Corrective Action Plans

Finding 530096 (2022-002)

Significant Deficiency 2022

CA

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Corrective Action Plan: In the time since the initial audit was due at the end of 2022, the organization experienced a substantial turnover in its senior administrative leadership team. I was engaged as the new Chief Executive Officer in November 2023, and have since hired a new General Manager, Dir...

Corrective Action Plan: In the time since the initial audit was due at the end of 2022, the organization experienced a substantial turnover in its senior administrative leadership team. I was engaged as the new Chief Executive Officer in November 2023, and have since hired a new General Manager, Director of Development, and worked closely with our accounting firm, who was engaged to replace the original CFO, after her retirement in 2022. Since this new team has assumed leadership, we have transitioned to new accounting and billing software platforms and developed or renewed policies and procedures that have improved monitoring, tracking, approval, and reporting procedures for all expenditures and revenues, across the organization. We have also upgraded to a cloud-based server/filesharing system and reorganized the filing and archival systems and procedures to ensure that files and documents are organized more clearly and more accessibly for key staff members, current and into the future. Anticipated Completion Date: Already implemented.

View Audit 348149

Finding 530095 (2022-001)

Significant Deficiency 2022

Pasadena Symphony Association

CA

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.512

Corrective Action Plan: In the time since the initial audit was due at the end of 2022, the organization experienced a substantial turnover in its senior administrative leadership team who initially were charged with tracking this grant and its reporting requirements. I was engaged as the new Chief ...

Corrective Action Plan: In the time since the initial audit was due at the end of 2022, the organization experienced a substantial turnover in its senior administrative leadership team who initially were charged with tracking this grant and its reporting requirements. I was engaged as the new Chief Executive Officer in November 2023, and have since hired a new General Manager, Director of Development, and worked closely with our accounting firm, which was engaged to replace the original CFO, after her retirement in 2022. Since this new team has assumed leadership, we have transitioned to new accounting and billing software platforms, developed or renewed policies and procedures to monitor, track, and report all expenditures and revenues, and to more accurately monitor, track, and report on impending grant reporting deadlines and requirements. We have also upgraded to a cloud -based server/file-sharing system and reorganized the filing and archival systems and procedures to ensure that files and documents are organized more clearly and more accessibly for both current and future staff members. Anticipated Completion Date: Already implemented.

View Audit 348149

Finding 530092 (2022-005)

Significant Deficiency 2022

South Big Horn Hospital District

WY

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

2022-005 - Reporting Corrective Action Plan: Management agrees with the finding and has committed the resources giving rise to the finding. Person(s) Responsible: M. Michael Garza Timing for Implementation: June 30, 2025

View Audit 348143

Finding 529977 (2022-004)

Material Weakness 2022

Fairbanks Rescue Mission, Inc.

AK

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Procurement, Suspension & Debarment

Financial Statement Finding: 2022-004 Material Weakness in Internal Control over Financial Reporting and Noncompliance – Allowable Costs/Cost Principles - Repeat Name and Contact Person: Pete Kelly, Chief Executive Officer Corrective Action: Management hired a Finance Director and contracted with an...

Financial Statement Finding: 2022-004 Material Weakness in Internal Control over Financial Reporting and Noncompliance – Allowable Costs/Cost Principles - Repeat Name and Contact Person: Pete Kelly, Chief Executive Officer Corrective Action: Management hired a Finance Director and contracted with an Accountant that has made significant improvements to the processes and record keeping to ensure that sufficient documentation is maintained by the Organization. Proposed Completion Date: January 1, 2024

View Audit 348068

Finding 529849 (2022-008)

Significant Deficiency 2022

First Nations Community Healthsource, Inc.

NM

Reporting Internal Control / Segregation of Duties § 200.512

Recommendation We recommend that management enhance its internal control structure, including financial close and reporting, to ensure timely filing of future Single Audit reporting packages. Management Response Corrective Action: FNCH’s management agrees with the auditor’s recommendation...

Recommendation We recommend that management enhance its internal control structure, including financial close and reporting, to ensure timely filing of future Single Audit reporting packages. Management Response Corrective Action: FNCH’s management agrees with the auditor’s recommendation. Due to the unprecedented challenges posed by the COVID-19 pandemic, the Finance Department experienced significant staffing disruptions, resulting in an 80% turnover rate, which notably included the departure of the CFO. Additionally, COVID-19 incidents among staff members adversely impacted attendance, leading to frequent absences that ranged from one to two weeks. This created severe staffing shortages that hampered the department's operations. The pandemic's effect extended beyond immediate staffing, complicating the recruitment of new employees in a competitive job market. Consequently, the Finance Department faced considerable difficulties in meeting its audit and tax filing deadlines. FNCH will implement correction action steps to address the timely submission of audit reports and tax filings. The CFO will ensure audited financial statements are completed in a timely manner by implementing enhanced internal controls, including timely bank reconciliations, financial close, and reporting, to ensure timely filing of audit reports and tax filings. Due Date of Completion: September 30, 2025 Responsible Party(ies): CEO, CFO

View Audit 347889

Finding 529528 (2022-005)

Material Weakness 2022

National Indian Health Board

DC

Reporting Subrecipient Monitoring

Summary of Finding Late reports, missing reports and variances from accounting records: Four of the financial reports were submitted late and four had a variance from the expenditures per the general ledger. In addition, programmatic reports were missing for both of the major programs tested. It is ...

Summary of Finding Late reports, missing reports and variances from accounting records: Four of the financial reports were submitted late and four had a variance from the expenditures per the general ledger. In addition, programmatic reports were missing for both of the major programs tested. It is important that all reports are timely filed and there is documentation to support all programmatic and financial reports. This ensures that the Organization is in compliance with Uniform Guidance, as well as ensuring that they are properly expending the funds and completing the goals of the grants. As of the end of the grant period there was an overall variance of $12,060 between the amounts reported on the financial reporting and the general ledger. We were also unable to obtain programmatic reports to verify that these were filed. Statement of Concurrence or Nonconcurrence This finding is concurred with due to staff turnover and the department being short-staffed. Corrective Action In response to the identified issues, the Organization has appointed a new Grants Director who is now responsible for overseeing all aspects of grant reporting, compliance, and fund management. The Grants Director implemented a new grant management software and comprehensive reporting tracker that monitors all deadlines to ensure the timely submission of financial and programmatic reports. This will also ensure proper record management, retention, and access. The Grants Director is also charged with reconciling reported expenditures with the general ledger and verifying that all grant deliverables are met in accordance with Uniform Guidance. These measures are designed to prevent future late or missing reports and to ensure that funds are properly expended and documented.

View Audit 347522

Finding 529316 (2022-002)

Material Weakness 2022

City of McKeesport

PA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Reporting § 200.403

CONDITION: During the calendar year 2022, the City did not utilize a formal general ledger system of accounting to track the financial activity (financial position and results of operations) for several ‘Funds’ held at the City. The activity of these funds is either 1) maintained in spreadsheet fash...

CONDITION: During the calendar year 2022, the City did not utilize a formal general ledger system of accounting to track the financial activity (financial position and results of operations) for several ‘Funds’ held at the City. The activity of these funds is either 1) maintained in spreadsheet fashion similar to a checkbook used in personal finances, 2) recorded partially (expenses only with no revenue), or 3) not tracked at all. As these funds are not maintained using the City’s accounting software package, management does not have the ability to efficiently generate financial reports necessary to provide management with the proper fiscal oversight. This condition included the American Rescue Plan Act (ARPA) funding known as the Coronavirus State and Local Fiscal Recovery Fund. However, it should be noted that City personnel were able to prepare spreadsheets to document which expenditures were utilized to prepare the necessary quarterly reporting requirements to the Department of Treasury. This is a repeat finding (2021-002) from the prior year. CRITERIA: Prudent internal control procedures in the areas of general ledger management and financial reporting include maintaining a formal general ledger system of accounting to track the activity of all ‘Funds’ maintained by the City. In specific as it relates to federal programs, Section 2 CFR 200.403(g) of the Uniform Guidance requires that federal costs must be adequately documented which would include the maintaining of a formal general ledger system of accounting for all ‘Funds’ of the City. MANAGEMENT’S CORRECTIVE ACTION PLAN: Management of the City will assess the current workload and expertise of the City’s business office personnel in an effort to determine a feasible timeframe to continue the process of creating a formal general ledger system of accounting for all City ‘Funds’ that are not already entered into the software accounting system. The timeframe for completion of this review will occur during the first nine months of calendar year 2025 with the intention of having the City be in full compliance with Section 2 CFR 200.403(g) of the Uniform Guidance which requires federal costs to be adequately documented which would include the maintaining of a formal general ledger system of accounting for all ‘Funds’ of the City.

View Audit 347342

Finding 529308 (2022-001)

Material Weakness 2022

City of McKeesport

PA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Reporting § 200.403

CONDITION: During the calendar year 2022, the City did not record the necessary adjustments to the various ‘Fund’ general ledgers of the City to properly reconcile the balance sheet accounts, such as cash, receivables, payables, and payroll-related liabilities to the underlying supporting documentat...

CONDITION: During the calendar year 2022, the City did not record the necessary adjustments to the various ‘Fund’ general ledgers of the City to properly reconcile the balance sheet accounts, such as cash, receivables, payables, and payroll-related liabilities to the underlying supporting documentation available at the City (which includes reconciliations of cash prepared independently by City personnel but do not agree to amounts reported in the various general ledgers). This included ‘Funds” containing significant federal funding such as the City’s Community Development Block Grant (CDBG) Program and American Rescue Plan Act (ARPA) funding known as the Coronavirus State and Local Fiscal Recovery Fund. CONDITION (Continued): As a result, the financial position and results of operations as shown throughout the calendar year were inaccurately stated. However, it should be noted that the Community Development Department of the City and other City personnel maintain separate financial reporting for these federal funds, independent of the aforementioned ‘Fund’ general ledgers sufficient to ascertain the revenues and expenditures of the federal programs. This is a repeat finding (2021-001) for the prior year. CRITERIA: Prudent internal control procedures in the areas of general ledger management and financial reporting include the reconciliation of all general ledger account balances to underlying supporting documentation monthly with independent oversight and approval as part of the process. In specific as it relates to federal programs, Section 2 CFR 200.403(g) of the Uniform Guidance requires that federal costs must be adequately documented which would include the applicable general ledgers of the City. MANAGEMENT’S CORRECTIVE ACTION PLAN: Management of the City will review the recommended options as presented by the Audit Firm’s recommendation for feasibility considering current manpower, expertise, and budgetary constraints. In addition, the City plans to ensure that written procedures for all accounting functions are implemented, reviewed and updated as necessary with the objective of ensuring that all balance sheet account balances are supported by the underlying documentation available at the City. The timeframe for completion of this review will occur during the first nine months of calendar year 2025 with the intention of having the City be in full compliance with Section 2 CFR 200.403(g) of the Uniform Guidance which requires federal costs to be adequately documented which would include the applicable general ledgers of the City.

View Audit 347342

Finding 529226 (2022-002)

Material Weakness 2022

Neighborhoods, Inc. of Battle Creek

MI

Allowable Costs / Cost Principles Material Weakness Reporting

Now that disbursements are 100% in-house, the President & CEO provides final written approval on all timecards and payables. Chairman of the Loan & Finance Committee remotely reviews journal entries in accounting software monthly. Contact Person Responsible for Corrective Action: Lisa Ripper Antic...

Now that disbursements are 100% in-house, the President & CEO provides final written approval on all timecards and payables. Chairman of the Loan & Finance Committee remotely reviews journal entries in accounting software monthly. Contact Person Responsible for Corrective Action: Lisa Ripper Anticipated Completion Date: 7/1/2023

View Audit 347220

Finding 529225 (2022-001)

Material Weakness 2022

Neighborhoods, Inc. of Battle Creek

MI

Reporting Internal Control / Segregation of Duties

In 2021, senior management contracted with a CPA firm to handle all accounting functions. Processes and procedures that were expected to be completed by contractor were not. As of 7/1/23, management brought accounting functions in house to gain control of books, provide more oversight and ensure acc...

In 2021, senior management contracted with a CPA firm to handle all accounting functions. Processes and procedures that were expected to be completed by contractor were not. As of 7/1/23, management brought accounting functions in house to gain control of books, provide more oversight and ensure accuracy. Contact Person Responsible for Corrective Action: Lisa Ripper Anticipated Completion Date: 7/1/2023

View Audit 347220

Finding 529160 (2022-004)

Significant Deficiency 2022

Oregon Coalition Against Domestic & Sexual Violence

OR

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.512

Contact person(s) responsible: Executive Director, Keri Moran-Kuhn Recommendation: We recommend that management implement procedures to ensure that all required reporting is submitted in a timely manner and in accordance with CFR 200.512 deadlines. Management’s Response: Corrective Action Plan: Duri...

Contact person(s) responsible: Executive Director, Keri Moran-Kuhn Recommendation: We recommend that management implement procedures to ensure that all required reporting is submitted in a timely manner and in accordance with CFR 200.512 deadlines. Management’s Response: Corrective Action Plan: During this time, the Coalition went through several temporary fiscal staff and one permanent hired staff that had made mistakes, with the effect of having to make adjustments in order to attempt to close accounting records. Controls have been put into place and permanent accounting manager, started in October 2024 and now on staff as of March 2025. Anticipated completion date: 09/30/25

View Audit 347141

Finding 529159 (2022-003)

Material Weakness 2022

Oregon Coalition Against Domestic & Sexual Violence

OR

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Contact person(s) responsible: Associate Director, BB Beltran Recommendation: The Coalition should establish monitoring procedures to ensure that charges to federal awards and other funders are adequately documented and approved and comply with all established policies. Specifically, adequate docume...

Contact person(s) responsible: Associate Director, BB Beltran Recommendation: The Coalition should establish monitoring procedures to ensure that charges to federal awards and other funders are adequately documented and approved and comply with all established policies. Specifically, adequate documentation should include original itemized invoices or receipts, and clear documentation of review and approval. Management Response: NEW Corrective Action Plan: OCADSV implemented a third-party service for tracking the Coalitions costs by program in January of 2023. The submission, coding, approval and payment are processed within this software, which also allows for an audit trail of the processes performed by user and quick access to scanned original documentation. Quarterly budget expense reimbursements are prepared and submitted for review to the Associate Director and/or the Grants Manager. The monthly/quarterly reports are reviewed and approved, with general ledger support, before sending them to the funding agency as the quarterly invoice for reimbursements. Anticipated completion date: 09/30/24

View Audit 347141

Finding 529156 (2022-003)

Significant Deficiency 2022

The Center: Resources for Teaching and Learning

IL

Reporting

The Organization will submit the current year and subsequent year audit reporting packages and data collection forms as soon as the audits are complete and available. The Organization is reviewing its procedures to file and submit audits timely beginning in the fiscal year ending June 30, 2024. The ...

The Organization will submit the current year and subsequent year audit reporting packages and data collection forms as soon as the audits are complete and available. The Organization is reviewing its procedures to file and submit audits timely beginning in the fiscal year ending June 30, 2024. The Organization accepts the recommendation.

View Audit 347130

Finding 528927 (2022-002)

Material Weakness 2022

Iliff School of Theology

CO

Student Financial Aid Reporting Material Weakness

Condition: Our audit procedures identified instances of inaccurate or untimely reporting of enrollment information to NSLDS. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The school ...

Condition: Our audit procedures identified instances of inaccurate or untimely reporting of enrollment information to NSLDS. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The school has also ensured that this third-party processor is properly coordinated with the registrar’s office to meet federal requirements for NSLDS enrollment reporting. Contact person responsible for corrective action: Jason Warr, VP for Business, Controller Anticipated Completion Date: May 2024

View Audit 346905

Finding 528809 (2022-001)

None 2022

Saraland Manor, Inc.

MS

HUD Housing Programs Reporting

We agree with Finding 2022-001 and the recommendations described above. We have engaged a CPA firm to perform a single audit for the periods December 31, 2021-2023.

View Audit 346857

Finding 528730 (2022-002)

None 2022

Greater Chatham Initiative

IL

Reporting Cash Management

GCI has since hired a dedicated contractor who submits vouchers consistent with the City of Chicago's due dates. This assumes that the City of Chicago also follows its own guidelines, provides contracts, and processes vouchers in a timely manner. Estimated Correction Date January 1, 2023.

View Audit 346791

Finding 528729 (2022-001)

None 2022

Greater Chatham Initiative

IL

Reporting

GCI's accountant had personal issues that prevented her from completing the fiscal year 2022 documents. In the future, we will employ another accountant as soon as they start missing important deadlines regardless of their circumstances. The 12/31/2022 filing will be completed on or before March 15...

GCI's accountant had personal issues that prevented her from completing the fiscal year 2022 documents. In the future, we will employ another accountant as soon as they start missing important deadlines regardless of their circumstances. The 12/31/2022 filing will be completed on or before March 15, 2025.

View Audit 346791

Finding 528244 (2022-006)

None 2022

City of Sanger

CA

Reporting § 200.512

The City is working with a consultant to catch up and get back on schedule to complete the audit in a timely manner. Consequently, the single audit report will be submitted to the Federal Audit Clearinghouse by the deadline.

View Audit 346271

Finding 527055 (2022-001)

None 2022

Village of Clayton, New York

NY

Reporting

The Village procured a new audit firm in January 2024 to complete its past audits and submissions for fiscal years 2022 and 2023. Upon submission of these reports, the Village will be up to date through May 31, 2023 with its filings. The Village is expected to have its May 31, 2024 audit and requi...

The Village procured a new audit firm in January 2024 to complete its past audits and submissions for fiscal years 2022 and 2023. Upon submission of these reports, the Village will be up to date through May 31, 2023 with its filings. The Village is expected to have its May 31, 2024 audit and required submissions completed on time, by February 28, 2025.

View Audit 346169

Finding 527031 (2022-008)

Material Weakness 2022

The Wellness Plan Medical Centers

MI

Material Weakness Reporting

Finding Number: 2022-008 Condition: Due to material entries identified and recorded during the 2022 financial statement audit of the Organization, the data submitted within the annual performance report was not accurate. Additionally, there was no evidence of review over the required reports. Planne...

Finding Number: 2022-008 Condition: Due to material entries identified and recorded during the 2022 financial statement audit of the Organization, the data submitted within the annual performance report was not accurate. Additionally, there was no evidence of review over the required reports. Planned Corrective Action: Management will enhance controls such that the preparation and review of account reconciliation in completed for all fiscal cycles in a timely manner. Contact person responsible for corrective action: Chief Financial Officer Anticipated Completion Date: 06/30/2025

View Audit 346114

Finding 526803 (2022-013)

None 2022

Muskogee County

OK

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Assistance Listing Number 21.027 Noncompliance Over Reporting - Major Federal Program - Coronavirus State and Local Fiscal Recovery Funds Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will ...

Assistance Listing Number 21.027 Noncompliance Over Reporting - Major Federal Program - Coronavirus State and Local Fiscal Recovery Funds Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to ensure that all grant funds are properly expended and properly reported.

View Audit 345862

Finding 526785 (2022-004)

Material Weakness 2022

Greater Bethel Temple Incorporated

PA

Questioned Costs Reporting School Nutrition Programs

Procure the services of an accounting professional to verify the accuracy and adherence to accounting methods and reporting procedures to assist with the administration of the Child and Adult Care Food Program (CACFP)

View Audit 345819 Questioned Costs: $1

Finding 526762 (2022-003)

Material Weakness 2022

Choctaw County City of Hugo Hospital Authority Dba Choctaw Memorial Hospital

OK

Internal Control / Segregation of Duties Eligibility Material Weakness § 200.303

Reporting - Material Weakness in Internal Control over Compliance and Noncompliance Deemed not Material Identification of the Federal Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution - 93.498. Finding Summary: The Authority tracked patiet care revenues intern...

Reporting - Material Weakness in Internal Control over Compliance and Noncompliance Deemed not Material Identification of the Federal Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution - 93.498. Finding Summary: The Authority tracked patiet care revenues internally within a spreadsheet. The calculations of revenue by payor within the spreadsheet and included in Period 2 report to HRSA, which are utilized to calculate lost revenues, contained errors. Responsible Individual: Dawn Ballard. Corrective Action Plan: While there were errors in the reported net patient revenue by payor for specific quarters, the total net patient service revenue, by quarter, was accurately reported and did not impact the calculated lost revenue. Management believes that the control process in place is sufficient to identify material errors in reported amounts. Anticipated Completion Date: January 15, 2025

View Audit 345762

Finding 526761 (2022-002)

Material Weakness 2022

Choctaw County City of Hugo Hospital Authority Dba Choctaw Memorial Hospital

OK

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Reporting - Material Weakness in Internal Control over Compliance and Material Noncompliance Identification of the Federal Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution - 93.498. Finding Summary: The Authority selected Option 1, as defined by HRSA, to calc...

Reporting - Material Weakness in Internal Control over Compliance and Material Noncompliance Identification of the Federal Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution - 93.498. Finding Summary: The Authority selected Option 1, as defined by HRSA, to calculate lost revenue. This option consists of reporting actual revenues from relevant quarters in the period of availability with the system calculating the lost revenues because of deadlines. The fiscal year 2021 single audit identified unallowable expenses totaling $263,861. The Company utilized excess lost revenues at the time to cover this difference. To capture the use of these lost revenues from Period 1, the Authority should have used Option 3, as defined by HRSA, to calculate and report lost revenues. Within that calculation, lost revenues could then be reduced by the $263,861. Responsible Individual: Dawn Ballard. Corrective Action Plan: Due to the timing of completion of the single audit requirements and identification of questioned costs, the report for Period 2 was unable to properly reflect the identified questioned costs. Management will implement process and procedures to ensure all required reports are completed accurately, in the event similar funding is received in the future. Anticipated Completion Date: January 16, 2025

View Audit 345762

Finding 526442 (2022-002)

Significant Deficiency 2022

State Education Resource Center

CT

Reporting Significant Deficiency

Description of Finding: As per the Code of Federal Regulations, Section 200.512 - Report Submission, the audit must be completed and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditors’ report, or nine months after the...

Description of Finding: As per the Code of Federal Regulations, Section 200.512 - Report Submission, the audit must be completed and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditors’ report, or nine months after the end of the audit period. The due date for the submission was September 30, 2022. The audit and reporting package was not submitted by the due date September 30, 2022. Statement of Concurrence or Nonconcurrence: The State Education Resource Center agrees with this finding. SERC experienced staffing shortages and related difficulties during the fiscal year. As such, SERC was not able to prepare timely for the audit for the Uniform Guidance, Data Collection Form, and reporting package to be filed by the due date. Corrective Action: In May of 2024, the State Education Resource Center hired a new Chief Financial Officer whose focus is to bring the organization up to date on all audits and reporting and to ensure that the Fiscal team has the proper tools and guidance to perform their tasks and to improve policy and process for the department. This will also aid in ensuring all necessary efforts will be taken to ensure timely submission of the audit, Data Collection Form, and reporting packages. Name of Contact Person: Jim Fried, Chief Financial Officer, 860-740-4263, fried@ctserc.org will be responsible for completing the corrective action plan. Projected Completion Date: The anticipated date for completing the corrective action plan is June 30, 2025. The action plan will be monitored on a bi-annual basis to ensure ongoing compliance.

View Audit 345377

Corrective Action Plans

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