Corrective Action Plans

Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size.

View Audit 341370

Finding 522103 (2023-005)

Material Weakness 2023

Kinston Community Health Center, Inc.

AL

Reporting

In Finding 2023-005, it was reported that the Organization did not comply with federal award requirements to submit an annual Federal Data Collection Form to the Federal Audit Clearinghouse, including audited financial statements, no later than nine months after the fiscal year ended November 30, 20...

In Finding 2023-005, it was reported that the Organization did not comply with federal award requirements to submit an annual Federal Data Collection Form to the Federal Audit Clearinghouse, including audited financial statements, no later than nine months after the fiscal year ended November 30, 2022. Management recognizes the importance of complying with federal grant requirement guidelines. In response to Finding 2023-005, Management concurs with the finding. In response to this a new audit firm was hired, and it is expected that data collection forms will be completed and submitted timely after the November 30, 2023 audit.

View Audit 341310

Finding 522100 (2023-004)

Material Weakness 2023

Kinston Community Health Center, Inc.

AL

Reporting

In Finding 2023-004, it was reported that the Uniform Data System report submitted to DHHS for the year ended December 31, 2023, and 2022, contained incorrect data for federal grants. Federal grants were overstated on Table 9D of the UDS report by approximately $1,590,784 and $1,747,674, respectivel...

In Finding 2023-004, it was reported that the Uniform Data System report submitted to DHHS for the year ended December 31, 2023, and 2022, contained incorrect data for federal grants. Federal grants were overstated on Table 9D of the UDS report by approximately $1,590,784 and $1,747,674, respectively. Management recognizes the importance of complying with federal reporting guidelines. In response to Finding 2023-004, efforts will be made to ensure that federal grants are correctly reported on the UDS report.

View Audit 341310

Finding 521708 (2023-003)

Material Weakness 2023

Beth Israel Lahey Health, Inc.

MA

Reporting Internal Control / Segregation of Duties

Management Response and Corrective Action Plan Finding 2023-003 – Reporting Program: Provider Relief Fund and American Rescue Plan Federal Agency: Health Resources and Services Administration Assistance Listing Number: 93.498 Responsible Individual: Katherine Bacher, VP of System Services Account...

Management Response and Corrective Action Plan Finding 2023-003 – Reporting Program: Provider Relief Fund and American Rescue Plan Federal Agency: Health Resources and Services Administration Assistance Listing Number: 93.498 Responsible Individual: Katherine Bacher, VP of System Services Accounting and Finance Contact Information: Katherine.bacher@bilh.org; 617-278-7059 Management agrees with the recommendation and moving forward, BILH will centralize the compilation of the SEFA, along with conducting periodic reconciliations of the schedule, the general ledger and supporting documentation. Management will also utilize its new accounting system to track all federal funding by requiring the appropriate worktags be utilized when recording such transactions, allowing for accurate reporting. Lastly, management will require at least two reviews of the SEFA. Corrective Action Plan: • Management will have training sessions with the Finance staff on the use of worktags when recording federal funding. • A new position has been created, Director of Technical Accounting, who will be responsible for compiling the SEFA and ensuring accuracy of the filing, with sign off by department managers who are submitting information • Director of Research Finance will review initial draft of SEFA for completeness and accuracy • VP of Revenue and Reimbursement will review the initial draft of SEFA for completeness and accuracy • VP of System Services Accounting and Finance will final review for completeness and accuracy Expected Completion Date: June 30, 2025 Status of Completion: In Process

View Audit 341213

Finding 521247 (2023-001)

Material Weakness 2023

The Island Water Association, Inc.

FL

Material Weakness Reporting Internal Control / Segregation of Duties

Management will continue to rely on the audit firm to draft the financial statements and the related notes to the financial statements, and will review, approve, and accept responsibility for the annual financial statements prior to their issuance. Management will continue to increase internal abili...

Management will continue to rely on the audit firm to draft the financial statements and the related notes to the financial statements, and will review, approve, and accept responsibility for the annual financial statements prior to their issuance. Management will continue to increase internal abilities and advancement in order to monimize reliance on audit firm for financial statements.

View Audit 341192

Finding 521243 (2023-003)

None 2023

Centers for New Horizons, Inc.

IL

Reporting

The Organization has taken steps to address this problem by hiring additional staff in the accounting department. Additionally, the accounting and operations departments are now separate and distinct departments. This allows for the appropriate individuals to have more time to concentrate on Alterna...

The Organization has taken steps to address this problem by hiring additional staff in the accounting department. Additionally, the accounting and operations departments are now separate and distinct departments. This allows for the appropriate individuals to have more time to concentrate on Alternatives finances and improve the timing and accuracy of the monthly and year-end financial close. The Organization experienced substantial growth of programmatic activities which required the department to focus on ongoing maintenance and tracking. The department expects to be able to take the results of these changes and properly close out the June 30, 2024 year end.

View Audit 341185

Finding 521127 (2023-003)

Material Weakness 2023

Lake County, Colorado

CO

Internal Control / Segregation of Duties Reporting

Problem: Lake County Government did not file quarterly or annual reports as required by Coronavirus State and Local Fiscal Recovery Funds as per Department of Treasury. Actions Steps: All Coronavirus State and Local Fiscal Recovery Funds must be managed going forward as per the standardized grant fu...

Problem: Lake County Government did not file quarterly or annual reports as required by Coronavirus State and Local Fiscal Recovery Funds as per Department of Treasury. Actions Steps: All Coronavirus State and Local Fiscal Recovery Funds must be managed going forward as per the standardized grant funding policy in both process and procedure. Status: Granted funds awarded to Lake County Government are managed and controlled via the BOCC voted and approved Lake County Grant Policy. Dates: July 2024 to present Goal: To accurately and reliably manage and report on all funds granted awarded to Lake County Government.

View Audit 341067

Finding 521112 (2023-008)

None 2023

Espanola Public School District

NM

Reporting § 200.512

Views of Responsible Officials and Planned Corrective Actions – The District is committed to enhancing its processes to ensure timely and efficient preparation for audit requests. To align with the standards set forth in the New Mexico Administrative Code Title 2, Chapter 2, Part 2, we will implemen...

Views of Responsible Officials and Planned Corrective Actions – The District is committed to enhancing its processes to ensure timely and efficient preparation for audit requests. To align with the standards set forth in the New Mexico Administrative Code Title 2, Chapter 2, Part 2, we will implement more robust internal procedures to improve audit readiness and ensure that all necessary documentation is readily available. These efforts will support compliance with deadlines and strengthen overall audit management across the District’s operations. Responsible Parties: Director of Finance and the District’s business office. Estimated Completion Date: December 30, 2024.

View Audit 341061

Finding 521048 (2023-001)

Significant Deficiency 2023

Meadows Mental Health Policy Institute for Texas

TX

Reporting Significant Deficiency Internal Control / Segregation of Duties

The Meadows Mental Health Policy Institute for Texas (the Institute) respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: 01/01/2023 – 12/31/2023 The findings from the Schedule of Findings and Questioned Costs identified in the December 05, 20...

The Meadows Mental Health Policy Institute for Texas (the Institute) respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: 01/01/2023 – 12/31/2023 The findings from the Schedule of Findings and Questioned Costs identified in the December 05, 2024, audit report are discussed below. Findings are numbered consistently with the numbers assigned in the schedule. Findings – Federal Awards Audit Significant Deficiency Federal Awards Program Audit Findings and Recommendations Finding 2023-001: Reporting – significant deficiency in internal control over compliance and compliance finding. All federal grants. Criteria: Grantees who are subject to single audit requirements are required to submit their Data Collection form to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditors’ report or 9 months after the audit period. Condition: The Institute’s Data Collection form was late for the years ended December 31, 2022, and 2023. Cause: Delays in completing the audits resulted in the Data Collection forms being submitted after 9 months from the end of the audit report. Effect: The Institute was not in compliance with single audit reporting requirements. Recommendation: Internal controls and processes should be implemented to ensure audits are completed in a timely manner to meet federal reporting deadlines. Institute Action Plan: • Hire new finance and accounting senior management [completed November 2024]. o Hired new CFO (October 2024; started January 02, 2025) o Hired new Controller (November 2024; starts February 17, 2025) Establish timeline for review and acceptance of 2024 audit [initiated December 2024]. o By May 01, 2025: Institute submits 2024 General Ledger and Trial Balance to auditor o May 01, 2025 – May 11, 2025: Auditor sends sample and other requests for information o May 12, 2025 – May 23, 2025: Audit fieldwork o Week of July 07, 2025: Auditor sends draft audit report to Institute management for review. o Week of July 21, 2025: Institute management reviews draft audit report and notes areas needing clarification and/or corrections. o By Week of August 11, 2025: Auditor provides a final revised audit report to Institute management. o Week of August 18, 2025: Institute management sends audit report to the Institute Board’s Audit and Finance Committee for review. o By week of September 1, 2025: The Audit and Finance Committee meets to review and accept final audit report on behalf of the Board. o By September 15, 2025: Data Collection Form is submitted to the Federal Audit Clearinghouse (i.e., well in advance of the September 30, 2025, submission due date for the Data Collection Form). o October 29, 2025: The Institute Board ratifies the Audit and Finance Committee’s acceptance of final audit report. • Q1-Q2 2025: Perform gap analysis evaluation of existing Accounting staff and address any gaps in coverage and provide access to and training on financial systems and historical data archives [initiated and ongoing]. Corrective Action Contact Person(s): Maryana Geller, Chief Financial and Administrative Officer Planned Completion Date for Corrective Action Plan: September 15, 2025

View Audit 340943

Finding 521010 (2023-003)

Material Weakness 2023

Pittsburgh Innovation District D/b/a Innovatepgh Partnership

PA

Subrecipient Monitoring Reporting

NEED FROM CLIENT…...

View Audit 340882

Finding 521009 (2023-004)

Material Weakness 2023

City of El Monte

CA

Reporting

New procedures have been established to ensure the separation of duties and responsibilities between the individuals who prepare grant reporting and the individuals who review the reports starting FY2024. The accounting manager gathers the data and prepares the grant reporting and then the Finance ...

New procedures have been established to ensure the separation of duties and responsibilities between the individuals who prepare grant reporting and the individuals who review the reports starting FY2024. The accounting manager gathers the data and prepares the grant reporting and then the Finance Director reviews and approves the reporting before it is submitted.

View Audit 340881

Finding 521006 (2023-001)

Material Weakness 2023

City of El Monte

CA

Reporting

The City hired an additional accountant on July 1, 2023, to oversee all of the Economic Development grants. This accountant is responsible for the review of all reporting and submission.

View Audit 340881

Finding 520959 (2023-002)

Material Weakness 2023

Hui No Ke Ola Pono, Inc.

HI

Reporting

During the fiscal year, funding sources or grantors, were not clearly defined by the grantors documents on the type of funding received by HNKOP. Due to the inability to define the funding source, these expenses were not included on the SEFA report. Since January 2023, all awards are verified with...

During the fiscal year, funding sources or grantors, were not clearly defined by the grantors documents on the type of funding received by HNKOP. Due to the inability to define the funding source, these expenses were not included on the SEFA report. Since January 2023, all awards are verified with the grantor if the funds are from a federal award, and has been noted on the SEFA report as such.

View Audit 340855

Finding 520958 (2023-001)

Material Weakness 2023

Hui No Ke Ola Pono, Inc.

HI

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Internal control over payroll and disbursements In January 2023 changes to any pay rates were submitted on a Personnel Action Form (PAF) by the Operations Manager. The PAF included the old pay rate and the new pay rate and was submitted to the Executive Director for review and approval. After app...

Internal control over payroll and disbursements In January 2023 changes to any pay rates were submitted on a Personnel Action Form (PAF) by the Operations Manager. The PAF included the old pay rate and the new pay rate and was submitted to the Executive Director for review and approval. After approval, the form was filed in the employees paper file, as well as uploaded to their electronic record on the ProService platform. In May 2024, we hired a Human Resources Specialist who is responsible for updating and maintaining all personnel files and processing of payroll records. In October 2023, we hired an Accounting Specialist (AS) who is responsible for the processing of all vendor disbursements. Prior to ordering items or services, a Purchase Requisiton (PR) is submitted by the program manager to the Executive Director or Programs Director for review and approval. Upon approval the PR is submitted to the Controller for expense and grant coding. PR is then submitted to the AS to assign a PR number and enter the expenses on the PR tracking log. When the PR has been assigned a PR number it is sent to the Operations Manager for purchasing. When the invoice is received the PR is matched to the invoice indicating proper approvals. If the purchase is over $5,000, a Procurement form is completed to solicit 3 bids and reviewed and approved by the Executive Director. If the purchase is over $20,000, the Procurement form is submitted to the Board of Directors for approval. All Procurement forms are attached to invoices for payment processing. Internal control over account balances During the fiscal year, it was noted that there were credit card entries that were duplicated, and have been corrected as of the date of this report. Due to miscommunication with the previous fiscal staff, payments made by credit card were entered as an invoice and as an adjusting journal entry.

View Audit 340855

Finding 520863 (2023-003)

None 2023

Northern Michigan Health Consortium

MI

Allowable Costs / Cost Principles Reporting § 200.512

It is the responsibility of the Finance Supervisor to ensure all contracts entered into includes language indicating if the funding is federal or state. If it is federal funding, the contract must include the federal assistance listing number, which will be reported on the year-end schedule of feder...

It is the responsibility of the Finance Supervisor to ensure all contracts entered into includes language indicating if the funding is federal or state. If it is federal funding, the contract must include the federal assistance listing number, which will be reported on the year-end schedule of federal awards. A single audit will be performed if the federal expenditures reach the maximum allowable per auditing standards. If a single audit is required, it will be completed and submitted to the appropriate grantors within nine months of the end of the fiscal year.

View Audit 340690

Finding 520847 (2023-005)

Material Weakness 2023

Municipality of Ceiba

PR

HUD Housing Programs Reporting

We concur with the finding. During the fiscal year 2024-2025, both reports for fiscal years 2021 and 2022 will be filed. Therefore, the conditions of the findings have been corrected.

View Audit 340664

Finding 520803 (2023-003)

Material Weakness 2023

County of Trinity

CA

Subrecipient Monitoring Reporting Program Income

Federal program title – Community Development Block Grant – CDBG – CFDA 14.228 Recommendation: CLA recommends the County develop procedures, such as reporting checklist to ensure that reporting requirements are tracked and met. Additionally, CLA recommends that the County perform cross training wi...

Federal program title – Community Development Block Grant – CDBG – CFDA 14.228 Recommendation: CLA recommends the County develop procedures, such as reporting checklist to ensure that reporting requirements are tracked and met. Additionally, CLA recommends that the County perform cross training with employees to ensure that knowledge is shared among the team members. Action taken in response to finding: The Grants department had two employees in FY 22/23. The Grant coordinator and assistant both terminated county employment in fiscal year 22/23 and left virtually no records. Information and materials, they did leave behind were stuffed in boxes and tracking in the electronic workbook was not fully completed. Admin staff trained the Grant employees but was unaware they were not following the process and procedures, and only saving information to their personal computer. Current admin staff requested the documents from prior staff members and they were received, though we are unsure if all were sent. Staff is doing their due diligence and working diligently to get back on track in monitoring activities, and train the newly hired staff. There is insufficient budget to hire the staff needed to fully monitor the CDBG efforts. Name(s) of the contact person(s) responsible for corrective action: Under direction of the County Administrative Officer, the Senior Financial Analyst Suzie Hawkins Planned completion date for correcting action plan: Undetermined at this time as the staff continues their current minimal CDBG efforts while still maintaining all other duties, and being short staffed. Existing CDBG workload is being closed out as fast as possible.

View Audit 340608

Finding 520779 (2023-003)

Significant Deficiency 2023

Progress House Inc.

CA

Reporting Allowable Costs / Cost Principles

Views of responsible officials and corrective action: We have adopted a SEFA worksheet to track federal award expenditures for each individual federal program to include the CFDA or other identifying number when the CFDA information is not available. Included in the SEFA worksheet, tracking of feder...

Views of responsible officials and corrective action: We have adopted a SEFA worksheet to track federal award expenditures for each individual federal program to include the CFDA or other identifying number when the CFDA information is not available. Included in the SEFA worksheet, tracking of federal awards received as a subrecipient, including the name of the pass-through entity and the identifying number assigned by the pass-through entity. All federal expenditures will be categorized per our contract statement on allowable cost expenses. Responsible Individual: Brangwyn Foley, Office Manager Implementation Date: July 2023

View Audit 340574

Finding 520702 (2023-003)

Material Weakness 2023

Community Health and Emergency Services, Inc.

IL

Reporting Allowable Costs / Cost Principles

2023-003 Inaccurate Schedule of Expenditures of Federal Awards Provider Relief Fund – CFDA #93.498 Condition: Management has all the information to complete the schedule of expenditures of federal awards in compliance with the Uniform Guidance but had inaccuracies discovered during audit procedure...

2023-003 Inaccurate Schedule of Expenditures of Federal Awards Provider Relief Fund – CFDA #93.498 Condition: Management has all the information to complete the schedule of expenditures of federal awards in compliance with the Uniform Guidance but had inaccuracies discovered during audit procedures. Federal expenditures of $1,560,441 were excluded from the schedule but were determined to have been reported as spent during the fiscal year. There were also $99,895 in federal expenditures reported for other grants that were determined to be overstated. Action Taken: • Management will prepare the schedule of expenditures of federal awards as part of the year end closing process each year to determine our audit requirements under Uniform Guidance and provide the schedule to the audit firm during the financial audit process. Anticipated Date of Completion and Name of Contact Person: June 30, 2024 – J.P. Champion, Chief Financial Officer

View Audit 340436

Finding 520695 (2023-001)

Significant Deficiency 2023

Fairfield University

CT

Student Financial Aid Special Tests & Provisions Reporting

Finding No. 2023-001 – Significant Deficiency and Noncompliance: Special Tests and Provisions – Enrollment Reporting Corrective Action The corrective action that will be taken is a graduates only enrollment report will be supplied to the National Student Clearinghouse (NSC) by the Registrar’s Offi...

Finding No. 2023-001 – Significant Deficiency and Noncompliance: Special Tests and Provisions – Enrollment Reporting Corrective Action The corrective action that will be taken is a graduates only enrollment report will be supplied to the National Student Clearinghouse (NSC) by the Registrar’s Office on a consistent schedule of submission within 60 days of each graduation period. Persons Responsible for Corrective Action The corrective action plan will be completed by Walter Rankin, Vice Provost for Graduate Continuing and Professional Studies and Danielle Quilligan, University Registrar. Completion Date Initial corrective action was completed by Lynn Kohrn, University Registrar and Allison Henderson, Assistant Registrar in October, 2023 with the submission of a graduates only enrollment report to the third-party service provider NSC. A schedule for consistent submissions of a graduates only enrollment report has already been provided to the NSC.

View Audit 340417

Finding 520658 (2023-004)

Significant Deficiency 2023

Autonomous Municipality of Mayaguez

PR

Reporting

#VALUE!

View Audit 340367

Finding 520582 (2023-001)

Material Weakness 2023

Centennial Square

MN

Material Weakness Reporting Internal Control / Segregation of Duties

Management will continue to rely on CliftonLarsonAllen to draft the financial statements and the related notes to the financial statements, and will review, approve, and accept responsibility for the annual financial statements prior to their issuance.

View Audit 340189

Corrective Action Plans

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