Corrective Action Plans

Finding 520096 (2022-001)

Significant Deficiency 2022

NY

Reporting

Finding No: 2022-001 General Ledger Analysis Response: Agree Planned Corrective Action: Management recognizes, understands and acknowledges the importance of routinely reconciling activities for significant accounts; receivables transactions cash and investment activity timely. To ensure that all th...

Finding No: 2022-001 General Ledger Analysis Response: Agree Planned Corrective Action: Management recognizes, understands and acknowledges the importance of routinely reconciling activities for significant accounts; receivables transactions cash and investment activity timely. To ensure that all these accounts are analyzed and reconciled on a timely basis with the bank statements activities, and all transactions recorded to agree general ledger balances, the Corporate Controller will orient the staff accounts and billing and receivable manager on strict adherence to the existing policy and procedure, which requires reconciliation at least 30 days after the closing of the month. There will be a draft detailed policy for these reconciliation timelines for submission for verification and approval. The policy will require that all adjusting entries be promptly recorded via a journal entry and that no adjustments to significant accounts are carried forward without proper disposition and resolution. The policy will further require that the Controller review each reconciliation for compliance no later than the last day of each month for the previous month. Anticipated Completion Date: Last 6 months of FYE 06.30.2025.

View Audit 339671

Finding 520033 (2022-004)

Material Weakness 2022

City of Nenana

AK

Reporting Material Weakness § 200.512

Finding 2022-004: Late Reporting and Noncompliance with Reporting Requirements Name of Contact: Josh Verhagen Corrective Action Plan: New and improved weekly communication between grant team and finance team. Proposed Completion Date: March 2025

View Audit 339515

Finding 520025 (2022-005)

Material Weakness 2022

Feeding San Diego

CA

Allowable Costs / Cost Principles Reporting

Identification of federal programs 21.027 – American Rescue Plan Act (ARPA) Condition The Organization does not have an adequate understanding of the requirements under the program agreement. And as such, under recorded claims. Views of Responsible Officials: Management agrees with the finding ...

Identification of federal programs 21.027 – American Rescue Plan Act (ARPA) Condition The Organization does not have an adequate understanding of the requirements under the program agreement. And as such, under recorded claims. Views of Responsible Officials: Management agrees with the finding and observation. Contact Person: Fendy Wogu, Finance Controller Proposed Completion Date: October 31, 2024

View Audit 339494

Finding 520021 (2022-004)

Significant Deficiency 2022

Feeding San Diego

CA

Allowable Costs / Cost Principles Cash Management Reporting

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

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

View Audit 339494

Finding 520020 (2022-003)

Significant Deficiency 2022

Feeding San Diego

CA

Allowable Costs / Cost Principles Reporting

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

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

View Audit 339494

Finding 520019 (2022-002)

Significant Deficiency 2022

Feeding San Diego

CA

Allowable Costs / Cost Principles Reporting

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

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

View Audit 339494

Finding 520018 (2022-001)

Significant Deficiency 2022

Feeding San Diego

CA

Eligibility Reporting

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

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

View Audit 339494

Finding 520017 (2022-006)

Significant Deficiency 2022

Feeding San Diego

CA

Allowable Costs / Cost Principles Reporting

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

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

View Audit 339494

Finding 519920 (2022-003)

Significant Deficiency 2022

Gateway Community Health Centers, Inc.

NC

Reporting Significant Deficiency

Responsible Parties: Interim Chief Financial Officer (Dan Miles), Finance Director (Kelly Glover). To facilitate timely and accurate preparation of a SEFA for fiscal year end, a monthly reconciliation of expenditures in the general ledger will be performed. Gateway’s CFO is responsible for ensuring ...

Responsible Parties: Interim Chief Financial Officer (Dan Miles), Finance Director (Kelly Glover). To facilitate timely and accurate preparation of a SEFA for fiscal year end, a monthly reconciliation of expenditures in the general ledger will be performed. Gateway’s CFO is responsible for ensuring grant-specific coding for the health center’s charts of accounts in order to identify eligible expenditures. Anticipated Date of Completion: Deadline: This is an ongoing requirement. Monthly.

View Audit 339361

Finding 519919 (2022-002)

Significant Deficiency 2022

Gateway Community Health Centers, Inc.

NC

Reporting Matching / Level of Effort / Earmarking Special Tests & Provisions

Responsible Parties: Board of Directors (Dr. Althea Riddick, Chair), Chief Executive Officer (Rose Turner), Interim Chief Financial Officer (Dan Miles), Finance Director (Kelly Glover). Agree. The health center will submit the 2024 statements before it’s due date. A calendar of scheduled financial r...

Responsible Parties: Board of Directors (Dr. Althea Riddick, Chair), Chief Executive Officer (Rose Turner), Interim Chief Financial Officer (Dan Miles), Finance Director (Kelly Glover). Agree. The health center will submit the 2024 statements before it’s due date. A calendar of scheduled financial reports is active and has been implemented effectively with the submission of this Audit. Anticipated Date of Completion: Deadline: February 28, 2025.

View Audit 339361

Finding 519888 (2022-003)

Material Weakness 2022

Fountain Christian Bilingual School Guayama. INC

PR

Reporting

We are actively seeking a company to provide guidance and assistance in report issuance, aiming to streamline and address these processes effectively.

View Audit 339219

Finding 519686 (2022-002)

Significant Deficiency 2022

Alivio Medical Center, Inc.

IL

Reporting § 200.512

The Center made the decision to change its independent audit firm. Per the Center’s bylaws, proposals from at least three other independent audit firms are required prior to making a selection. The process of selecting a new audit firm concluded past the deadline for submission of the audit report t...

The Center made the decision to change its independent audit firm. Per the Center’s bylaws, proposals from at least three other independent audit firms are required prior to making a selection. The process of selecting a new audit firm concluded past the deadline for submission of the audit report to the Federal Audit Clearinghouse. Upon the commencement of the fiscal year 2022 audit, the Center’s Chief Financial Officer resigned. There were delays in providing the supporting documentation to the auditors to complete the audit. Management recruited a new Chief Financial Officer, who started in January 2024. Management is fully committed to making any necessary changes to its financial reporting policies and procedures to comply with independent auditing of financial statements being completed in accordance with Federal and State Regulations, as well as with commonly accepted industry standards.

View Audit 338769

Finding 519386 (2022-003)

Significant Deficiency 2022

Serv Centers of New Jersey, Inc.

NJ

Reporting

Contact Person Responsible for Corrective Action: Bob Rosvold, CFO. Corrective Action Taken or Planned: A more timely monthly financial statement close process has been implemented with the creation of checklists and the upgrading of the financial system, including general ledger. Anticipated Comple...

Contact Person Responsible for Corrective Action: Bob Rosvold, CFO. Corrective Action Taken or Planned: A more timely monthly financial statement close process has been implemented with the creation of checklists and the upgrading of the financial system, including general ledger. Anticipated Completion Date: These improvements were initiated in fiscal year 2023 and are under further development in fiscal years 2024 and 2025.

View Audit 338297

Finding 519364 (2022-005)

Material Weakness 2022

Confluence Health

WA

Material Weakness Reporting Internal Control / Segregation of Duties

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

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

View Audit 338246

Finding 519363 (2022-004)

Material Weakness 2022

Confluence Health

WA

Material Weakness Reporting Internal Control / Segregation of Duties

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

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

View Audit 338246

Finding 519255 (2022-003)

Material Weakness 2022

Wakemed

NC

Reporting Material Weakness § 200.502 § 200.508 § 200.510

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

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

View Audit 337911

Finding 519254 (2022-002)

Significant Deficiency 2022

Wakemed

NC

Eligibility Cash Management Reporting

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

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

View Audit 337911

Finding 519253 (2022-001)

Significant Deficiency 2022

Wakemed

NC

Reporting Significant Deficiency

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

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

View Audit 337911

Finding 519126 (2022-012)

Material Weakness 2022

Cleveland County

OK

Subrecipient Monitoring Reporting § 200.303

ALN 21.023 - Lack of Internal Controls and Noncompliance with Reporting Requirement – Emergency Rental Assistance Program (Repeat Finding 2021-010) Beginning in October of 2021, the U.S. Department of the Treasury changed the ERA1 and ERA2 reporting requirements. In fact, each quarter of 2021 had va...

ALN 21.023 - Lack of Internal Controls and Noncompliance with Reporting Requirement – Emergency Rental Assistance Program (Repeat Finding 2021-010) Beginning in October of 2021, the U.S. Department of the Treasury changed the ERA1 and ERA2 reporting requirements. In fact, each quarter of 2021 had various reporting changes. The County changed the manner of reporting which did result in difficulty in reconciling. Previous reports had several changes and had to be re-reconciled and amended. Therefore, it was determined to change to reporting when the subrecipient spent, rather than the county. The County contacted the U.S. Department of the Treasury, who stated any, and all reports should be corrected in the next reporting cycle, rather than retrospectively. The County agrees that some of the prior County Clerk’s records were not in proper order. The County has a new Clerk in place as of July 1, 2024, and is working diligently to improve processes and procedures to prevent this from occurring again in the future. Cleveland County takes the auditor's findings seriously and has already implemented several improvements in documentation, monitoring, and reporting practices. Cleveland County is working toward improvements for fiscal year 2025 and has reconciled billing to align with the contract scope of work. However, we recognize the need for documented internal controls and are committed to addressing all recommendations to ensure compliance and transparency in future programs. The County appreciates the constructive feedback and will continue to refine its processes to betterserve its citizens.

View Audit 337659

Finding 519000 (2022-002)

Significant Deficiency 2022

The Health Care Authority of the City of Huntsville

AL

Reporting Internal Control / Segregation of Duties § 200.303 § 200.512

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

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

View Audit 337494

Finding 518978 (2022-004)

Significant Deficiency 2022

House of Hope Community Development Corporation

RI

Reporting § 200.512

FINDING 2022-003: Significant Deficiency Late Audit Reporting Recommendation: Implement procedures and controls to ensure that future audits are completed and submitted in a timely manner. Action Taken: Management agrees with the auditor's finding and recommendation. The new Depu...

FINDING 2022-003: Significant Deficiency Late Audit Reporting Recommendation: Implement procedures and controls to ensure that future audits are completed and submitted in a timely manner. Action Taken: Management agrees with the auditor's finding and recommendation. The new Deputy Director of Finance will play a key role in ensuring adherence to audit timelines and enhancing overall reporting efficiancy.

View Audit 337426

Finding 518977 (2022-003)

Significant Deficiency 2022

House of Hope Community Development Corporation

RI

Reporting Internal Control / Segregation of Duties § 200.303 § 200.334

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

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

View Audit 337426

Finding 518896 (2022-001)

Significant Deficiency 2022

Rural Coalition

DC

Reporting

Rural Coalition will be implementing clear, standardized procedures for all program and services. We will also be conducting a comprehensive review of current resource allocation and develop a more effective budget management plan so the grant funds can be managed efficiently removing the reporting ...

Rural Coalition will be implementing clear, standardized procedures for all program and services. We will also be conducting a comprehensive review of current resource allocation and develop a more effective budget management plan so the grant funds can be managed efficiently removing the reporting backlog we face frequently.

View Audit 337355

Finding 518846 (2024-005)

Significant Deficiency 2022

Somali Community Link INC

OH

Reporting § 200.302

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

View Audit 337223

Finding 518845 (2024-004)

Material Weakness 2022

Somali Community Link INC

OH

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

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

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

View Audit 337223 Questioned Costs: $1

Corrective Action Plans

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