Corrective Action Plans

Finding 401099 (2023-003)

Material Weakness 2023

WA

Reporting § 200.303

Planned Corrective Action: To address a gap identified internally by the Health Board, a new, comprehensive reconciliation and reporting process has been established. This gap was recognized when new finance department leadership assumed their positions prior to audit fieldwork, leading to the devel...

Planned Corrective Action: To address a gap identified internally by the Health Board, a new, comprehensive reconciliation and reporting process has been established. This gap was recognized when new finance department leadership assumed their positions prior to audit fieldwork, leading to the development and implementation of immediate corrective actions. Management at the Health Board has implemented a robust internal control process that includes reconciliation in two phases, which was developed in collaboration with our grants team. This documented process ensures thorough reconciliation and robust internal controls. It enhances the accuracy and timeliness of our financial reporting, particularly for FFR SF-425 submissions, thereby strengthening our overall financial management practices. The following outlines the detailed steps of this process, divided into two critical phases: Phase I: Revenue, Expenses, and Cash Reconciliation 1. Reconciliation by FP&A Analyst: Ensures that the figures and documents entered in Sage Intacct align with the Payment Management System (PMS) regarding authorized grant amounts and drawdown amounts at each month-end close. 2. Grant Receivable Invoices: Recorded in Sage Intacct as part of the month-end close process. A billing or AR accountant collects the expenses and enters corresponding revenue amounts, which the system uses to generate invoices. 3. Notification of Drawdown: The FP&A Analyst notifies the Director of FP&A and the Account Manager via email about the drawdown and the corresponding invoice amount. 4. Verification and Processing: The Director of FP&A verifies the amount and processes the drawdown from PMS to the bank. 5. Monthly CFO Report: The CFO receives a monthly status report. Phase II: FFR Reporting 1. Weekly PMS Review: Every Monday, the PMS is reviewed to identify any projects pending or expired for quarterly, annual, and final report periods. 2. Preparation of Revenue Reports: The billing or AR accountant prepares the direct and indirect revenue based on expense amounts. 3. Submission for Approval: The prepared revenue reports are submitted in the PMS for approval by the Director of FP&A. 4. Final Submission: After the DFPA's approval and final submission in the PMS, the information appears in the Grant Solution system for further approval by the program and grants team. 5. PMS Report: Receive an approval or rejection report from the PMS. Name of Responsible Party: Zecharias Mesgane, CMA, Director of FP&A Anticipated Completion Date: September 30, 2024

View Audit 309158

Finding 401097 (2023-004)

None 2023

Milford Housing Authority

NE

Internal Control / Segregation of Duties Special Tests & Provisions Reporting

Noncompliance and Internal Controls over Compliance for Special Tests and Provisions: Corrective Action Planned: The Milford Housing Authority will evaluate its system of internal control over special tests and provisions to determine how the Authority can better monitor and comply with reserve re...

Noncompliance and Internal Controls over Compliance for Special Tests and Provisions: Corrective Action Planned: The Milford Housing Authority will evaluate its system of internal control over special tests and provisions to determine how the Authority can better monitor and comply with reserve requirements of its award agreement. Anticipated Completion Date: December 31, 2023. Responsible: Management and Board of Commissioners.

View Audit 309124

Finding 400985 (2023-001)

None 2023

Feeding Pennsylvania

PA

Procurement, Suspension & Debarment Reporting § 200.512

View of Responsible Official: During the year following June 30, 2022, Feeding Pennsylvania experienced temporary staffing capacity issues that delayed our ability to timely prepare for and complete the relevant audit. Feeding Pennsylvania has since resolved these capacity issues through the hiring ...

View of Responsible Official: During the year following June 30, 2022, Feeding Pennsylvania experienced temporary staffing capacity issues that delayed our ability to timely prepare for and complete the relevant audit. Feeding Pennsylvania has since resolved these capacity issues through the hiring of a new CEO and the addition of experienced accounting personnel to support the CFO in strengthening internal controls and enhancing accounting and audit preparation processes.

View Audit 309048

Finding 400984 (2023-002)

Material Weakness 2023

Elko County, Nevada

NV

Questioned Costs Subrecipient Monitoring Material Weakness

Finding Number 2023-002 Federal Award Agency: U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds CFDA #: 21.027 Finding Summary: During the performance of the audit, it was noted the County did not correctly report quarterly expenditures for amounts related t...

Finding Number 2023-002 Federal Award Agency: U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds CFDA #: 21.027 Finding Summary: During the performance of the audit, it was noted the County did not correctly report quarterly expenditures for amounts related to items reported under loss of revenue for each quarter in the fiscal year. Responsible Individuals: Susan Paprocki, Elko County Comptroller Corrective Action Plan: Management will closely review the Project and Expenditure Report User Guide to ensure future reports are in compliance and are properly reviewed prior to submission. Anticipated Completion Date: 6/30/2024

View Audit 309046

Finding 400975 (2023-004)

Significant Deficiency 2023

B'nai B'rith Women Senior Citizen Housing

TX

HUD Housing Programs Reporting Internal Control / Segregation of Duties § 200.512

We will follow the HUD filing requirements of the regulatory agreement going forward. The financial statements for the year ended April 30, 2023 will be submitted electronically to HUD no later than June 30, 2024.

View Audit 309038

Finding 400970 (2023-001)

Significant Deficiency 2023

B'nai B'rith Women Senior Citizen Housing

TX

Internal Control / Segregation of Duties Reporting Significant Deficiency

We have recorded all adjusting entries to correct misstatements. We will implement measures to ensure all supporting schedules and documents are reconciled to the underlying general ledger accounts consistently and timely going forward.

View Audit 309038

Finding 400948 (2023-007)

Significant Deficiency 2023

Housing Authority of the City of Dodge City

KS

Questioned Costs HUD Housing Programs Reporting

2023-007. SEMAP Supporting Documentation Corrective action planned: QC on all indicators is now being completed as required. Contact person: Matt Brady, Executive Director. Anticipated completion date: September 30, 2024

View Audit 309004

Finding 400947 (2023-006)

Significant Deficiency 2023

Housing Authority of the City of Dodge City

KS

Questioned Costs HUD Housing Programs Reporting

2023-006. Significant Audit Adjustments Corrective action planned: I have spoken with Lindsey and Company and will better communicate. Contact person: Matt Brady, Executive Director. Anticipated completion date: September 30, 2024

View Audit 309004

Finding 400925 (2023-001)

Significant Deficiency 2023

Washington County Memorial Hospital

MO

Questioned Costs Reporting Significant Deficiency

U.S. Department of Health and Human Services Washington County Memorial Hospital (“Hospital”) respectfully submits the following corrective action plan for the year ended August 31, 2023. Audit period: September 1, 2022 – August 31, 2023 The findings from the schedule of findings and questioned cos...

U.S. Department of Health and Human Services Washington County Memorial Hospital (“Hospital”) respectfully submits the following corrective action plan for the year ended August 31, 2023. Audit period: September 1, 2022 – August 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 – 001 COVID-19 Provider Relief Fund 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. Action taken in response to finding: The Hospital will ensure that they use the appropriate method of reporting lost revenue calculations in the future reporting periods. Name of the contact person responsible for corrective action: Debra Pratt, CFO. Planned completion date for corrective action plan: September 1, 2024 If the Department of Health and Human Services has questions regarding this plan, please call Debra Pratt, CFO at (573) 438 5451 Ext 771.

View Audit 308970

Finding 400921 (2023-003)

Material Weakness 2023

Lyons Fire District

NY

Internal Control / Segregation of Duties Reporting

Segregation of Duties Auditors’ Recommendation: The Fire District should continue to obtain involvement from the Board of Fire Commissioners in reviewing monthly financial reports and approving expenditures. In addition, the Fire District should consider having a Board member prepare or review bank ...

Segregation of Duties Auditors’ Recommendation: The Fire District should continue to obtain involvement from the Board of Fire Commissioners in reviewing monthly financial reports and approving expenditures. In addition, the Fire District should consider having a Board member prepare or review bank reconciliations for each of its bank accounts. Fire District Response: Meghan Nagel, Treasurer, and Brian Engels, Board chairman, understand the importance of having strong segregation of duties and will attempt to separate certain responsibilities as outline above for the year ending December 31, 2024, but does prove difficult in a small district with minimal employees. The Fire District will continue to have the Board review monthly reports and approve expenditures. Further, the Fire District will continue to print the operating account reconciliation and will have that reviewed by a board member. The Fire District will start printing the reconciliation for all other accounts for them to be reviewed by a board member, as well continuing to print each bank statement to be reviewed.

View Audit 308952

Finding 400882 (2023-001)

Significant Deficiency 2023

City of Brighton

CO

Questioned Costs Subrecipient Monitoring Reporting § 200.301

The City agrees with the finding. The City will improve internal controls over the Performance and Expenditure report review process and ensure this review addresses all aspects of the reports and is completed prior to submission. Corrective action was taken in spring of 2024 when the issue was iden...

The City agrees with the finding. The City will improve internal controls over the Performance and Expenditure report review process and ensure this review addresses all aspects of the reports and is completed prior to submission. Corrective action was taken in spring of 2024 when the issue was identified during the 2023 audit. Responsible Official: Catrina Asher, Finance Director Planned completion date for corrective action plan: March 31, 2024.

View Audit 308914

Finding 400881 (2023-001)

Material Weakness 2023

Ottawa Elementary School District 141

IL

Subrecipient Monitoring Material Weakness Reporting

Management is currently confident with the abilities of the accounting staff to prepare interim financial statements. The District has also accepted the additional risk associated with the auditor drafting year-end financial statements including the notes to the financial statements. Management wi...

Management is currently confident with the abilities of the accounting staff to prepare interim financial statements. The District has also accepted the additional risk associated with the auditor drafting year-end financial statements including the notes to the financial statements. Management will review, approve, and take responsibility for the financial statements.

View Audit 308909

Finding 400876 (2023-001)

Material Weakness 2023

Sustainable Northwest

OR

Reporting Cash Management Material Weakness

Finding # 2023-001 Material Weakness over Preparation of Schedule of Federal Expenditures (SEFA) The Organization did not identify all federal expenditures and significant adjustments were required to the SEFA prepared by management. Corrective Action: The Organization agrees with and independent...

Finding # 2023-001 Material Weakness over Preparation of Schedule of Federal Expenditures (SEFA) The Organization did not identify all federal expenditures and significant adjustments were required to the SEFA prepared by management. Corrective Action: The Organization agrees with and independently identified this issue and proactively implemented a new payroll process as of January 2024 in order to address this issue. This will ensure all expenses are tracked in one system for all purposes. In addition the Organization created a new grant tracking field in the chart of accounts which tracks the Assistance Listing numbers of all grants, allowing for the automated creation of the SEFA, as well as providing an internal control to ensure that revenue recognition policies and relevant federal guidelines are correctly applied to all funding sources. Anticipated Completion Date: January 2024

View Audit 308903

Finding 400862 (2023-001)

None 2023

Liberty Resources, Inc.

PA

Reporting

Name of the contact person responsible for corrective action: Glenn Seagraves, CFO Corrective Action Plan: The delay in filing was the result of significant staff turnover in Liberty Resources Inc.’s finance department producing the Organization's financial statements and the limited availability ...

Name of the contact person responsible for corrective action: Glenn Seagraves, CFO Corrective Action Plan: The delay in filing was the result of significant staff turnover in Liberty Resources Inc.’s finance department producing the Organization's financial statements and the limited availability of other resources to assist in the preparation of the financial statements. The Organization has developed and implemented a staffing plan that has adjusted the responsibilities of existing staff and has also hired new additional staff since the end of the June 30, 2023 fiscal year. Anticipated completion date: The plan has been implemented and will continue to be monitored to ensure the Organization’s ability to complete the Single Audit financial statements in a timely manner and that the data collection form can be submitted in compliance with the Single Audit requirements.

View Audit 308891

Finding 400847 (2023-003)

Significant Deficiency 2023

Louisiana Delta Service Corps

LA

Special Tests & Provisions Questioned Costs Subrecipient Monitoring

2023-003 Compliance of Special Tests and Provisions – National Service Criminal History Checks: Management Response: Management will ensure an individual who does not perform the adjudication will review and document whether information was entered correctly and whether the adjudications are proper ...

2023-003 Compliance of Special Tests and Provisions – National Service Criminal History Checks: Management Response: Management will ensure an individual who does not perform the adjudication will review and document whether information was entered correctly and whether the adjudications are proper and documented prior to a member’s start date. Responsible Person: Lisa Moore, Executive Director Anticipated Remediation Date: Fiscal year ending August 31, 2024

View Audit 308865

Finding 400846 (2023-002)

Significant Deficiency 2023

Louisiana Delta Service Corps

LA

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.303 § 200.404

2023-002 Approval of Living Allowance Payments: Management Response: Management will include others on correspondence regarding approval of payroll, which will help detect when an approval of payroll is not made timely. If payroll is not approved before paid, then Management will perform a documente...

2023-002 Approval of Living Allowance Payments: Management Response: Management will include others on correspondence regarding approval of payroll, which will help detect when an approval of payroll is not made timely. If payroll is not approved before paid, then Management will perform a documented review to ensure payroll payments are proper. Management will also develop a policy to stop living allowance payments timely when a member will not meet their service hour obligation. Responsible Person: Lisa Moore, Executive Director Anticipated Remediation Date: Fiscal year ending August 31, 2024

View Audit 308865

Finding 400845 (2023-001)

Material Weakness 2023

Louisiana Delta Service Corps

LA

Internal Control / Segregation of Duties Questioned Costs Cash Management § 200.303

2023-001 Segregation of Duties: Management Response: Due to the size of LDSC’s administrative staff, complete segregation of duties is not economically feasible. However, during the 2023 fiscal year, LDSC created a financial policies handbook that outlines controls and responsibilities in the financ...

2023-001 Segregation of Duties: Management Response: Due to the size of LDSC’s administrative staff, complete segregation of duties is not economically feasible. However, during the 2023 fiscal year, LDSC created a financial policies handbook that outlines controls and responsibilities in the financial reporting cycle. We will ensure the areas recommended above are added to our current policy to the extent it is economically feasible. Responsible Person: Lisa Moore, Executive Director Anticipated Remediation Date: Fiscal year ending August 31, 2024

View Audit 308865

Finding 400843 (2023-033)

Significant Deficiency 2023

City of Grand Prairie Texas

TX

Questioned Costs Reporting Significant Deficiency

Planned Corrective Action: ARPA Grant Funds are now being approved by the Controller before submitting to the Treasury Website. Responsible officials: Luis Barrera, Controller, will be responsible for approvals before submitting the expenditures Planned completion date: The approval process was impl...

Planned Corrective Action: ARPA Grant Funds are now being approved by the Controller before submitting to the Treasury Website. Responsible officials: Luis Barrera, Controller, will be responsible for approvals before submitting the expenditures Planned completion date: The approval process was implemented on October 31, 2023

View Audit 308851

Finding 400841 (2023-002)

Material Weakness 2023

Housing and Redevelopment Authority of Owatonna

MN

Internal Control / Segregation of Duties Eligibility Material Weakness

Finding: 2023-002 Lack of Proper Review – Eligibility, Reporting, and Special Provisions Federal agency: U.S. Department of Housing and Urban Development Federal program Title: Housing Choice Voucher Program Assistance Listing Number: 14.871 and 14.879 Federal Award Identification Number and Year: ...

Finding: 2023-002 Lack of Proper Review – Eligibility, Reporting, and Special Provisions Federal agency: U.S. Department of Housing and Urban Development Federal program Title: Housing Choice Voucher Program Assistance Listing Number: 14.871 and 14.879 Federal Award Identification Number and Year: N/A Pass-Through Agency: N/A Pass-Through Number(s): N/A Award Period: December 31, 2023 Type of Finding: Material Weakness in Internal Control Over Compliance Recommendation: We recommend the HRA implement controls over all areas of the federal program so that controls are in place and working. Views of Responsible Officials: There is no disagreement with the audit finding. Action Taken in Response to Finding: The HRA will assess the controls over the federal program and make changes as deemed necessary. Name of the Contact Person Responsible for Corrective Action Plan: Rhonda Moen, Finance Manager Planned Completion Date for Corrective Action Plan: December 31, 2024.

View Audit 308850

Finding 400838 (2023-001)

Significant Deficiency 2023

Comunidades Latinas Unidas En Servicio INC

MN

Reporting Questioned Costs Allowable Costs / Cost Principles

Management Response: CLUES’ financial management detected an oversight in billing a specific unallowable cost to certain grants that fund our Behavioral Health (“BH”) clinics. The oversight was promptly investigated, and we immediately remedied the situation with the affected funders. CLUES has take...

Management Response: CLUES’ financial management detected an oversight in billing a specific unallowable cost to certain grants that fund our Behavioral Health (“BH”) clinics. The oversight was promptly investigated, and we immediately remedied the situation with the affected funders. CLUES has taken action to prevent similar potential errors in the future. Two of our grants account for the majority of the improper billing total. The funders agreed that we can charge other billable expenses not previously covered. CLUES expended all funds with the funder’s approval. This matter was resolved and reported to the funder’s satisfaction. Action taken in response to finding: Management immediately identified the scope of the billing discrepancy, contacted the funders to resolve it, and have incorporated training and monitoring procedures internally to ensure we do not inadvertently bill such unallowable costs again. Proper review processes have been implemented to detect and prevent similar findings in the future. Name of the contact person responsible for corrective action: Ryan Robinson (VP of Finance & Administration) Planned completion date for corrective action plan: This matter was resolved in May 2024.

View Audit 308846

Finding 400835 (2023-006)

Significant Deficiency 2023

Firstfollowers

IL

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.329

Company-wide reports are submitted monthly to the Board of Directors for approval. Reports that are submitted are separated by grant, so that the Board of Directors can see the activity in each grant for each month during the fiscal year. The reports submitted to the funders by Marlon Mitchell are t...

Company-wide reports are submitted monthly to the Board of Directors for approval. Reports that are submitted are separated by grant, so that the Board of Directors can see the activity in each grant for each month during the fiscal year. The reports submitted to the funders by Marlon Mitchell are taken from the financial reports that are approved by the Board of Directors. In addition, Marlon does not enter the financial information, nor does he prepare the monthly reports submitted to the Board. He serves as a fourth set of eyes on the information before the reports are submitted to the funders. Khayriyah Mitchell enters all of the revenue and expenditures into the accounting system, Shanelle Herman reconciles the bank and credit card accounts and runs the reports for the Board of Directors, the Board reviews and approves the financial statements, and Marlon Mitchell uses the approved financial information to create the reports to the grant funding agencies.

View Audit 308844

Finding 400824 (2023-002)

Material Weakness 2023

Unified School District #250

KS

School Nutrition Programs Internal Control / Segregation of Duties Reporting

USD #250 has implemented new procedures to ensure that information provided to the Food Service Director is correct. Personnel have been trained in the poper way to run reports under the District's accounting system. In addition, the Director of Business Operations will review the annual food serv...

USD #250 has implemented new procedures to ensure that information provided to the Food Service Director is correct. Personnel have been trained in the poper way to run reports under the District's accounting system. In addition, the Director of Business Operations will review the annual food service report prepared by the Food Service Director before it is submitted to the Kansas Department of Education.

View Audit 308841

Finding 400813 (2023-001)

Material Weakness 2023

Baycare Health System, Inc. and Affiliates

FL

Reporting § 200.303

Finding No. Name of Responsible Official Management’s Response to Findings Description of Corrective Action 2023-001 John Proni, Director of Finance_x0002_Hospital Division Management agrees with the finding for CFDA 93.498 where Period 5 Provider Relief Funds (PRF) were excluded on the original SE...

Finding No. Name of Responsible Official Management’s Response to Findings Description of Corrective Action 2023-001 John Proni, Director of Finance_x0002_Hospital Division Management agrees with the finding for CFDA 93.498 where Period 5 Provider Relief Funds (PRF) were excluded on the original SEFA and an adjustment of $9,234,533 was required. 2023-001 John Proni, Director of Finance_x0002_Hospital Division Management agrees with the finding and the corrected amount on the federal SEFA. On the original draft of the SEFA, for CFDA 93.914 expenses were included from February 2024 dates of service. An adjustment of $152,329 was required Management will ensure that in preparation of the SEFA, (1) a team member will assemble the initial reconciliation, (2) management will review the initial reconciliation and review the consolidation from all BayCare entities to the combined SEFA, (3) A final review will be conducted by the Director. Sign-off from each preparer/reviewer shall be required. Meetings will be conducted as needed with departments outside of Hospital Finance to ensure completeness and accuracy of data. Anticipated Completion Date Completion of SEFA for Fiscal Year 2024 will be completed in first quarter 2025.

View Audit 308838

Finding 400812 (2023-001)

Significant Deficiency 2023

Orchard Hospital and Affiliate

CA

Reporting Significant Deficiency Questioned Costs

Management acknowledges the delay in completing the FYE 2023 audit and filing the Data Collection Form (SF-SAC) on time. We have since completed the audit and submitted the required documentation to the Federal Audit Clearinghouse. To prevent recurrence of this issue the following corrective actio...

Management acknowledges the delay in completing the FYE 2023 audit and filing the Data Collection Form (SF-SAC) on time. We have since completed the audit and submitted the required documentation to the Federal Audit Clearinghouse. To prevent recurrence of this issue the following corrective actions will be implemented: -Establish a detailed timeline for the audit process, including key milestones and deadlines -Conduct regular progress review to ensure adherence to the timeline -Allocate additional resources to the finance departments as needed during critical periods to ensure timely completion of tasks -Improve communication between the audit team and mangement to promptly address any issues that may cause delays. Responsible Party: Ed Gonzalez, CFO, will be responsible for overseeing the implementation and execution of this corrective action plan. Estimated Completion Date: The corrective actions outlined above are expected to be fully implemented by May 31, 2024. We are committed to ensuring compliance with all financial reporting obligations and will take the necessary steps to prevent future occurrences of such delays.

View Audit 308835

Finding 400804 (2023-001)

None 2023

Cal-Pep

CA

Procurement, Suspension & Debarment Reporting Questioned Costs

Late Filing of Required Reporting of Federal Awards/Grant. CAL-PEP Inc.’s Data Collection Form and Reporting Package was not submitted to the Federal Clearinghouse within extended due date. Corrective Action Plan: Policy and Procedures on the submittal of Data Collection Form and Reporting Package t...

Late Filing of Required Reporting of Federal Awards/Grant. CAL-PEP Inc.’s Data Collection Form and Reporting Package was not submitted to the Federal Clearinghouse within extended due date. Corrective Action Plan: Policy and Procedures on the submittal of Data Collection Form and Reporting Package to the Federal Clearing House within extended due date had been established. Policy is shown below: The reporting package for the Federal clearing house must be submitted 30 days after receipt of auditor's report, or 9 months after end of the fiscal year whichever comes first, (February). In order to meet the deadline, a request to start the company audit will be arrange at the earliest, by August every year. In case an Audit Report is expected not to be receive within 9 months after fiscal year, a written extension must be submitted by the Finance Manager.

View Audit 308830

Corrective Action Plans

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