Corrective Action Plans

Finding 395057 (2021-010)

Material Weakness 2021

Stephens County

OK

Reporting

The BOCC is working to design and implement internal controls, to ensure accurate reporting of revenues on the Schedule of Federal Awards (SEFA) and ensure compliance with federal requirments over federal awards.

View Audit 304990

Finding 394676 (2021-016)

Material Weakness 2021

Housing Authority of the City of Fayetteville

IL

Procurement, Suspension & Debarment Reporting Internal Control / Segregation of Duties

Views of Responsible Officials and Planned Corrective Actions: Owing to a transition in staff, the current administration faced challenges in locating and providing requested documents that substantiate all expenditures. The Executive Director and Director of Finance have diligently undertaken meas...

Views of Responsible Officials and Planned Corrective Actions: Owing to a transition in staff, the current administration faced challenges in locating and providing requested documents that substantiate all expenditures. The Executive Director and Director of Finance have diligently undertaken measures since the commencement of their roles to establish a systematic electronic filing system for all documentation, alongside a meticulous arrangement for the preservation of original documents, facilitating convenient and efficient review processes.

View Audit 304565

Finding 394595 (2021-002)

Significant Deficiency 2021

The County of Lebanon, Pennsylvania

PA

Internal Control / Segregation of Duties Material Weakness Reporting

Segregation of Duties over Reporting: The Department was in need of additional accounting personnel and as of December 2023 a new employee was hired so adequate oversight will be corrected going forward.

View Audit 304491

Finding 394547 (2021-104)

Significant Deficiency 2021

Pancare of Florida, INC

FL

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.328

Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hired a new Chief Financ...

Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its reporting policy and implemented the changes. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented

View Audit 304417

Finding 394531 (2021-108)

Significant Deficiency 2021

Pancare of Florida, INC

FL

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.328

Lack of Documentation Related to Reporting Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within th...

Lack of Documentation Related to Reporting Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implement

View Audit 304417

Finding 394033 (2021-001)

Significant Deficiency 2021

Envision Community Services INC

IL

Reporting Internal Control / Segregation of Duties

We will have our current accountant set a schedule for performing monthly closes of the financial statements so they can be presented in summary format to management and the board of directors. We will require that the President/CEO and other key members of the management team and the board of direc...

We will have our current accountant set a schedule for performing monthly closes of the financial statements so they can be presented in summary format to management and the board of directors. We will require that the President/CEO and other key members of the management team and the board of directors review the monthly financial reports provided by the accountant so that all board members understand the financial position and results of activities of ECS on a regular and consistent basis. Finally, we will develop a transition plan with procedures requiring that whomever is responsible for the accounting and financial reporting function for ECS reconcile all financial accounts and close the financial records for the month prior to departure to ensure a smooth transition ECS’s accounting and financial reporting function to the next person responsible for its maintenance

View Audit 304159

Finding 394020 (2021-003)

Significant Deficiency 2021

Abilities Network, Inc.

MD

Subrecipient Monitoring Reporting Significant Deficiency § 200.303 § 200.328 § 200.329

U.S. Department of Health and Human Services 2021-003 Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend that the Organization design, implement and monitor internal controls over reporting as well as maintain source documentation to sup...

U.S. Department of Health and Human Services 2021-003 Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend that the Organization design, implement and monitor internal controls over reporting as well as maintain source documentation to support amounts reported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will maintain evidence of timely submission of reports, review of reports and documentation to support amounts reported. Additionally, management will implement a formal documentation retention policy. Name of the contact person responsible for corrective action: Lyn Elliot, CEO Planned completion date for corrective action plan: 3/1/2024

View Audit 304152

Finding 393843 (2023-002)

Significant Deficiency 2021

Hospital Comunitario Buen Samaritano, Inc.

PR

Subrecipient Monitoring Reporting Significant Deficiency § 200.512

We agree that we have not been reporting on a timely basis current findings and results. We have established a calendar to ensure that the submission of all required annual reporting, be strictly followed by our newly created job position (Federal Funding Accounting Coordinator). The plan will be ap...

We agree that we have not been reporting on a timely basis current findings and results. We have established a calendar to ensure that the submission of all required annual reporting, be strictly followed by our newly created job position (Federal Funding Accounting Coordinator). The plan will be approved by the Board and implemented no later than April 26th, 2024.

View Audit 304036

Finding 393829 (2021-003)

Material Weakness 2021

Okeene Municipal Hospital and Schallmo Authority

OK

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles

Given the complexity of the reporting requirements, including changing FAQ's, reporting deadline extensions, and the inability to update reporting to reflect expenses incurred within the guidelines such as lost revenue the Authority will apply such expenses as offsets to its provider relief fund dis...

Given the complexity of the reporting requirements, including changing FAQ's, reporting deadline extensions, and the inability to update reporting to reflect expenses incurred within the guidelines such as lost revenue the Authority will apply such expenses as offsets to its provider relief fund distributions. The Authority will continue to monitor the Health and Human Resources Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements and the most recently distributed Provide Relief Fund frequently asked questions which provide details on requirements related to the program.

View Audit 304032 Questioned Costs: $1

Finding 393828 (2021-002)

Material Weakness 2021

Okeene Municipal Hospital and Schallmo Authority

OK

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles

Given the complexity of the reporting requirements, including changing FAQ's, reporting deadline extensions, and the inability to update reporting to reflect expenses incurred within the guidelines such as lost revenue the Authority will apply such expenses as offsets to its provider relief fund dis...

Given the complexity of the reporting requirements, including changing FAQ's, reporting deadline extensions, and the inability to update reporting to reflect expenses incurred within the guidelines such as lost revenue the Authority will apply such expenses as offsets to its provider relief fund distributions. The Authority will continue to monitor the Health and Human Resources Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements and the most recently distributed Provide Relief Fund frequently asked questions which provide details on requirements related to the program.

View Audit 304032 Questioned Costs: $1

Finding 393784 (2021-012)

Significant Deficiency 2021

Housing Authority of the City of Pueblo

CO

HUD Housing Programs Reporting Significant Deficiency

U.S. Department of Housing and Urban Development – CFDA #14.182/14.856 Section 8 Project-based Cluster– 2021 Reporting Significant Deficiency in Internal Control over Compliance Finding Summary: The Authority was not able to provide signed and dated copies of HUD-52663 and HUD-52681 reports submitte...

U.S. Department of Housing and Urban Development – CFDA #14.182/14.856 Section 8 Project-based Cluster– 2021 Reporting Significant Deficiency in Internal Control over Compliance Finding Summary: The Authority was not able to provide signed and dated copies of HUD-52663 and HUD-52681 reports submitted in 2021. In addition, the Authority did not submit timely revised reports after they had received notification from certain landlords who were opting out of the Mod Rehab program in 2021. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: Due to staff turnover at the Executive level and in the Accounting Department, these forms were misplaced and we were not able to reproduce them. We have established procedures to ensure that all forms filed with HUD will be filed timely and saved electronically so that this should not happen again. Anticipated Completion Date: January 2023

View Audit 303983

Finding 393764 (2021-003)

Significant Deficiency 2021

Gateway Community Health Centers, Inc.

NC

Reporting Significant Deficiency Internal Control / Segregation of Duties

Management Response: This finding has been corrected, management concur that in the past, we have been late in filing both our form 990 with the IRS and our Audit report with the Federal Audit Clearinghouse (FAC). For filing our 990 taxes return our tax year ends September 30, and with the submissio...

Management Response: This finding has been corrected, management concur that in the past, we have been late in filing both our form 990 with the IRS and our Audit report with the Federal Audit Clearinghouse (FAC). For filing our 990 taxes return our tax year ends September 30, and with the submission of this Audit we are current. Management has put in place procedures and processes to ensure that the return is filed in a timely manner. Gateway’s Board is regularly updated regarding the Audits and the 990 this is an effective business practice monthly documented meeting with the Board of Directors. Gateway Board of Directors are involved with the engagement of all Auditors, this has always been an active procedure and remains ongoing.

View Audit 303939

Finding 393713 (2021-002)

None 2021

Community Development Partnership

MA

Reporting

The required financial reports and forms for Fred Bell Way were not submitted to the RD due to numerous changes in personnel in the Finance Department and issues related to the accounting system conversion in March 2021. We anticipate that the FY21, FY22 and FY23 audits will all be completed in May...

The required financial reports and forms for Fred Bell Way were not submitted to the RD due to numerous changes in personnel in the Finance Department and issues related to the accounting system conversion in March 2021. We anticipate that the FY21, FY22 and FY23 audits will all be completed in May 2024 putting us in the position to provide the RD with all delinquent reports. Anticipated Completion Date October 15, 2024.Responsible Contact Person-Kathleen Boyce, CFAO

View Audit 303856

Finding 393710 (2021-004)

Significant Deficiency 2021

Community Development Partnership

MA

Reporting Subrecipient Monitoring Significant Deficiency § 200.502 § 200.510

In collaboration with the audit team, we will correct the procedures used to develop the Schedule of Expenditures of Federal Awards to ensure that it is completed correctly and accurately .Anticipated Completion Date April 30,2024.Responsible Contact Person-Kathleen Boyce, CFAO

View Audit 303856

Finding 393537 (2021-003)

Material Weakness 2021

Tucson Audubon Society

AZ

Material Weakness Reporting Internal Control / Segregation of Duties

National Park Service Conservation, Protection, outreach, and Education – Assistance Listing No. 15.954 Recommendation: We recommend management review its current processes and procedures to ensure reports are submitted timely, reviewed, and ensure evidence is retained to support the compilation, r...

National Park Service Conservation, Protection, outreach, and Education – Assistance Listing No. 15.954 Recommendation: We recommend management review its current processes and procedures to ensure reports are submitted timely, reviewed, and ensure evidence is retained to support the compilation, review, and submission of the reports and ensure compliance with UG. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As of the fall of fiscal year 2023, all Federal Reporting has been brought up to date. TAS now tracks all reporting due dates and requirements in a spreadsheet that is managed by our Program point person in conjunction with the finance staff to ensure both Project Performance Reports and Financial Reports are submitted by the federal due dates. Name(s) of the contact person(s) responsible for corrective action: Kim Lopez, Director of Finance & Operations, Erin Zylstra, Quantitative Ecologist Planned completion date for corrective action plan: COMPLETED

View Audit 303685

Finding 393331 (2021-005)

Material Weakness 2021

Village of North Syracuse Housing Authority

NY

HUD Housing Programs Reporting

Finding # 2021-005 Report Submission Corrective Action Plan: The new director and staff know that SEMAP reports are due annually. They also know that the report is the responsibility of the director to complete the SEMAP filing. The director who was in place during the 2019-2020-2021 should have fi...

Finding # 2021-005 Report Submission Corrective Action Plan: The new director and staff know that SEMAP reports are due annually. They also know that the report is the responsibility of the director to complete the SEMAP filing. The director who was in place during the 2019-2020-2021 should have filed the SEMAP report.

View Audit 303605

Finding 393269 (2021-002)

Significant Deficiency 2021

University of Central Missouri

MO

Reporting Significant Deficiency

Corrective Action The University Financial Aid Office will implement processes to review Pell response files more closely to identify rejects more timely and increasing the frequency of Pell reconciliations. Anticipated Completion Date: October 31, 2021 (once this came to our attention) Contact P...

Corrective Action The University Financial Aid Office will implement processes to review Pell response files more closely to identify rejects more timely and increasing the frequency of Pell reconciliations. Anticipated Completion Date: October 31, 2021 (once this came to our attention) Contact Person: Tony Lubbers, Financial Aid Director

View Audit 303551

Finding 392975 (2021-003)

Significant Deficiency 2021

Chicago Minority Supplier Development Council, Inc.

IL

Cash Management Reporting Matching / Level of Effort / Earmarking

Finding 2021-003 Cash Management Federal Agency: U.S. Department of Commerce Program Name: MBDA Business Center Assistance Listing #: 11.805 Questioned Costs: None Corrective Action: We ag...

Finding 2021-003 Cash Management Federal Agency: U.S. Department of Commerce Program Name: MBDA Business Center Assistance Listing #: 11.805 Questioned Costs: None Corrective Action: We agree with the auditor's comments and actions stated in the recommendation. CMSDC will update its policies and procedures to include procedures for reconciling expenditures to cash drawdowns monthly. Contact Person: Jose Robles Michelena, Executive Vice President Anticipated Completion Date: In efforts to improve and prevent the above finding CMSDC engaged a new accounting firm as of September of 2021 and they also brought in new leadership in April of 2022.

View Audit 303304

Finding 392970 (2021-002)

None 2021

Chicago Minority Supplier Development Council, Inc.

IL

Reporting

Finding 2021-002, 2020-01 Noncompliance with Uniform Guidance's Report Submission Requirements - Repeating Finding Federal Agency: U.S. Department of Commerce Pr...

Finding 2021-002, 2020-01 Noncompliance with Uniform Guidance's Report Submission Requirements - Repeating Finding Federal Agency: U.S. Department of Commerce Program Name: MBDA Business Center Assistance Listing #: 11.805 Questioned Costs: None Corrective Action: We agree with the auditor's comments and actions stated in the recommendation. Management will complete the financial close and reporting process three months after the end of the fiscal year. Contact Person: Jose Robles Michelena, Executive Vice President Anticipated Completion Date: In effort to improve and prevent the above finding CMSDC engaged a new accounting firm as of September of 2021 and they also brought in new leadership in April of 2022.

View Audit 303304

Finding 392957 (2021-001)

Significant Deficiency 2021

Children's Hospital of Philadelphia

PA

Reporting Subrecipient Monitoring

Management agrees with the finding that federal funds related to program 93.354 of $2.3 million were incorrectly excluded from the FY 2021 SEFA and believes this omission is immaterial (less than 1% of the total FY 2021 SEFA) and therefore does not significantly impact our FY 2021 financial statemen...

Management agrees with the finding that federal funds related to program 93.354 of $2.3 million were incorrectly excluded from the FY 2021 SEFA and believes this omission is immaterial (less than 1% of the total FY 2021 SEFA) and therefore does not significantly impact our FY 2021 financial statements or funding activity. As CHOP is committed to full compliance with reporting requirements for all external agencies, our organization determined that even though not material to the federal funding received during FY2021, correcting, and refiling the FY 2021 SEFA is the appropriate action to take. We acknowledge that this contract was unique and executed during an unsettled time due to the Coronavirus pandemic. CHOP has since enhanced internal controls with respect to our award intake, review and set up processes to ensure full and complete external reporting including but not limited to the SEFA. Enhancements to the process, include detailed intake checklists, increased staff training and awareness regarding review of all contracts to evaluate full and complete data elements are provided. In addition, CHOP performs routine data audits on the set ups of awards and will ensure a more detailed review of guidance for reporting requirements occurs in the future, and inquiries sent when the guidance is unclear. James Avington, AVP – Finance at CHOP, will have responsibility for this corrective action plan.

View Audit 303244

Finding 392608 (2021-008)

Material Weakness 2021

Fairbanks Rescue Mission, Inc.

AK

Questioned Costs Subrecipient Monitoring Material Weakness

Federal Award Finding: 2021-008 Material Weakness in Internal Control over Compliance and Nompliance - Reporting Requirements. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with extensiv...

Federal Award Finding: 2021-008 Material Weakness in Internal Control over Compliance and Nompliance - Reporting Requirements. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with extensive banking and accounting experience to create a higher level of scrutiny and oversite of the Missions finances. We contracted a professional accounting/bookkeeping firm {Midnight Sun Bookkeeping Services) and empowered them to establish procedures and practices consistent with GAAP {Generally Accepted Accounting Principles) as well as track and participate in day to day activities of Accounting; thereby, assuring accuracy of financial data and assuring compliance. We have formalized check writing, money handling, and credit card control procedures. Switched to an online time tracking system for employees and digitized all employee documents. Created an online filing system for all grant expenses Proposed Completion Date: January 01, 2024

View Audit 302911 Questioned Costs: $1

Finding 392607 (2021-007)

Material Weakness 2021

Fairbanks Rescue Mission, Inc.

AK

Questioned Costs HUD Housing Programs Subrecipient Monitoring

Federal Award Finding: 2021-007 Material Weakness in Internal Control over Compliance and Noncompliance - Eligibility Requirement. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with exte...

Federal Award Finding: 2021-007 Material Weakness in Internal Control over Compliance and Noncompliance - Eligibility Requirement. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with extensive banking and accounting experience to create a higher level of scrutiny and oversite of the Missions finances. We contracted a professional accounting/bookkeeping firm {Midnight Sun Bookkeeping Services) and empowered them to establish procedures and practices consistent with GAAP {Generally Accepted Accounting Principles) as well as track and participate in day to day activities of Accounting; thereby, assuring accuracy of financial data and assuring compliance. We have formalized check writing, money handling, and credit card control procedures. Switched to an online time tracking system for employees and digitized all employee documents. Created an online filing system for all grant expenses Proposed Completion Date: January 01, 2024

View Audit 302911 Questioned Costs: $1

Finding 392605 (2021-005)

Material Weakness 2021

Fairbanks Rescue Mission, Inc.

AK

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Financial Statement and Federal Award Finding: 2021-005 Material Weakness in Internal Control over Financial Reporting and Compliance and Noncompliance -Allowable Costs/Cost Principles. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's...

Financial Statement and Federal Award Finding: 2021-005 Material Weakness in Internal Control over Financial Reporting and Compliance and Noncompliance -Allowable Costs/Cost Principles. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with extensive banking and accounting experience to create a higher level of scrutiny and oversite of the Missions finances. We contracted a professional accounting/bookkeeping firm (Midnight Sun Bookkeeping Services) and empowered them to establish procedures and practices consistent with GAAP (Generally Accepted Accounting Principles) as well as track and participate in day to day activities of Accounting; thereby, assuring accuracy of financial data and assuring compliance. We have formalized check writing, money handling, and credit card control procedures. Switched to an online time tracking system for employees and digitized all employee documents. Created an online filing system for all grant expenses Proposed Completion Date: January 01, 2024

View Audit 302911 Questioned Costs: $1

Finding 392602 (2021-001)

Significant Deficiency 2021

Mentasta Traditional Council

AK

Subrecipient Monitoring Reporting Significant Deficiency

Significant Deficiency in Internal Control over Compliance, Noncompliance – Reporting Name of Contact Person: Anita Andrews, Tribal Administrator Corrective Action Plan: As we continue to recover from the many set-backs over the past few years related to COVID-19 we will strive to ensure that ...

Significant Deficiency in Internal Control over Compliance, Noncompliance – Reporting Name of Contact Person: Anita Andrews, Tribal Administrator Corrective Action Plan: As we continue to recover from the many set-backs over the past few years related to COVID-19 we will strive to ensure that our future audits are completed in time to file the form SF-SAC within the required nine months of our fiscal year end (9/30). Our corrective action plan includes: - Closing the fiscal year books within 90 days after our fiscal year end (excluding any required adjusting journal entries that may be necessary). - Scheduling our audit to occur within 100 days after our fiscal year end. - Obtaining a final audit report prior to the end of June following our fiscal year end. Proposed Completion Date: We are anticipating that the completion date of the above corrective action plan will be for Fiscal Year 2023.

View Audit 302903

Finding 392596 (2021-002)

Material Weakness 2021

Self Regional Healthcare and Affiliates

SC

Reporting Allowable Costs / Cost Principles Material Weakness

Contact Person: Timothy Evans Managements Response: The issue involved not keeping manual purchase order requests that contained original approvals for a period of greater than two years. At the time of the audit the original manual purchase requisition requests had not been saved or scanned. ...

Contact Person: Timothy Evans Managements Response: The issue involved not keeping manual purchase order requests that contained original approvals for a period of greater than two years. At the time of the audit the original manual purchase requisition requests had not been saved or scanned. When we recognized this deficiency, we immediately changed our processes so that all original requests for purchase orders that have the authorizing signatures are saved for a period of 5 years. Completion Date: January 2024.

View Audit 302889

Corrective Action Plans

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