
Material Weakness 2022
Aerospace MacHinists Joint Training Committee
WA
Questioned Costs Material Weakness Reporting § 200.507
Corrective Action Plan: All federal grant revenue will be tracked with specific coding to ensure that Directors are aware of revenue accruals as they relate to minimum thresholds for single audits, and in a manner that allows for timely filing of future audits to the single audit clearing house. Mon...
Corrective Action Plan: All federal grant revenue will be tracked with specific coding to ensure that Directors are aware of revenue accruals as they relate to minimum thresholds for single audits, and in a manner that allows for timely filing of future audits to the single audit clearing house. Monthly reconciliations will ensure that general ledger entries and account balances are updated and corrected on a timely basis, and in a manner that will allow for enough time for the audit to be completed by the deadline. Anticipated Completion Date: Completed
View Audit 310790
Finding 403907 (2022-007)
Material Weakness 2022
Aerospace MacHinists Joint Training Committee
WA
Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.302
Corrective Action Plan: After monthly reconciliations, financial statements will be delivered to AJAC Directors monthly. AJAC Accounting Department will hold monthly close calls to collaborate with AJAC Directors to ensure accuracy of financials. Anticipated Completion Date: Completed
Corrective Action Plan: After monthly reconciliations, financial statements will be delivered to AJAC Directors monthly. AJAC Accounting Department will hold monthly close calls to collaborate with AJAC Directors to ensure accuracy of financials. Anticipated Completion Date: Completed
View Audit 310790
Finding 403889 (2022-003)
Significant Deficiency 2022
West Alabama Aids Outreach, Inc.
AL
Questioned Costs Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303
Since completion of the fiscal year ended 9/30/2022, the Organization has added a Director of Grants Management, two grant billers and a purchasing manager to help ensure policies and procedures are being followed. In response to this finding, the CFO and Director of Grants Management have institute...
Since completion of the fiscal year ended 9/30/2022, the Organization has added a Director of Grants Management, two grant billers and a purchasing manager to help ensure policies and procedures are being followed. In response to this finding, the CFO and Director of Grants Management have instituted multiple internal processes to confirm administrative fees do not exceed 10% of grant award. The grant biller will prepare a monthly reimbursement schedule in Excel which shows the budgeted amount for each category. The Director of Grants Management reviews and approves this schedule to ensure it meets the grant requirements. Each individual monthly reimbursement form is approved and signed by the Director of Grants Management to confirm accuracy. Then the reimbursement form submitted is entered in a master spreadsheet "Projects by Line Item" which shows original budget, monthly amounts billed for each budget line item, and remaining balance for each item. This is reviewed each month to ensure no amounts, including the administrative costs exceed approved amounts. Anticipated Completion Date: 9/30/2023 Responsible Contact Person: Chris White, CFO
View Audit 310763 Questioned Costs: $1
Finding 403888 (2022-002)
Significant Deficiency 2022
West Alabama Aids Outreach, Inc.
AL
Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303
The CFO has instituted multiple approvals for each reimbursement or purchase request. Since completion of the fiscal year ended 9/30/2022, the Organization has added a Director of Grants Management, two grant billers, and a purchasing manager to help ensure policies and procedures are being followe...
The CFO has instituted multiple approvals for each reimbursement or purchase request. Since completion of the fiscal year ended 9/30/2022, the Organization has added a Director of Grants Management, two grant billers, and a purchasing manager to help ensure policies and procedures are being followed. For reimbursements, employees will complete an Employee Reimbursement Form which is signed by the employee and employee's direct supervisor. For purchase requests, employees will complete a Purchase Order form which is signed by the employee and the employee's supervisor. The signed form is sent to the finance department where it is entered in Bill.com for payment by accounts payable personnel. The Director of Finance approves the reimbursement or purchase on Bill.com, then the CFO approves and releases for payment. The approved Reimbursement Form or Purchase Order is sent to the Director of Grants Management, and if eligible, attached to the monthly billing to grantor for reimbursement. Anticipated Completion Date: 9/30/2023 Responsible Contact Person: Chris White, CFO
View Audit 310763
Finding 403822 (2022-007)
Significant Deficiency 2022
Jft Recovery and Veterans Support Services
PA
Procurement, Suspension & Debarment Questioned Costs Allowable Costs / Cost Principles § 200.302 § 200.303 § 200.318 § 200.319 § 200.430
Policies will be placed and adopted by the agency that meet the UG code. These policies will be placed in the fiscal manual. The fiscal manual will be created by using federal guidelines and by using the DDAP fiscal manual as guidance.
Policies will be placed and adopted by the agency that meet the UG code. These policies will be placed in the fiscal manual. The fiscal manual will be created by using federal guidelines and by using the DDAP fiscal manual as guidance.
View Audit 310733
Finding 403820 (2022-005)
Material Weakness 2022
Jft Recovery and Veterans Support Services
PA
Questioned Costs Allowable Costs / Cost Principles Cash Management
As of 2023 we will be adding the following policy to the fiscal manual and to the operations manual to read as follows: All monthly program reports shall be completed by the coordinator and sent to the Deputy Director for approval, once approved they will be sent to the Fiscal Coordinator. The Fis...
As of 2023 we will be adding the following policy to the fiscal manual and to the operations manual to read as follows: All monthly program reports shall be completed by the coordinator and sent to the Deputy Director for approval, once approved they will be sent to the Fiscal Coordinator. The Fiscal Coordinator will then complete the billing amount and fiscal narrative then the report will be reviewed by the Deputy Director. Once approved the report will be presented to the Executive Director for final review, approval and signature and date placed on each report before it is sent to the funder. All program coordinators will complete a JFT outcomes report that is placed in an electronic reporting system and these reports will be reviewed quarterly by the Deputy Director. The Deputy Director does data analysis and these reports are placed in narrative form by the Deputy Director quarterly and the year-end report. These are shared with the funders according to the reporting requirements in the grant. All reports must be to funders by the 15th of the following month, unless otherwise stated in funder contract. The following policy will also be added to the fiscal manual: All budget modifications will be written up on the budget modification form and sent to the funder electronically once approved the form will be notated and include the funders signature, written on the form verbal communication from the funder, or a copy of the email with funder approval.
View Audit 310733
Finding 403819 (2022-004)
Material Weakness 2022
Jft Recovery and Veterans Support Services
PA
Questioned Costs Allowable Costs / Cost Principles
In 2022 and 2023 we have developed a system that better separated and tracked expenditures by grant. We have made the following adjustments already: 1. We have purchased software and a device to read and store receipts into the computer system. We have purchased and are using QuickBooks. All ex...
In 2022 and 2023 we have developed a system that better separated and tracked expenditures by grant. We have made the following adjustments already: 1. We have purchased software and a device to read and store receipts into the computer system. We have purchased and are using QuickBooks. All expenditures and incoming funds will be placed into the QuickBooks system. Any expenditure is then filed by grant, by month with a copy of the invoice, bill, etc. documentation as well as the receipt that corresponds. All files will be kept in a locked cabinet in the fiscal office. At the end of each year all past year records will be stored and kept for 7 years. 2. We have hired a person to do data entry and bookkeeping part time. 3. We have devoted our Administrative Coordinator to take responsibility for HR and fiscal matters to serve as a check and balance system as well as to take the larger load from the Fiscal Coordinator since we have grown. 4. The final thing JFT has done is to hire an accounting firm called Gift CPAs to come in as a final check and balance. Gift CPAs has been able to give our agency training on fiscal matters that were not clear, they have been able to expand our knowledge and use of the QuickBooks System and helped us set up proper checks and balances to better ensure that everything that is charged to each grant is well documented.
View Audit 310733 Questioned Costs: $1
Finding 403818 (2022-003)
Material Weakness 2022
Jft Recovery and Veterans Support Services
PA
Questioned Costs Allowable Costs / Cost Principles § 200.430
JFT does have all the board minutes on file. However, because we were a small agency, salary rates were not often changed. Additionally, all salary rates and changes were always driven by the ability to obtain the funding needed. Since we were small and there was not always a lot to discuss with ...
JFT does have all the board minutes on file. However, because we were a small agency, salary rates were not often changed. Additionally, all salary rates and changes were always driven by the ability to obtain the funding needed. Since we were small and there was not always a lot to discuss with the board our board only met twice a year. Therefore, all salary was discussed with the board president, then taken to the board. Unfortunately, there is no formal documentation at this time. As of 2023 our board now meets quarterly. Therefore, the following policy will be included in the fiscal manual: the JFT board of directors will hold a public meeting quarterly. All matters of pay rates and salaries will be approved at the start of each grant cycle. State and county grants will be discussed prior to the July 1 start dates, all federal grants will be discussed prior to October 1. Any changes in salary must be approved by the board and documented in official board minutes. All board minutes will be placed in a locked file in the Fiscal Coordinator’s office.
View Audit 310733
Finding 403817 (2022-002)
Material Weakness 2022
Jft Recovery and Veterans Support Services
PA
Questioned Costs Allowable Costs / Cost Principles § 200.430
Starting in 2023 all employees of the Organization will complete formal time sheets. These sheets will be signed by the Administrative Coordinator and by the Fiscal Coordinator and then entered into the system each pay period to rectify this finding.
Starting in 2023 all employees of the Organization will complete formal time sheets. These sheets will be signed by the Administrative Coordinator and by the Fiscal Coordinator and then entered into the system each pay period to rectify this finding.
View Audit 310733 Questioned Costs: $1
Finding 403816 (2022-001)
Material Weakness 2022
Jft Recovery and Veterans Support Services
PA
Internal Control / Segregation of Duties Questioned Costs Material Weakness
In 2022 we were a small agency with minimal experience with federal and state grants. All our funding prior to this was private donations, fundraising and county funding. We grew very quickly in a short period of time. At the beginning of 2020, when we first received federal funding, we had six emp...
In 2022 we were a small agency with minimal experience with federal and state grants. All our funding prior to this was private donations, fundraising and county funding. We grew very quickly in a short period of time. At the beginning of 2020, when we first received federal funding, we had six employees and have since grown to over 40 employees. Since the time of the audit, we have gained knowledge and have already made changes to better meet the needs of our grant providers and our organization. With the segregation of duties, we started out with just one person handling the billing and the Executive Director overseeing all fiscal aspects. In the beginning of 2023, we have added two staff that work directly with the fiscal department to help with the segregation of duties and to have improved checks and balances in this department.
View Audit 310733
Nacogdoches Memorial Hospital District
TX
Allowable Costs / Cost Principles Questioned Costs Special Tests & Provisions
We are in receipt of the findings required to be reported by the single audit for COVID19 Claims Reimbursement for the Uninsured Program and the COVID19 Coverage Assistance Fund specifically, regarding discrepancies in funding received under a different employer identifier number. Management does no...
We are in receipt of the findings required to be reported by the single audit for COVID19 Claims Reimbursement for the Uninsured Program and the COVID19 Coverage Assistance Fund specifically, regarding discrepancies in funding received under a different employer identifier number. Management does not dispute the finding. The District is in it’s second year after going through an asset purchase transaction, whereby the physical assets were retained by the District, but the operations of the hospital were sold. As the District moves forward, we will work to develop policies and procedures over financial reporting to ensure they only request reimbursement for federal grants for programs with the correct employer identification number. Lynn Lindsey, Chief Financial Officer, will be responsible to ensure that this is accomplished and will begin to implement new procedures. The corrective action plan will be implemented by September 30, 2024.
View Audit 310696
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