Corrective Action Plans

Finding 10111 (2021-005)

Material Weakness 2021

Hill & Dales General Hospital and Subsidiary

MI

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.303

Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Finding Summary: The Organization claimed expenses that were reimbursed by other funding sources. These exp...

Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Finding Summary: The Organization claimed expenses that were reimbursed by other funding sources. These expenses were improperly included in the HHS Special Report which caused the report to be inaccurate. Responsible Individuals: Renee Henry, Director of Finance Corrective Action Plan: The Organization will implement internal control policies to ensure all amounts reimbursed by other funding sources are adequately documented and reduced from the eligible expenditure listing and ensure are properly recorded in the report required to be submitted to the federal agency. The Organization will also implement a review process to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: March 31, 2024

View Audit 13756 Questioned Costs: $1

Finding 10110 (2021-004)

Material Weakness 2021

Hill & Dales General Hospital and Subsidiary

MI

Subrecipient Monitoring Material Weakness Reporting § 200.303

Finding 2021-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Finding Summary: The Organization’s final lost revenue calculation identified as eligible and claimed under...

Finding 2021-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Finding Summary: The Organization’s final lost revenue calculation identified as eligible and claimed under the Provider Relief Fund program did not agree to the amount claimed in the report submitted to the Department of Health and Human Services for Period 1. Responsible Individuals: Renee Henry, Director of Finance Corrective Action Plan: Management will implement a control process and policy which includes monitoring over amounts reported relating to lost revenue amounts and the related calculation. Anticipated Completion Date: March 31, 2024

View Audit 13756

Finding 10109 (2021-003)

Material Weakness 2021

Hill & Dales General Hospital and Subsidiary

MI

Allowable Costs / Cost Principles Eligibility Material Weakness § 200.303

Finding 2021-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Finding Summary: The Organization did not have an adequate internal control policy in place to ensure revie...

Finding 2021-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Finding Summary: The Organization did not have an adequate internal control policy in place to ensure review and approval of the lost revenue calculation and report submitted to the Department of Health and Human Services for Period 1. Responsible Individuals: Renee Henry, Director of Finance Corrective Action Plan: Management will implement a control process and policy which includes a secondary review and approval of any future lost revenue calculation and report submitted under the federal program. Anticipated Completion Date: March 31, 2024

View Audit 13756

Finding 9575 (2021-001)

Material Weakness 2021

Cascadia Behavioral Healthcare, Inc.

OR

Reporting

In accordance with OMB Uniform Guidance, we have provided below Cascadia Behavioral Healthcare, Inc. and Affiliates’ response and corrective action plan addressing the findings in the “Report on Federal Awards in Accordance with the OMB Uniform Guidance” for the fiscal year that ended June 30, 2021....

In accordance with OMB Uniform Guidance, we have provided below Cascadia Behavioral Healthcare, Inc. and Affiliates’ response and corrective action plan addressing the findings in the “Report on Federal Awards in Accordance with the OMB Uniform Guidance” for the fiscal year that ended June 30, 2021. Finding 2021-001: Schedule of Expenditures of Federal Awards (SEFA) – Material Weakness in Internal Control over Compliance Management agrees with the finding and the auditor’s recommendation. Contact Person responsible for corrective action: Ryan Wilson Ryan.wilson@cascadiahealth.org Corrective Action Planned: For the year ended June 30, 2022, additional procedures were incorporated into our SEFA preparation process including steps to identify contracts containing federal award amounts. These steps included 1) additional layers of review by the revenue management team, 2) additional internal review of any confirmations received from state and local agencies indicating federal funding, and 3) additional review of the draft SEFA for completeness. Anticipated Completion Date: Management has resolved this matter.

View Audit 13243

Finding 9523 (2021-002)

Significant Deficiency 2021

Women's Coalition of St. Croix

VI

Reporting

The STOP Annual Subgrantee award was filed two-weeks late in FY2021 due to transitions in staff. In the future, WCSC’s Executive Director will ensure to file this report within thirty days of the end of the calendar year. She will work with program staff to collect the necessary statistics for the ...

The STOP Annual Subgrantee award was filed two-weeks late in FY2021 due to transitions in staff. In the future, WCSC’s Executive Director will ensure to file this report within thirty days of the end of the calendar year. She will work with program staff to collect the necessary statistics for the report beginning in December of each year, ensuring that there is ample time to prepare and submit the report. If there are any anticipated delays to filing this report, the Executive Director will obtain written permission for an extension from the grantor. Estimated Completion Date: Fiscal Year 2022

View Audit 13179

Finding 9521 (2021-001)

None 2021

Women's Coalition of St. Croix

VI

Reporting § 200.512

Transitions in WCSC financial personnel during and after year-end resulted delays to the audit process for this audit period (FY2021) and the subsequent audit period ending September 30, 2022. To address this problem, WCSC hired a fiscal consultant in August 2022 to oversee the fiscal office, prepar...

Transitions in WCSC financial personnel during and after year-end resulted delays to the audit process for this audit period (FY2021) and the subsequent audit period ending September 30, 2022. To address this problem, WCSC hired a fiscal consultant in August 2022 to oversee the fiscal office, prepare and complete all grant reports, and to coordinate all fiscal audits. WCSC also hired a full-time bookkeeper in October 2022 to conduct day-to-day financial transactions and to assist with audit and grant reporting. WCSC has already engaged its Auditors to conduct the FY2022 audit, which will commence immediately following the completion of the FY2021 audit. This would put WCSC on track to complete the FY2023 audit by June 2024, thus meeting the requirement to submit the audit to the Federal Audit Clearing House within nine months after year-end. The timeline for the completion of the two subsequent audits is as follows: Estimated Completion Date: June 30, 2024

View Audit 13179

Finding 9478 (2021-002)

Significant Deficiency 2021

County of Stephens

TX

Subrecipient Monitoring Reporting

The County will begin to track grant receipts and expenditures through the County Judge's office and put checks and balances in place with duplicate tracking by the County Treasurer. Grants will be tracked in an excel spreadsheet by State and Federal grant expenditures to ensure that the County is o...

The County will begin to track grant receipts and expenditures through the County Judge's office and put checks and balances in place with duplicate tracking by the County Treasurer. Grants will be tracked in an excel spreadsheet by State and Federal grant expenditures to ensure that the County is overseeing grants in a way that it will be prepared in the event that a siingle audit is triggered in any given year.

View Audit 12996

Finding 9284 (2021-005)

None 2021

Gary Chicago International Airport Authority

IN

Reporting

Audit Finding: Late Issuance of the 2021 Single Audit Reporting Package. Corrective Action Taken: We have taken the necessary steps to ensure timeliness of the financial close each year moving forward. Due to multiple restatements from the 2020 audit as well as adjustments/corrections to the financi...

Audit Finding: Late Issuance of the 2021 Single Audit Reporting Package. Corrective Action Taken: We have taken the necessary steps to ensure timeliness of the financial close each year moving forward. Due to multiple restatements from the 2020 audit as well as adjustments/corrections to the financials, it delayed the completion and issuance of the 2021 single audit. The authority understands and takes accountability for moving the audit forward in a timely manner. The late issuance of the 2021 audit will also effective the issuance of the 2022 audit however, we are confident that the 2023 audit will close timely and subsequent single audit filings. Responsible Parties: Dasha Chandler-Thompson, Finance Manage and Daniel Vicari, Executive Director. Anticipated Completion Date: 09/30/2024

View Audit 12719

Finding 9231 (2021-003)

Significant Deficiency 2021

400-408 Housing Development Fund Company INC

NY

Subrecipient Monitoring Reporting Significant Deficiency

Management has acknowledged a breach in protocol and is in the process of transferring the tenants' security deposits collected and held in the operating bank account to a segregated bank account.

View Audit 12646

Finding 9230 (2021-002)

Significant Deficiency 2021

400-408 Housing Development Fund Company INC

NY

HUD Housing Programs Cash Management Reporting

Management has acknowledged a breach in protocol and deposited the current year’s surplus cash on December 2, 2021.

View Audit 12646

Finding 9191 (2021-003)

Material Weakness 2021

Women's Center of East Texas

TX

Allowable Costs / Cost Principles Cash Management Material Weakness

A policy has been implemented that requires the HR Director (whome processed payroll) to submit biweekly payroll to the Executive Director to review and approve prior to payroll being issued. An electronic approval is saved for each pay period. Further, the Finance Director and Executive Director ha...

A policy has been implemented that requires the HR Director (whome processed payroll) to submit biweekly payroll to the Executive Director to review and approve prior to payroll being issued. An electronic approval is saved for each pay period. Further, the Finance Director and Executive Director have implemented frequent payroll allocation reviews to ensure that employees are properly allocating their time between funding sources. Secondly, when preparing invoices, the Grant Administrator submits drafts to the Finance Director and Executive Director to review and approve, and any billings that the Finance Director prepares are reviewed and approved by the Executive Director.

View Audit 12563

Finding 9188 (2021-001)

Material Weakness 2021

Women's Center of East Texas

TX

Allowable Costs / Cost Principles Cash Management Material Weakness

A policy has been implemented that requires the HR Director (whome processed payroll) to submit biweekly payroll to the Executive Director to review and approve prior to payroll being issued. An electronic approval is saved for each pay period. Further, the Finance Director and Executive Director ha...

A policy has been implemented that requires the HR Director (whome processed payroll) to submit biweekly payroll to the Executive Director to review and approve prior to payroll being issued. An electronic approval is saved for each pay period. Further, the Finance Director and Executive Director have implemented frequent payroll allocation reviews to ensure that employees are properly allocating their time between funding sources. Secondly, when preparing invoices, the Grant Administrator submits drafts to the Finance Director and Executive Director to review and approve, and any billings that the Finance Director prepares are reviewed and approved by the Executive Director.

View Audit 12563

Finding 8725 (2021-002)

Significant Deficiency 2021

City of Port Arthur

TX

Reporting Cash Management Significant Deficiency

Finding: 2021-002: Untimely and Inaccurate Reporting Corrective Action Plan Internal control policies and procedures surrounding reporting will be reviewed and updated, if necessary, to ensure that future reports are submitted accurately and timely. Person(s) Responsible Director of Finance Con...

Finding: 2021-002: Untimely and Inaccurate Reporting Corrective Action Plan Internal control policies and procedures surrounding reporting will be reviewed and updated, if necessary, to ensure that future reports are submitted accurately and timely. Person(s) Responsible Director of Finance Controller Anticipated Completion Date An updated policy manual was approved by the City Council on January 17,2023. New policies and procedures are expected to be fully implemented by March 31, 2024.

View Audit 11871

Finding 8676 (2021-001)

Material Weakness 2021

Okanogan County Child Development Association

WA

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Cash Management

Recommendation: The Association continue to work internally and with software vendors and outside consultants as needed to implement a chart of accounts and custom reporting tools that will assist them in complying with federal regulations. Explanation of disagreement with audit finding: There is...

Recommendation: The Association continue to work internally and with software vendors and outside consultants as needed to implement a chart of accounts and custom reporting tools that will assist them in complying with federal regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: Containment Upon discovering flaws in the new financial system we immediately hired a third‐party consultant who was experienced with our newly implemented software system (MIP) as well as fiscal best practices. This consultant was made available to the Fiscal team at the time, offering support in the transition to the new software. Root Cause Not all information was migrated into the new software system in a timely manner, making it difficult to use at its full potential. OCCDA had a large turnover in the fiscal team during the audit processing, making it difficult to find information or pull reports that were not fully migrated. The transition to the new fiscal software was during the height of the COVID‐19 pandemic, making it difficult to complete training and migration of the new system. Action Taken Immediately, the OCCDA Executive Director worked directly with the remaining team members to ensure business continuity in the fiscal department. Promptly, the chart of accounts was updated to track grants separately as well as any carry‐over funds. Also, an additional support membership was purchased through NP Solutions which specializes in MIP implementation and software. During the recruitment and hiring of staff, the new Fiscal/HR Director has delegated tasks that streamline duties, creating separation of duties where appropriate to ensure effective internal controls. The fiscal team positions have not only been delegated separate tasks but have also been provided in‐depth training on them. The leadership team has been trained on allowable costs and charged with reviewing their assigned budgets each month. Already our Fiscal Manager has implemented running monthly spending reports. The Leadership team members work monthly with the Fiscal Manager to review the reports and line‐by‐line reports when appropriate to seek clarification and ensure that we are reporting accurately. The Fiscal/HR Director, Fiscal Manager, and Fiscal Assistant were sent to an in‐depth MIP training this year to increase skills and knowledge of software to align with GAPP practices. Also, the Fiscal/HR Director has completed a Uniform Guidance training this year and our Fiscal Manager will be taking this training in the coming year. Moving forward in 2024, the Fiscal Manager will continue to update the chart of accounts to organize the general ledger and enhance our reports for ease of use and ensure accuracy. On or before March 2024 the chart of accounts will be updated. For example, each time a new funding source is received a new program code will be created allowing for tracking and reporting. Our internal policy indicates that we will have regular reviews and ensure compliance. Our new Fiscal Manager has current relationships with the software team allowing for questions to be asked and answered quickly. Name(s) of contact person(s) responsible for corrective action: Fiscal Manager Planned completion date for corrective action plan: In process to be completed by March 2024 (Q1)

View Audit 11832

Finding 8646 (2021-004)

Significant Deficiency 2021

Shoshone-Paiute Tribe of the Duck Valley Indian Reservation

NV

Reporting

The audit report has not been timely completed and submitted to the funding agency or the federal audit clearinghouse.

View Audit 11801

Finding 8646 (2021-004)

Significant Deficiency 2021

Shoshone-Paiute Tribe of the Duck Valley Indian Reservation

NV

Reporting

Contact person Mike Cecco, CFO

View Audit 11801

Finding 8646 (2021-004)

Significant Deficiency 2021

Shoshone-Paiute Tribe of the Duck Valley Indian Reservation

NV

Reporting

Anticipation completion Date 6/30/2024

View Audit 11801

Finding 8646 (2021-004)

Significant Deficiency 2021

Shoshone-Paiute Tribe of the Duck Valley Indian Reservation

NV

Reporting

FY 2022 is in arrears. This finding will continue until we have submitted the FY 2023 audit no later than June 30, 2024; then, this finding will not repeat.

View Audit 11801

Finding 8603 (2021-001)

None 2021

Alma Family Services

CA

Reporting Internal Control / Segregation of Duties § 200.507

View of Responsible Officials and Planned Corrective Actions: Despite Alma having a well-established accounting process in place to ensure the timely and accurate generation of financial reports, the delays in presenting schedules during this audit were influenced by unforeseen circumstances. Notabl...

View of Responsible Officials and Planned Corrective Actions: Despite Alma having a well-established accounting process in place to ensure the timely and accurate generation of financial reports, the delays in presenting schedules during this audit were influenced by unforeseen circumstances. Notably, scheduling conflicts arose due to the audit coinciding with either concurrent program reviews or audits mandated by the County, compelling Alma to prioritize accordingly. Alma is proactively adapting its infrastructure and operational framework to enhance efficiency continuously. Management expresses confidence in the effectiveness of the current plan and response, believing it will mitigate similar issues in future audits. Personnel Responsible and position: Lourdes Caracoza, CEO/President Wally Racela, Chief Financial Officer Anticipated Completion: December 31, 2023

View Audit 11675

Finding 8453 (2021-005)

Material Weakness 2021

Veterans Transition Center of California

CA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.307

In response to finding number 2021-SA5, management agrees with the finding and will design, implement, and maintain policies and procedures that ensure program income is tracked and expended appropriately.

View Audit 11397 Questioned Costs: $1

Finding 8452 (2021-004)

Material Weakness 2021

Veterans Transition Center of California

CA

Questioned Costs Reporting

In response to finding number 2021-SA4, management agrees with the finding and will design, implement, and maintain policies and procedures that ensure Federal grant reporting is complete, accurate, and timely.

View Audit 11397 Questioned Costs: $1

Finding 8450 (2021-002)

Material Weakness 2021

Veterans Transition Center of California

CA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303

In response to finding number 2021-SA2, management agrees with the finding and will design, implement, and maintain internal controls over all direct and material compliance areas (other than eligibility). Additionally, management will ensure that the Organization’s internal controls comply with the...

In response to finding number 2021-SA2, management agrees with the finding and will design, implement, and maintain internal controls over all direct and material compliance areas (other than eligibility). Additionally, management will ensure that the Organization’s internal controls comply with the Comptroller General of the United States’s “Standards for Internal Control in the Federal Government” or COSO’s “Internal Control Integrated Framework”.

View Audit 11397 Questioned Costs: $1

Finding 8449 (2021-001)

Material Weakness 2021

Veterans Transition Center of California

CA

Questioned Costs Reporting

In response to finding number 2021-SA1, management agrees with the finding and will design, implement, and maintain internal controls that ensure the figures reported on the SEFA properly represent expenditures incurred in the Organization’s accounting software; and that the reported figures are rec...

In response to finding number 2021-SA1, management agrees with the finding and will design, implement, and maintain internal controls that ensure the figures reported on the SEFA properly represent expenditures incurred in the Organization’s accounting software; and that the reported figures are reconciled timely to the general ledger. Further, management will take measures to train personnel in SEFA reporting requirements to help ensure that the preparation of the SEFA report is accurate and ties to the general ledger.

View Audit 11397 Questioned Costs: $1

Finding 8247 (2021-006)

Material Weakness 2021

Round Valley Indian Tribes

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

The Tribes will ensure compliance with future reporting requirements, such as review and enhancement of reporting procedures, personnel training, and monitoring and oversight by management.

View Audit 10880

Finding 8038 (2021-002)

Significant Deficiency 2021

Caldwell County, Missouri

MO

Subrecipient Monitoring Reporting § 200.510

Our office will collect all documentation of awards and enter each award into the budget. We will establish a separate folder for each grant award and retain copies of the grant award documents, vendor quotes, invoices, and payments in the office of the county clerk. We will obtain receipts of reve...

Our office will collect all documentation of awards and enter each award into the budget. We will establish a separate folder for each grant award and retain copies of the grant award documents, vendor quotes, invoices, and payments in the office of the county clerk. We will obtain receipts of revenues.

View Audit 10535

Corrective Action Plans

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