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Corrective Action Plans

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Finding 369900 (2022-002)
Material Weakness 2022
Vermont Association for Mental Health and Addiction Recovery, INC
VT
Internal Control / Segregation of Duties Reporting Special Tests & Provisions
Recommendation: We recommend to correct these deficiencies, management would need to hire personnel with adequate accounting experience to perform these functions. The Town would need to weigh the costs of these corrections verse the benefit. Action Taken: We agree with the recommendation, we have...
Recommendation: We recommend to correct these deficiencies, management would need to hire personnel with adequate accounting experience to perform these functions. The Town would need to weigh the costs of these corrections verse the benefit. Action Taken: We agree with the recommendation, we have hired a 3rd party bookkeeper who is a CPA with multiple years of Non-Profit experience and grant reporting.
View Audit 291395
Finding 369777 (2022-010)
Material Weakness 2022
City of Warren
MN
Questioned Costs Reporting Internal Control / Segregation of Duties
Contact Person – Shannon Mortenson, City Administrator Corrective Action Plan – The City will establish a policy to ensure all reports are submitted timely. Completion Date - January 31, 2024
Contact Person – Shannon Mortenson, City Administrator Corrective Action Plan – The City will establish a policy to ensure all reports are submitted timely. Completion Date - January 31, 2024
View Audit 291301
Finding 369734 (2022-002)
Significant Deficiency 2022
The Township of Upper Darby
PA
Reporting Internal Control / Segregation of Duties
Corrective Action: The Township has implemented financial policies and procedures to ensure a timely independent audit process and subsequent timely filing of the audit with the Federal Audit Clearinghouse.
Corrective Action: The Township has implemented financial policies and procedures to ensure a timely independent audit process and subsequent timely filing of the audit with the Federal Audit Clearinghouse.
View Audit 291182
Finding 369732 (2022-001)
Material Weakness 2022
The Township of Upper Darby
PA
Internal Control / Segregation of Duties Reporting
Corretive Action: The Controller with the assistance of a third-party accounting firm are in the process of developing formal written internal controls and procedures at the department level with input from department staff.
Corretive Action: The Controller with the assistance of a third-party accounting firm are in the process of developing formal written internal controls and procedures at the department level with input from department staff.
View Audit 291182
Finding 369691 (2022-001)
Material Weakness 2022
Kansas Alliance for Wetlands and Streams INC
KS
Internal Control / Segregation of Duties Cash Management Reporting
2022-001 Financial Reporting Oversight Responsible Party: Libby Albers, Executive Director Implementation Date: 2/15/2024 1. KAWS Executive Director, will continue to log deposits and deposit documentation in an internal spreadsheet and reporting each deposit to the KAWS Accountant via email. The ...
2022-001 Financial Reporting Oversight Responsible Party: Libby Albers, Executive Director Implementation Date: 2/15/2024 1. KAWS Executive Director, will continue to log deposits and deposit documentation in an internal spreadsheet and reporting each deposit to the KAWS Accountant via email. The Conservation Easement Specialist will check the deposit spreadsheet against the monthly bank statements to ensure that all deposits are present. This extra reviewer of bank statements is independent of any of the parties handling the deposits. 2. Executive Director will request quarterly Profit and Loss and Transaction reports by Job from the outsourced accountant, and compare the data against the expense reporting platforms, payment requests, and bank statements. 3. Executive Director will discuss the issue of reallocation of expenses being changed after quarterly reports have been provided and request that the outsourced accountant locks the Quickbooks data at the end of each month’s reconciliation. Should the data need to be unlocked the outsourced accountant will notify the Executive Director. Although this still places Quickbooks control with the accountant, it will create additional steps required of the accountant.
View Audit 291137
Finding 369682 (2022-001)
Significant Deficiency 2022
Hands of Healing Residential Treatment Center, Inc.
TX
Questioned Costs Procurement, Suspension & Debarment Reporting
Hands of Healing Residential Treatment Center, Inc. respectfully submits the following correction action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Doeren Mayhew, 2600 North Loop West, Suite 600, Houston, TX 77092. The finding discussed belo...
Hands of Healing Residential Treatment Center, Inc. respectfully submits the following correction action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Doeren Mayhew, 2600 North Loop West, Suite 600, Houston, TX 77092. The finding discussed below from the Schedule of Findings and Questioned Costs (the schedule) for the year ended December 31, 2022 is numbered consistently with the number assigned in the schedule. Federal Award Finding 2022-001. Corrective Action Plan: Management understands that the annual audit must be filed within nine months of the organization's year-end and adhere to specific reporting requirements of federal grant contracts. Management has put additional processes in place within the chain of command to ensure that reports are submitted timely by the due date. Staff tasked with completing the reports will also be coached on the importance of drafting reports well in advance of the due date to give time for review, approval, and submittal by management. Contact Person Responsible for Corrective Action: Mr. Victor Weetly, President. Anticipated Completion Date: The corrective action plan will be completed by February 29, 2024.
View Audit 291098
Finding 369676 (2022-003)
Material Weakness 2022
Earlham Community School District
IA
Internal Control / Segregation of Duties Reporting
We will continue to review procedures and re-align duties to obtain the maximum internal control possible.
We will continue to review procedures and re-align duties to obtain the maximum internal control possible.
View Audit 291081
Finding 369645 (2022-005)
Material Weakness 2022
Fremont-Mills Community School District
IA
Internal Control / Segregation of Duties Reporting
Compensating controls to address the segregation of duties internal control deficiency due to limited staff size have been established in these areas to obtain the maximum internal control possible under current circumstances. Additionally, an operational sharing agreement for Business Manager Serv...
Compensating controls to address the segregation of duties internal control deficiency due to limited staff size have been established in these areas to obtain the maximum internal control possible under current circumstances. Additionally, an operational sharing agreement for Business Manager Services was entered into with a neighboring district for fiscal years 2023 and 2024 to further address the segregation of duties internal control weakness.
View Audit 291025
Finding 369558 (2022-001)
Significant Deficiency 2022
Altius Institute for Biomedical Sciences
WA
Questioned Costs Reporting Significant Deficiency § 200.512
Management’s Corrective Action Plan For the Year Ended December 31, 2022 Finding Number 2022-001 Contact Person(s): Chanya Swartz, Director of Finance and Controller Corrective Action Planned: Over the last few years, we had significant turn-over of personnel within the finance and accounting depart...
Management’s Corrective Action Plan For the Year Ended December 31, 2022 Finding Number 2022-001 Contact Person(s): Chanya Swartz, Director of Finance and Controller Corrective Action Planned: Over the last few years, we had significant turn-over of personnel within the finance and accounting department and had an ERP implementation to upgrade our accounting system in 2023. They impacted our processes and things getting done in a timely manner. However, we believe that we have now turned the corner and the personnel situation and processes are now under control. This should ensure that all processes including the submission of “Single Audit Reports” will get back on track and we do not anticipate any more delays moving forward. Anticipated Completion Date: Date completed September 30, 2024
View Audit 290871
Ozark Christian College
MO
Reporting § 200.328 § 200.329
Planned Corrective Action: We will review existing reporting procedures and ensure appropriate adjustments are made for any new federal awards’ specific reporting compliance requirements or when any existing federal awards’ specific reporting requirements are updated. Name of Contact Person: Rachel ...
Planned Corrective Action: We will review existing reporting procedures and ensure appropriate adjustments are made for any new federal awards’ specific reporting compliance requirements or when any existing federal awards’ specific reporting requirements are updated. Name of Contact Person: Rachel Watson, Business Office Director/Controller, watson.rachel@occ.edu Anticipated completion date: Immediate implementation of corrective action, only applicable when new funds are awarded or existing federal awards’ reporting requirements change.
View Audit 290830
Finding 369476 (2022-001)
Significant Deficiency 2022
City of St. Louis Mental Health Board of Trustees
MO
Subrecipient Monitoring Reporting Significant Deficiency
FFATA Reporting U.S. Department of Health and Human Services Recommendation: We recommend the agency implement a process that includes tracking timely submission of the Federal Funding Accountability and Transparency Act (FFATA) reports and training employees on the FFATA reporting requirements. Exp...
FFATA Reporting U.S. Department of Health and Human Services Recommendation: We recommend the agency implement a process that includes tracking timely submission of the Federal Funding Accountability and Transparency Act (FFATA) reports and training employees on the FFATA reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Annually, the City of St. Louis Mental Health Board of Trustees will review expenditures to ensure FFATA reporting is completed for all eligible subrecipient and contracts. Name(s) of the contact person(s) responsible for corrective action: Serena Muhammad Planned completion date for corrective action plan: September 30, 2024
View Audit 290694
Finding 369475 (2022-002)
Significant Deficiency 2022
Jackson Park Hospital Foundation
IL
Questioned Costs Reporting Significant Deficiency
Recommendation: We recommend the Hospital design controls to ensure documentation is completed timely and sufficiently on how costs are necessary to respond to COVID-19. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to findi...
Recommendation: We recommend the Hospital design controls to ensure documentation is completed timely and sufficiently on how costs are necessary to respond to COVID-19. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Hospital will ensure that controls are put into place to report lost revenues in accordance with HHS guidelines. Name of the contact person responsible for corrective action: Barry Mandell, VP Special Projects. Planned completion date for corrective action plan: April 1, 2022
View Audit 290693
Finding 369474 (2022-001)
Significant Deficiency 2022
Jackson Park Hospital Foundation
IL
Questioned Costs Allowable Costs / Cost Principles Reporting
Recommendation: We recommend the Hospital design controls to ensure documentation is completed timely and sufficiently on how costs are necessary to respond to COVID-19. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management has identified that th...
Recommendation: We recommend the Hospital design controls to ensure documentation is completed timely and sufficiently on how costs are necessary to respond to COVID-19. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management has identified that the Hospital has more than a sufficient amount of lost revenues related to COVID-19 to offset this difference. Action taken in response to finding: The Hospital will ensure that controls are put into place to capture Covid specific costs in accordance with HHS guidelines. Name of the contact person responsible for corrective action: Barry Mandell, VP Special Projects. Planned completion date for corrective action plan: April 1, 2022
View Audit 290693 Questioned Costs: $1
Finding 369453 (2022-004)
Significant Deficiency 2022
Boone County Fiscal Court
KY
Subrecipient Monitoring Reporting § 200.331
The guidance was unclear when reporting began in 2021. The delineation is now understood and will be corrected in the next quarterly report to the Treasury Department. Anticipated Completion Date: January 31, 2024.
The guidance was unclear when reporting began in 2021. The delineation is now understood and will be corrected in the next quarterly report to the Treasury Department. Anticipated Completion Date: January 31, 2024.
View Audit 290646
Finding 369403 (2022-001)
Significant Deficiency 2022
Workforce Alliance of the North Bay
CA
Reporting Significant Deficiency Internal Control / Segregation of Duties
The Alliance will meet the annual filing requirements by implementing new procedures to the single Audit process. The Alliance will create a fiscal policy to construct a project timeline to have a completed Single Audit process. The Alliance will create a fiscal policy to construct a project timelin...
The Alliance will meet the annual filing requirements by implementing new procedures to the single Audit process. The Alliance will create a fiscal policy to construct a project timeline to have a completed Single Audit process. The Alliance will create a fiscal policy to construct a project timeline to have a completed Single Audit prior to the annual deadline. This detailed project timeline will ensure that the Alliance completes the necessary subtasks to complete the Single Audit on time in future years.
View Audit 290597
Finding 367431 (2022-008)
Material Weakness 2022
Municipality of Utuado
PR
Questioned Costs Cash Management Material Weakness
The finding was corrected. The payer of the Concessionaire, which has access to the system, was appointed. According to internal procedure, she does not issue payments until she is sure that the account has a budget.
The finding was corrected. The payer of the Concessionaire, which has access to the system, was appointed. According to internal procedure, she does not issue payments until she is sure that the account has a budget.
View Audit 290434
Finding 367392 (2022-010)
Significant Deficiency 2022
Northampton County
NC
Questioned Costs Eligibility Reporting
Finding 2022-010 Untimely Review of SSI Termination Name of contact: Felicia Bullock, Family and Children's Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2022-011 Inadequate Requests for Information Name of contact: Corrective Action: Proposed Completion Date: Corrective A...
Finding 2022-010 Untimely Review of SSI Termination Name of contact: Felicia Bullock, Family and Children's Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2022-011 Inadequate Requests for Information Name of contact: Corrective Action: Proposed Completion Date: Corrective Actions for finding 2022-006, 2022-007, 2022-008, 2022-009 and 2022-010 also apply to State Award findings. Section IV - State Award Findings and Question Costs The week of March 20, 2023 with implementation effective immediately. Meeting with Adult Medicaid supervisor to ensure Family and Children's Medicaid staff receives terminated SSI cases in a timely manner to ensure a timely review of those cases.
View Audit 290407
Finding 367386 (2022-006)
Material Weakness 2022
Coffeyville Regional Medical Center, Inc.
KS
Questioned Costs Material Weakness Reporting
Reference Number 2022-004, 2022-005, and 2022-006 Finding summary: These three findings all related to specific provider relief fund reporting of lost revenues by the Medical Center. The Medical Center experienced turnover in key accounting staff during the start of 2023 which resulted in the upda...
Reference Number 2022-004, 2022-005, and 2022-006 Finding summary: These three findings all related to specific provider relief fund reporting of lost revenues by the Medical Center. The Medical Center experienced turnover in key accounting staff during the start of 2023 which resulted in the updated option iii reporting for lost revenues. To be modified. The current staff modified the method of calculating loss revenues from the Phase 1 reporting and were unaware of the potential impact on previously reported funding. Errors were also noted in the accumulation of data and in the reporting which was due to inadequate control processes surrounding the review and approval of the computation by someone independent of the calculation process. Corrective Action Plan: We do not anticipate having to complete a future provider relief fund reporting submission. However, for any future federal grant reporting requirements we will implement a process to have an independent individual review the reporting information along with supporting documentation prior to submission of the grant reporting form. The independent review will be documented in writing as to the date and time of the review and approval. Anticipated Completion Date: This will be implemented with the next federal grant reporting.
View Audit 290401 Questioned Costs: $1
Finding 367385 (2022-005)
Material Weakness 2022
Coffeyville Regional Medical Center, Inc.
KS
Questioned Costs Material Weakness Reporting
Reference Number 2022-004, 2022-005, and 2022-006 Finding summary: These three findings all related to specific provider relief fund reporting of lost revenues by the Medical Center. The Medical Center experienced turnover in key accounting staff during the start of 2023 which resulted in the upda...
Reference Number 2022-004, 2022-005, and 2022-006 Finding summary: These three findings all related to specific provider relief fund reporting of lost revenues by the Medical Center. The Medical Center experienced turnover in key accounting staff during the start of 2023 which resulted in the updated option iii reporting for lost revenues. To be modified. The current staff modified the method of calculating loss revenues from the Phase 1 reporting and were unaware of the potential impact on previously reported funding. Errors were also noted in the accumulation of data and in the reporting which was due to inadequate control processes surrounding the review and approval of the computation by someone independent of the calculation process. Corrective Action Plan: We do not anticipate having to complete a future provider relief fund reporting submission. However, for any future federal grant reporting requirements we will implement a process to have an independent individual review the reporting information along with supporting documentation prior to submission of the grant reporting form. The independent review will be documented in writing as to the date and time of the review and approval. Anticipated Completion Date: This will be implemented with the next federal grant reporting.
View Audit 290401
Finding 367384 (2022-004)
Material Weakness 2022
Coffeyville Regional Medical Center, Inc.
KS
Questioned Costs Material Weakness Reporting
Reference Number 2022-004, 2022-005, and 2022-006 Finding summary: These three findings all related to specific provider relief fund reporting of lost revenues by the Medical Center. The Medical Center experienced turnover in key accounting staff during the start of 2023 which resulted in the upda...
Reference Number 2022-004, 2022-005, and 2022-006 Finding summary: These three findings all related to specific provider relief fund reporting of lost revenues by the Medical Center. The Medical Center experienced turnover in key accounting staff during the start of 2023 which resulted in the updated option iii reporting for lost revenues. To be modified. The current staff modified the method of calculating loss revenues from the Phase 1 reporting and were unaware of the potential impact on previously reported funding. Errors were also noted in the accumulation of data and in the reporting which was due to inadequate control processes surrounding the review and approval of the computation by someone independent of the calculation process. Corrective Action Plan: We do not anticipate having to complete a future provider relief fund reporting submission. However, for any future federal grant reporting requirements we will implement a process to have an independent individual review the reporting information along with supporting documentation prior to submission of the grant reporting form. The independent review will be documented in writing as to the date and time of the review and approval. Anticipated Completion Date: This will be implemented with the next federal grant reporting.
View Audit 290401
Finding 367227 (2022-005)
Material Weakness 2022
Municipality of Barceloneta
PR
Procurement, Suspension & Debarment Questioned Costs Material Weakness
Statement of Condition: The Municipality’s disbursement test, we tested 113 vouchers and found 2 disbursements without System Award Management number or not active. Correction Action Planned for 2022-005: To forestall similar situations in the future, we are actively reviewing and fortifying our su...
Statement of Condition: The Municipality’s disbursement test, we tested 113 vouchers and found 2 disbursements without System Award Management number or not active. Correction Action Planned for 2022-005: To forestall similar situations in the future, we are actively reviewing and fortifying our supplier’s selection processes while implementing robust contractual measures. It is important to underscore that this response was an exceptional one to address non-compliance, and we are steadfast in our commitment to avoiding such occurrences in the future. Anticipated Completion Date JUNE 2023
View Audit 290336
Finding 367220 (2022-004)
Material Weakness 2022
Municipality of Barceloneta
PR
HUD Housing Programs Reporting Material Weakness
Statement of Condition: The Municipality did not submit the required Financial Reports to the US Housing and Urban Development of fiscal year ending June 30, 2022, during the required period. The unaudited Financial Report was not submitted on or before August 31, 2022, also, the audited Financial R...
Statement of Condition: The Municipality did not submit the required Financial Reports to the US Housing and Urban Development of fiscal year ending June 30, 2022, during the required period. The unaudited Financial Report was not submitted on or before August 31, 2022, also, the audited Financial Report was not submitted on or before September 30, 2022. Correction Action Planned for 2022-004: For the upcoming fiscal year, we are actively seeking a company to provide guidance and assistance in reporting issuance, aiming to streamline and address these processes effectively. Anticipated Completion Date JUNE 2023
View Audit 290336
Finding 367218 (2022-003)
Material Weakness 2022
Municipality of Barceloneta
PR
Material Weakness Reporting
Statement of Condition: Preliminary Financial reports and programs financial information were available on August 22, 2023, to prepare the Single Audit Reporting Package. Correction Action Planned for 2022-003: We are actively seeking a company to provide guidance and assistance in report issuance...
Statement of Condition: Preliminary Financial reports and programs financial information were available on August 22, 2023, to prepare the Single Audit Reporting Package. Correction Action Planned for 2022-003: We are actively seeking a company to provide guidance and assistance in report issuance, aiming to streamline and address these processes effectively. Anticipated Completion Date JUNE 2023
View Audit 290336
Finding 367180 (2022-065)
Material Weakness 2022
State of Nevada
NV
Reporting Allowable Costs / Cost Principles Material Weakness § 200.303
Finding 2022-065: Reporting. The Nevada Division of Public and Behavioral Health (DPBH) did not maintain underlying documentation to support the amounts reported in annual and midyear Performance Progress Reports (PPR). Nevada Division of Public and Behavioral Health response: The Nevada Division of...
Finding 2022-065: Reporting. The Nevada Division of Public and Behavioral Health (DPBH) did not maintain underlying documentation to support the amounts reported in annual and midyear Performance Progress Reports (PPR). Nevada Division of Public and Behavioral Health response: The Nevada Division of Public and Behavioral Health accepts this finding and will initiate corrective action as described below. Corrective Action: The Bureau of Behavioral Health, Wellness, and Prevention (BBHWP) developed a document retention system to ensure subgrantee grant reports and supporting documentation is saved and is easily accessible for each award period. This new system will remove unnecessary barriers for accessing reports moving forward. Date of Completion: BBHWP: December 2023 Responsible Party: BBHWP State Opioid Response Unit: Breanne Van Dyne, Health Program Manager II If you have any questions, please contact Kitty DeSocio, Administrative Services Officer IV at 775-684-3481 or by email at kdesocio@health.nv.gov.
View Audit 290300
Finding 367178 (2022-063)
Significant Deficiency 2022
State of Nevada
NV
Matching / Level of Effort / Earmarking Reporting § 200.303
Finding 2022-063: Earmarking. The Division of Public and Behavioral Health (DPBH) did not have evidence of monitoring administrative, infrastructure development, data collection, and reporting costs to ensure they did not exceed the maximum allowable. Nevada Division of Public and Behavioral Health ...
Finding 2022-063: Earmarking. The Division of Public and Behavioral Health (DPBH) did not have evidence of monitoring administrative, infrastructure development, data collection, and reporting costs to ensure they did not exceed the maximum allowable. Nevada Division of Public and Behavioral Health response: The Nevada Division of Public and Behavioral Health accepts this finding and will initiate corrective action as described below. Corrective Action: The Bureau of Behavioral Health, Wellness, and Prevention (BBHWP) developed a tracking tool in the federal grant reconciliation to monitor BBHWP and the sub-recipients Administration Costs and Reporting Costs that is gathered from BBHWP expenses and monthly Requests for Reimbursements from sub-recipients. Data collection is requested from the Sub-Recipients on a quarterly basis to ensure that the data costs do not exceed the maximum allowable by the grant. Date of Completion: BBHWP: December 2023 Responsible Party: BBHWP State Opioid Response Unit: Theresa Callahan, Management Analyst II If you have any questions, please contact Kitty DeSocio, Administrative Services Officer IV at 775-684-3481 or by email at kdesocio@health.nv.gov.
View Audit 290300
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