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Corrective Action Plans

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Finding 1164837 (2021-001)
Material Weakness 2021
Olympic Medical Center
WA
Reporting § 200.512
November 10,2025 Clallam County Public Hospital District No. 2, dba Olympic Medical Center (OMC) Corrective Action Plan Year Ended December 31,202I Finding 2021-001 Responsible Official: Dennis Stillman, Interim CFO Correction Action and Timing: With the volume of COVID-19 federal programs and the r...
November 10,2025 Clallam County Public Hospital District No. 2, dba Olympic Medical Center (OMC) Corrective Action Plan Year Ended December 31,202I Finding 2021-001 Responsible Official: Dennis Stillman, Interim CFO Correction Action and Timing: With the volume of COVID-19 federal programs and the related complexities associated with the evolving guidance, it was challenging to prepare the Schedule of Expenditures of Federal Awards (SEFA) and related support completely and accurately for the single audit by the required due dates. Before the COVID-19 pandemic, grant expenditures related to federal programs rarely surpassed the single audit threshold, and the single audit threshold for OMC is unlikely to be surpassed in the future. To prepare for the possibility of future federal grant awards, all applications and contracts for federal awards will require review and approval by OMC's Contracts department. All applications for federal awards will be forwarded to the Chief Financial Officer for evaluation, acceptance, and record-keeping for Schedule of Expenditure of Federal Awards, SEFA. The recordkeeping for SEFA will be for accuracy, completeness, and reconciliation with accounting records. These records will support the performance of the single audit. OMC will implement this Corrective Action Plan effective November I,2025 Stillman Interim CFO Contracts Manager Controller cc
View Audit 374663
Finding 1164267 (2021-006)
Material Weakness 2021
Puerto Rico Emergency Management and Disasters Bureau
PR
Reporting Matching / Level of Effort / Earmarking § 200.302 § 200.327 § 200.329
Corrective Action Plan: PREMA will establish and document formal procedures for the preparation, review, reconciliation, and timely submission of SF-425 Federal Financial Reports for EMPG grants by implementing a report reconciliation checklist requiring agreement of reported data to PRIFAS and SEFA...
Corrective Action Plan: PREMA will establish and document formal procedures for the preparation, review, reconciliation, and timely submission of SF-425 Federal Financial Reports for EMPG grants by implementing a report reconciliation checklist requiring agreement of reported data to PRIFAS and SEFA records, ensuring each report includes federal and recipient share, drawdown activity, and unliquidated obligations, designating an official responsible for report review and approval prior to submission with evidence of filing retained, and providing staff training on federal reporting requirements under 2 CFR 200.327–200.329 to improve accuracy, completeness, and compliance in federal financial reporting. Lead Person: Maritza Torres, Fiscal Area Director, and Contractors (Robles & Assoc.). Anticipated Completion Date: December 2025.
View Audit 373614
Finding 1164266 (2021-005)
Material Weakness 2021
Puerto Rico Emergency Management and Disasters Bureau
PR
Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.302 § 200.328
Corrective Action Plan: PREMA will establish and enforce procedures to ensure that quarterly SF-425 or equivalent COR3 financial reports are prepared, reviewed, reconciled to PRIFAS and SEFA records, and submitted within required deadlines; PREMA will create reconciliation checklists, ensure reports...
Corrective Action Plan: PREMA will establish and enforce procedures to ensure that quarterly SF-425 or equivalent COR3 financial reports are prepared, reviewed, reconciled to PRIFAS and SEFA records, and submitted within required deadlines; PREMA will create reconciliation checklists, ensure reports include federal and recipient share, drawdown activity, and unliquidated obligations, designate responsible personnel for review and approval prior to filing with evidence of submission retained, and provide staff training on federal reporting requirements under 2 CFR 200.327–200.329 to strengthen compliance and accuracy in financial reporting. Lead Person: Maritza Torres, Fiscal Area Director, and Contractors (Robles & Assoc.). Anticipated Completion Date: December 2025.
View Audit 373614
Finding 1164265 (2021-004)
Material Weakness 2021
Puerto Rico Emergency Management and Disasters Bureau
PR
Reporting Procurement, Suspension & Debarment Subrecipient Monitoring § 200.510 § 200.511 § 200.512 § 200.515
Corrective Action Plan: PREMA will improve its audit reporting process to ensure timely submission of the Single Audit reporting package by strengthening internal controls over report preparation, establishing a reporting calendar that includes milestones for completing reconciliations and required ...
Corrective Action Plan: PREMA will improve its audit reporting process to ensure timely submission of the Single Audit reporting package by strengthening internal controls over report preparation, establishing a reporting calendar that includes milestones for completing reconciliations and required documentation, and coordinating with fiscal, program, and grants staff to ensure financial data, the SEFA, and supporting information are complete and ready within the Uniform Guidance deadline; PREMA will also assess staffing needs, implement procedures to track reporting progress, and provide training to personnel involved in the audit submission process. Lead Person: Maritza Torres, Fiscal Area Director, and Contractors (Robles & Assoc.). Anticipated Completion Date: December 2025.
View Audit 373614
Finding 1164263 (2021-001)
Material Weakness 2021
Puerto Rico Emergency Management and Disasters Bureau
PR
Reporting Subrecipient Monitoring § 200.302 § 200.328
Corrective Action Plan: PREMA will strengthen internal controls over financial management and reporting by improving the maintenance of subsidiary records, enhancing PRIFAS reconciliations, increasing coordination among fiscal, program, and grants personnel, and establishing written procedures to en...
Corrective Action Plan: PREMA will strengthen internal controls over financial management and reporting by improving the maintenance of subsidiary records, enhancing PRIFAS reconciliations, increasing coordination among fiscal, program, and grants personnel, and establishing written procedures to ensure timely, accurate, and complete financial information for the Statement, SEFA, and required federal reports; PREMA will also evaluate staffing needs, provide training on PRIFAS and federal reporting requirements, and conduct periodic reviews to ensure compliance with reporting deadlines and data accuracy. Lead Person: Maritza Torres, Fiscal Area Director, and Contractors (Robles & Assoc.). Anticipated Completion Date: December 2025.
View Audit 373614
Finding 1163085 (2021-002)
Material Weakness 2021
J-TECH INSTITUTE, INC.
CA
Allowable Costs / Cost Principles Material Weakness Reporting § 200.512
Audit Finding: Finding 2021-002: Submission of Single Audit Management’s Comments on Findings and Recommendation: We concur with the auditor's findings. Management’s Corrective Action Plan: We now are aware of the audit requirements and are committed to compliance. The Organization will engage audit...
Audit Finding: Finding 2021-002: Submission of Single Audit Management’s Comments on Findings and Recommendation: We concur with the auditor's findings. Management’s Corrective Action Plan: We now are aware of the audit requirements and are committed to compliance. The Organization will engage auditors to perform subsequent period audits, as applicable. Employee / Division Responsible for Execution: Executive Director Timeline and Estimated Completion Date: Effective Immediately
View Audit 372661
Finding 1163015 (2021-008)
Material Weakness 2021
Ruth Ellis Center, Inc.
MI
Questioned Costs Subrecipient Monitoring Material Weakness § 200.303
View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant ...
View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant Program Director and CEO/Executive Director, or by the CFO, along with the invoice for the expenditure, and explanation of reason for the charge to the specific grant.
View Audit 372604
Finding 1163014 (2021-007)
Material Weakness 2021
Ruth Ellis Center, Inc.
MI
Questioned Costs Subrecipient Monitoring Material Weakness § 200.303
View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant ...
View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant Program Director and CEO/Executive Director, or by the CFO, along with the invoice for the expenditure, and explanation of reason for the charge to the specific grant.
View Audit 372604
Finding 1162823 (2021-012)
Material Weakness 2021
Chester Upland School District
PA
Questioned Costs Reporting
Finding 2021-012 - Repeat of 2020-009; Reporting Description of Finding: The School District reports related to several grants were either filed late or not at all. The accuracy of the reports that were filed could not be determined, as the supporting documentation or reconciliations for the amounts...
Finding 2021-012 - Repeat of 2020-009; Reporting Description of Finding: The School District reports related to several grants were either filed late or not at all. The accuracy of the reports that were filed could not be determined, as the supporting documentation or reconciliations for the amounts disclosed in the report were not complete. District Position: The School District concurs with the finding. Corrective Action to be Taken: The District has appointed a Federal Programs Coordinator who is familiar with the Single Audit requirements of the Uniform Guidance. Management and the Federal Programs Coordinator have implemented policies and procedures to identify grant reporting due dates and identify relevant grant information and source documentation need to for reporting requirements. The Federal Programs Coordinator reviews grant reporting filing deadlines on a regular basis and reconciles source documentation to the general ledger in the accounting software with Business Office management prior to filing quarterly and final expenditure reports. Timetable for Implementation: Implemented for 2022-2023 fiscal year Monitoring to be Performed: The Receiver and Business Manager will monitor timely and continued implementation. Responsible Person with Scope of Authority: Receiver and Business Manager
View Audit 372470
Finding 1162314 (2021-003)
Material Weakness 2021
Levee Road Water Association, Inc.
KY
Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties
The Association concurs with the recommendation. The Association has implemented a new procedure to ensure that any future reporting compliance requirements related to the expenditure of federal funds are completed on a timely basis.
The Association concurs with the recommendation. The Association has implemented a new procedure to ensure that any future reporting compliance requirements related to the expenditure of federal funds are completed on a timely basis.
View Audit 372132
Finding 1162248 (2021-004)
Material Weakness 2021
Stephens Memorial Hospital
TX
Allowable Costs / Cost Principles Questioned Costs Reporting
Corrective Action Plan for Finding 2021-004, Reporting and Activities Allowed/Unallowed and Allowable Costs/Cost Principles We are in receipt of the findings required to be reported by the single audit for Period 1 reporting for payments received from the Provider Relief Fund (PRF), specifically, re...
Corrective Action Plan for Finding 2021-004, Reporting and Activities Allowed/Unallowed and Allowable Costs/Cost Principles We are in receipt of the findings required to be reported by the single audit for Period 1 reporting for payments received from the Provider Relief Fund (PRF), specifically, regarding discrepancies in the reporting requirements and auditing for the above period for the PRF. Management does not dispute the finding. The District will work to develop policies over financial reporting for future periods for PRF reporting and auditing. The District will perform detailed analysis of the reporting requirements in accordance with the guidelines set forth by HRSA. The District CEO, Gena Speer, will oversee this to ensure that this is accomplished. The District had enough expenditures for Period 1 and 4 funding received to cover any disqualified lost revenues that were utilized as a basis for the funds received. The Corrective Action Plan will be implemented by September 30, 2025.
View Audit 372059 Questioned Costs: $1
Finding 1162247 (2021-003)
Material Weakness 2021
Stephens Memorial Hospital
TX
Allowable Costs / Cost Principles Questioned Costs Reporting
Corrective Action Plan for Finding 2021-003, Reporting and Activities Allowed/Unallowed and Allowable Costs/Cost Principles We are in receipt of the findings required to be reported by the single audit for Period 1 reporting for payments received from the Provider Relief Fund (PRF), specifically, re...
Corrective Action Plan for Finding 2021-003, Reporting and Activities Allowed/Unallowed and Allowable Costs/Cost Principles We are in receipt of the findings required to be reported by the single audit for Period 1 reporting for payments received from the Provider Relief Fund (PRF), specifically, regarding discrepancies in the reporting requirements and auditing for the above period for the PRF. Management does not dispute the finding. The District will work to develop policies over financial reporting for future periods for PRF reporting and auditing. The District will perform detailed analysis of the reporting requirements in accordance with the guidelines set forth by HRSA. The District CEO, Gena Speer, will oversee this to ensure that this is accomplished. The Corrective Action Plan will be implemented by September 30, 2025.
View Audit 372059 Questioned Costs: $1
Finding 1162227 (2021-004)
Material Weakness 2021
Stonewall County Hospital District
TX
Allowable Costs / Cost Principles Eligibility Questioned Costs
Corrective Action Plan for Finding 2021-004 We are in receipt of the finding required to be reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting and Activities Allowed or Unallowed and Allowable Costs/Cost Principles Reporting. Management agrees with the ...
Corrective Action Plan for Finding 2021-004 We are in receipt of the finding required to be reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting and Activities Allowed or Unallowed and Allowable Costs/Cost Principles Reporting. Management agrees with the finding. Policies and procedures over federal grant reporting will be modified to ensure reports are prepared using complete and accurate information. We will increase compensating controls for introducing additional oversight and review for future federal funding reporting. Lewis Robbins, CFO, will be responsible to ensure this is accomplished. The District had enough lost revenues related to Period 1, as reported in the Period 4 reporting submission, that the error determined in Finding 2021-003 will not result in a conflict with funding received. The Corrective Action Plan will be implemented by September 30, 2025.
View Audit 372037 Questioned Costs: $1
Finding 1162226 (2021-003)
Material Weakness 2021
Stonewall County Hospital District
TX
Allowable Costs / Cost Principles Questioned Costs Cash Management
Corrective Action Plan for Finding 2021-003 We are in receipt of the finding required to be reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting and Activities Allowed or Unallowed and Allowable Costs/Cost Principles Reporting. Management agrees with the ...
Corrective Action Plan for Finding 2021-003 We are in receipt of the finding required to be reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting and Activities Allowed or Unallowed and Allowable Costs/Cost Principles Reporting. Management agrees with the finding. Policies and procedures over federal grant reporting will be modified to ensure reports are prepared using complete and accurate information. We will increase compensating controls for introducing additional oversight and review for future federal funding reporting. Lewis Robbins, CFO, will be responsible to ensure this is accomplished. The District had enough lost revenues related to Period 1, as reported in the Period 4 reporting submission, that the error determined in Finding 2021-003 will not result in a conflict with funding received. The Corrective Action Plan will be implemented by September 30, 2025.
View Audit 372037 Questioned Costs: $1
Finding 1162168 (2021-007)
Material Weakness 2021
JOHN C. FREMONT HEALTHCARE DISTRICT
CA
Reporting Significant Deficiency Internal Control / Segregation of Duties
JCFHD experienced substantial leadership and staff turnover in key financial roles over multiple years, including the CEO, CFO, and finance team. As a result, the individuals who originally prepared the lost revenues calculation were no longer employed at the facility when the Uniform Guidance audit...
JCFHD experienced substantial leadership and staff turnover in key financial roles over multiple years, including the CEO, CFO, and finance team. As a result, the individuals who originally prepared the lost revenues calculation were no longer employed at the facility when the Uniform Guidance audit was conducted. This led to challenges in locating complete supporting documentation for the original calculation, resulting in additional calculations being necessary. Under new leadership, JCFHD has prioritized the development and implementation of robust policies and procedures to ensure that all relevant financial documentation is readily accessible for future Uniform Guidance audits. These measures are intended to strengthen internal controls and improve audit readiness. Corrective Action: 1. Provide additional training to finance staff on GAAP financial reporting and disclosure requirements to strengthen internal review and oversight. 2. Implement a documented review process for financial statements and footnotes prepared by external auditors, including CFO and Board-level approval prior to issuance. Completion Date: Within 120 days.
View Audit 371977
Finding 1162167 (2021-006)
Material Weakness 2021
JOHN C. FREMONT HEALTHCARE DISTRICT
CA
Reporting Significant Deficiency
JCFHD experienced significant turnover in CEO, CFO, and finance positions over multiple years resulting in delays in completing the Uniform Guidance audit. JCFHD is under new leadership and has prioritized implementing policies and procedures to ensure future uniform guidance audits are completed an...
JCFHD experienced significant turnover in CEO, CFO, and finance positions over multiple years resulting in delays in completing the Uniform Guidance audit. JCFHD is under new leadership and has prioritized implementing policies and procedures to ensure future uniform guidance audits are completed and filed timely. Corrective Action: 1. Develop and implement written accounting policies and procedures aligned with GAAP and COSO principles. 2. Establish a monthly reconciliation calendar for all significant balance sheet accounts, with supervisory review and sign-off. 3. Provide training to accounting staff on new policies, reconciliation standards, and documentation requirements. 4. Assign the Accountant to monitor compliance and report quarterly to the CFO on reconciliation status and control improvements. Completion Date: Target completion within 90 days.
View Audit 371977
Finding 1161633 (2021-001)
Material Weakness 2021
L.b.s.h. Housing Corporation
NY
Reporting
Management will work with their independent auditor to ensure that a proper data collection form will be submitted on a timely basis for the 2021 audit.
Management will work with their independent auditor to ensure that a proper data collection form will be submitted on a timely basis for the 2021 audit.
View Audit 371523
Finding 1161494 (2021-005)
Material Weakness 2021
Bristow Housing Authority
OK
HUD Housing Programs Reporting
Corrective Action Plan Finding: Finding 2021-005-Board Minutes-Reporting Condition: We do not have access to any board minutes between the minutes of the January 28, 2022 and December 26, 2023. Current management represents that they are not aware of any board minutes for that period, or if the boar...
Corrective Action Plan Finding: Finding 2021-005-Board Minutes-Reporting Condition: We do not have access to any board minutes between the minutes of the January 28, 2022 and December 26, 2023. Current management represents that they are not aware of any board minutes for that period, or if the board met. Corrective Action Planned As noted above, the Authority now holds regular board meetings and the minutes are generated. Person responsible for corrective action: Diane Adams, Executive Director Telephone: (918) 367-5558 Housing Authority of Bristow, Oklahoma Fax: (918) 367-2341 1110 S. Chestnut Bristow, OK 74010 Anticipated Completion Date- June 30, 2026
View Audit 371390
Finding 1161150 (2021-003)
Material Weakness 2021
Pulaski Memorial Hospital
IN
Reporting
Corrective action: Management has implemented internal controls over compliance in place to assist with the timely preparation of the SEFA.
Corrective action: Management has implemented internal controls over compliance in place to assist with the timely preparation of the SEFA.
View Audit 371159
Finding 1161149 (2021-002)
Material Weakness 2021
Pulaski Memorial Hospital
IN
Questioned Costs Allowable Costs / Cost Principles Reporting
Corrective action: Management understands the due date for single audit reporting package submission to the Federal Audit Clearinghouse and filed as soon as possible
Corrective action: Management understands the due date for single audit reporting package submission to the Federal Audit Clearinghouse and filed as soon as possible
View Audit 371159
Finding 1161064 (2021-004)
Material Weakness 2021
Coal County Healthcare Authority
OK
Internal Control / Segregation of Duties Questioned Costs Allowable Costs / Cost Principles
Condition - Expenditures reported to HRSA were not in accordance with Pub. L. No. 116-136, 134 Stat. 563 Plan of Corrective Action Much research was performed by the Authority's leadership to identify guidance from HRSA including reviewing FAQs, Fact Sheets, consulting attorneys, auditors, consultan...
Condition - Expenditures reported to HRSA were not in accordance with Pub. L. No. 116-136, 134 Stat. 563 Plan of Corrective Action Much research was performed by the Authority's leadership to identify guidance from HRSA including reviewing FAQs, Fact Sheets, consulting attorneys, auditors, consultants and other parties. The complexity of the reporting requirements, including changing FAQ's and our inability to gain a definite approval of the use of our funds, resulted in the Authority filing the its submission based on the best available information at the time. The Authority's position is that the Provider Relief Funds were appropriately expensed using additional expenses and lost revenues not initially submitted to the portal. The Authority will continue to monitor the guidance for use of funds provided by HRSA and will strive to appropriately utilize all funds in the future. The Authority will review the most recently distributed Provider Relief Fund FAQ's which provide details on requirements related to the program Contact person: Chris Martin, CEO cmartin@ccghospital.com (580)927-2327 Expected implementation:2024 - 2025
View Audit 371035 Questioned Costs: $1
Finding 1159993 (2021-003)
Material Weakness 2021
Native Village of Tyonek
AK
Reporting § 200.328 § 200.329 § 200.501
Management has contracted with a contract accountant who has already started audit preparation services for future audits. The 2022 has been started and will be completed shortly. The 2023 audit will be started shortly. The Native Village expects to be fully caught up by their fiscal year 2025 audit...
Management has contracted with a contract accountant who has already started audit preparation services for future audits. The 2022 has been started and will be completed shortly. The 2023 audit will be started shortly. The Native Village expects to be fully caught up by their fiscal year 2025 audit.
View Audit 370455
Finding 1159992 (2021-002)
Material Weakness 2021
Native Village of Tyonek
AK
Reporting Questioned Costs § 200.328 § 200.329
Management will ensure that all required grant reporting, both financial and/or narrative/programmatic will be prepared and submitted timely. The final reporting for the Treasury CARES ACT has been completed and submitted subsequent to year end.
Management will ensure that all required grant reporting, both financial and/or narrative/programmatic will be prepared and submitted timely. The final reporting for the Treasury CARES ACT has been completed and submitted subsequent to year end.
View Audit 370455
Finding 1159785 (2021-010)
Material Weakness 2021
Program of Academic Exchange
NY
Questioned Costs Reporting § 200.512
PAX will establish appropriate policies, procedures, and controls to ensure that future submissions of Uniform Guidance reports are filed timely. The primary deliverable will be timely audit completion and submission. Dije Kucana, Comptroller, and Bradley Smith, CEO, effective immediately
PAX will establish appropriate policies, procedures, and controls to ensure that future submissions of Uniform Guidance reports are filed timely. The primary deliverable will be timely audit completion and submission. Dije Kucana, Comptroller, and Bradley Smith, CEO, effective immediately
View Audit 370334
Finding 1155786 (2021-005)
Material Weakness 2021
Medstar, Inc.
MI
Questioned Costs Allowable Costs / Cost Principles Material Weakness
Condition: The Organization was unable to provide supporting documentation to substantiate the allowability and accuracy of the expenses and lost revenue submitted in the portal. Planned Corrective Action: Company is an emergency services (ambulance, first responder, and was instrumental in the admi...
Condition: The Organization was unable to provide supporting documentation to substantiate the allowability and accuracy of the expenses and lost revenue submitted in the portal. Planned Corrective Action: Company is an emergency services (ambulance, first responder, and was instrumental in the administration of the monoclonal antibodies) - healthcare company and was during the pandemic. Company was able to provide general ledger information by personnel classification in aggregate monthly with percentages related to the Covid pandemic, Company changed payroll companies in June, 2022 from Trion to DM Payroll -where we were unable to access the payroll registers by personnel name. Medstar has full access to payroll registers through DM Payroll. Contact person responsible for corrective action: Lalainia Budyznowski Anticipated Completion Date: 06/30/2022 - Completed
View Audit 368173 Questioned Costs: $1
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