Corrective Action Plans

Finding 504064 (2022-008)

Material Weakness 2022

Unified Government of Wyandotte County and Kansas City, Kansas

KS

Subrecipient Monitoring § 200.303 § 200.332

Finding 2022-008 U.S. Department of Health and Human Services, passed through Kansas Department of Aging Aging Cluster – ALN 93.044 - Special Programs for the Aging_Title III, Part B_Grants for Supportive Services and Senior Centers - 2201KSOASS and 2201KSOACM ALN 93.045 – Speicl Programs for the ...

Finding 2022-008 U.S. Department of Health and Human Services, passed through Kansas Department of Aging Aging Cluster – ALN 93.044 - Special Programs for the Aging_Title III, Part B_Grants for Supportive Services and Senior Centers - 2201KSOASS and 2201KSOACM ALN 93.045 – Speicl Programs for the Aging_Title III, Part C_Nutrition Services – 2201KSOCAHC Management’s Response: Management concurs. Risk assessments are an important component of award management. We have developed a risk assessment tool for use by department personnel in risk assessments for sub recipients. Views of Responsible Officials and Corrective Action: Department grant management personnel will receive training around risk assessments and provided our monitoring tool for their assessments. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

View Audit 326473

Finding 504061 (2022-007)

Significant Deficiency 2022

Unified Government of Wyandotte County and Kansas City, Kansas

KS

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.303

Finding 2022-007 U.S. Department of Health and Human Services, passed through Kansas Department of Aging Aging Cluster – ALN 93.044 - Special Programs for the Aging_Title III, Part B_Grants for Supportive Services and Senior Centers - 2201KSOASS and 2201KSOACM ALN 93.045 – Speicl Programs for the ...

Finding 2022-007 U.S. Department of Health and Human Services, passed through Kansas Department of Aging Aging Cluster – ALN 93.044 - Special Programs for the Aging_Title III, Part B_Grants for Supportive Services and Senior Centers - 2201KSOASS and 2201KSOACM ALN 93.045 – Speicl Programs for the Aging_Title III, Part C_Nutrition Services – 2201KSOCAHC Management’s Response: Management concurs. Debarment and suspension checks are an important aspect of award management. Views of Responsible Officials and Corrective Action: Department grant management personnel and procurement will need to ensure that these checks are happening prior to engaging in supply chain events with suppliers. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

View Audit 326473

Finding 503688 (2022-007)

None 2022

North Fork Area Transit

NE

Subrecipient Monitoring Internal Control / Segregation of Duties

Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The fraudster has been convicted and is incarcerated. The Organization has since implemented stronger internal controls to prevent and detect future occurrences of fraud or error. Name(s) of Responsible ...

Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The fraudster has been convicted and is incarcerated. The Organization has since implemented stronger internal controls to prevent and detect future occurrences of fraud or error. Name(s) of Responsible Individuals Lacy Kimes, Board President Anticipated Completion Date Already implemented.

View Audit 325903

Finding 503687 (2022-006)

Significant Deficiency 2022

North Fork Area Transit

NE

Equipment & Real Property Management Subrecipient Monitoring § 200.313

Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The Organization will update its property records to include all required information. Additionally, the Organization plans to complete a physical inventory count and related reconciliation on an annual ...

Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The Organization will update its property records to include all required information. Additionally, the Organization plans to complete a physical inventory count and related reconciliation on an annual basis. Name(s) of Responsible Individuals Lacy Kimes, Board President Anticipated Completion Date October 31, 2024

View Audit 325903

Finding 503678 (2022-005)

None 2022

Southwestern Christian University, Inc.

OK

Student Financial Aid Cash Management Subrecipient Monitoring

Credit Balances and Heightened Cash Monitoring 2 (HCM2) Compliance Planned Corrective Action: Southwestern Christian University will provide ongoing training to current staff as well as new staff on HCM1 and/or HCM2 compliance regulations with the Department of Education. SCU will have additional s...

Credit Balances and Heightened Cash Monitoring 2 (HCM2) Compliance Planned Corrective Action: Southwestern Christian University will provide ongoing training to current staff as well as new staff on HCM1 and/or HCM2 compliance regulations with the Department of Education. SCU will have additional staff review student accounts for credit balances that would result from disbursements of Title IV Aid. Person Responsible for Corrective Action Plan: Rita Palmer, Director of Financial Aid Anticipated Date of Completion: Immediately

View Audit 325887

Finding 503676 (2022-004)

Significant Deficiency 2022

Southwestern Christian University, Inc.

OK

Subrecipient Monitoring Reporting Significant Deficiency

Common Origination and Disbursement (COD) Reporting Planned Corrective Action: Southwestern Christian University will provide ongoing training to employees involved in posting batches to student ledgers. This training will include the importance of understanding when posting batches to student ledg...

Common Origination and Disbursement (COD) Reporting Planned Corrective Action: Southwestern Christian University will provide ongoing training to employees involved in posting batches to student ledgers. This training will include the importance of understanding when posting batches to student ledgers, batch dates cannot be changed from the posting information provided by the financial aid department. The 10 student's disbursement dates have been updated in COD to reflect the disbursement date of the student ledger. All 10 students in the finding were from the same batch. Person Responsible for Corrective Action Plan: Rita Palmer, Director of Financial Aid Anticipated Date of Completion: Immediately

View Audit 325887

Finding 503671 (2022-002)

Significant Deficiency 2022

Public Defender Association

WA

Allowable Costs / Cost Principles Subrecipient Monitoring Significant Deficiency

Significant deficiency in internal control over compliance for allowable costs related to adequate documentation. Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: • This is primarily related to the absence of receipts for expen...

Significant deficiency in internal control over compliance for allowable costs related to adequate documentation. Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: • This is primarily related to the absence of receipts for expense items under $75. There are three items contributing to this finding: 1) Receipts that were not able to be located related to employees who had left the organization and did not provide receipts prior to departure - $0 of sample list. 2) Receipts that were simply not able to be found - $0 from sample list. 3) In general, PDA relies on our credit card platform for the repository of credit card receipts. The forum used during 2021 was “Elan”. Elan only retains receipts up to a maximum of 12 months from the date of spending. Due to the timing of the audit, in most cases 7-12 months had passed when the receipts were requested, and we were not able to extract from that system and therefore relied on employees’ records (see #1-2 above). Total amount related to expiration of receipts in Elan - $114.40. • PDA’s policy is to retain and upload receipts for all spending, no minimum. • In May of 2022, PDA moved to a new credit card platform (“Center”), which retains receipts into perpetuity. Anticipated completion date: This was implemented in May of 2022. Name(s) of the contact person(s) responsible for corrective action: Co-Executive Directors, Finance team

View Audit 325874

Finding 503648 (2022-001)

Significant Deficiency 2022

Hughes Village Council

AK

Subrecipient Monitoring Reporting Significant Deficiency

Finding 2022-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Jennifer Babcock Corrective Action Plan: Hughes Village Council is now compliant with all past due audits. In order to ensure audits are completed on time, HVC will sch...

Finding 2022-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Jennifer Babcock Corrective Action Plan: Hughes Village Council is now compliant with all past due audits. In order to ensure audits are completed on time, HVC will schedule the audit at least 3 months prior to the March deadline. Proposed Completion Date: 10/15/2024

View Audit 325853

Finding 503562 (2022-005)

Material Weakness 2022

Kagman Community Health Center, Inc.

MP

Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking

Finding No. 2022-005 KCHC disagrees with the finding that it is in noncompliance with the applicable period of performance requirements. The sample request was received after the August 19 meeting with the CEO and board representative, during which it was noted that no further samples would be acce...

Finding No. 2022-005 KCHC disagrees with the finding that it is in noncompliance with the applicable period of performance requirements. The sample request was received after the August 19 meeting with the CEO and board representative, during which it was noted that no further samples would be accepted as the audit had extended beyond one year. The delays were due to staffing challenges both on the part of the auditor and within KCHC. In FY 2025, KCHC has started the following corrective actions ensuring that all records are systematically filed and digitized for easy retrieval, regardless of changes in staff. This new system allows for seamless access to documents and a clear audit trail: 1. DocuSign for Document Management: In FY2025, KCHC adopted DocuSign to facilitate the management of financial documents. While DocuSign does not automatically upload supporting documents to the accounting software, it provides an efficient way to manage approvals and ensure an audit trail. After approval, the assigned accountant is responsible for manually uploading the supporting documents into the accounting software to ensure they are properly recorded and retrievable for audit purposes. 2. Timely Upload and Filing of Documentation: To address the delays, KCHC has updated its procedures requiring that all financial staff upload supporting documents at the time of expenditure approval or payment. This process will ensure that no documentation is missing or delayed, and all records are maintained in compliance with federal guidelines. 3. Ongoing Monitoring and Reporting: The CFO will oversee quarterly internal audits to ensure that the enhanced recordkeeping system is functioning effectively and that all expenditures continue to comply with the period of performance requirements. Progress will be reported to the Board of Directors to ensure transparency and ongoing compliance. By taking these corrective actions, KCHC will ensure that all expenditures are supported by proper documentation, uploaded timely, and readily available for audit review, preventing any future delays or compliance issues. Implementation Timeline: Completed as of August 31, 2024 with continued updates and monitoring. Responsible person: Arlene Deleon Guerrero, CFO

View Audit 325728 Questioned Costs: $1

Finding 503560 (2022-003)

Significant Deficiency 2022

Kagman Community Health Center, Inc.

MP

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.403

Finding No. 2022-003 KCHC agrees with the finding and understands the importance of maintaining robust recordkeeping and documentation procedures to comply with federal cost principles. We acknowledge the discrepancies noted in the audit findings regarding non-payroll expenditures. To address th...

Finding No. 2022-003 KCHC agrees with the finding and understands the importance of maintaining robust recordkeeping and documentation procedures to comply with federal cost principles. We acknowledge the discrepancies noted in the audit findings regarding non-payroll expenditures. To address these issues, KCHC has implemented the following actions: • Strengthening Documentation Controls: KCHC has reinforced its recordkeeping procedures, requiring that all expenditures be fully supported by accurate documentation before approval. The accounting department has implemented additional review layers to ensure that all supporting documents, including receipts and invoices, are properly matched and retained. • Enhanced Training for Staff: Staff responsible for processing and documenting expenditures have undergone training to improve awareness of federal cost principles and documentation requirements. This training will ensure that all expenditures are supported by accurate, complete, and timely documentation. • Monitoring and Oversight: KCHC has introduced regular internal audits to monitor compliance with documentation standards. These audits will help identify any potential discrepancies early and ensure timely corrective action. Implementation Timeline: KCHC began implementation of these changes in FY 2025 under the CFO. The organization remains confident that these measures will address the audit findings and improve compliance with 2 CFR section 200.403(e). KCHC is committed to maintaining the highest standards of financial management and accountability. Responsible person: Arlene DeleonGuerrero, CFO

View Audit 325728 Questioned Costs: $1

Finding 503189 (2022-002)

Material Weakness 2022

City of Manhattan, Kansas

KS

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Management’s Response (Unaudited) – The Community Development staff is in the process of preparing all outstanding FFATA reports and is developing a compliance checklist to ensure that these reports are filed timely. Corrective Action Plan (Unaudited) – The Community Development staff will create a...

Management’s Response (Unaudited) – The Community Development staff is in the process of preparing all outstanding FFATA reports and is developing a compliance checklist to ensure that these reports are filed timely. Corrective Action Plan (Unaudited) – The Community Development staff will create a checklist to ensure that these reports are filed timely once the agreements with the subrecipients have been approved.

View Audit 325285

Finding 503076 (2022-004)

Significant Deficiency 2022

Pulaski County, Missouri

MO

Subrecipient Monitoring Reporting Cash Management

Pulaski County will review the recommendations as presented and work to adjust internal controls to prepare SEFA information in accordance with the recommendations of the auditor.

View Audit 325095

Finding 501922 (2022-004)

Material Weakness 2022

Hill & Dales General Hospital and Subsidiary

MI

Subrecipient Monitoring Material Weakness Reporting § 200.303

Finding 2022-004 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 Initial Fiscal Year Finding Occurred: 2021 Finding Summary: The Corporation’s final lost revenue calculatio...

Finding 2022-004 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 Initial Fiscal Year Finding Occurred: 2021 Finding Summary: The Corporation’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 3 and Period 4. Additionally, the Corporation’s total net patient care revenues did not agree to the amount in the report submitted to the Department of Health and Human Services for Period 4. Responsible Individuals: Renee Henry, Corporate Controller Corrective Action Plan: Management will implement a control process which includes monitoring over amounts reported relating to lost revenue amounts and the related calculation. Anticipated Completion Date: March 31, 2024

View Audit 324085

Finding 501723 (2022-001)

Significant Deficiency 2022

Disability Rights California

CA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN For the Year Ended September 30, 2022 Finding 2022-001 Program: Coronavirus State and Local Fiscal Recovery Funds CFDA No.: 21.027 Federal Agency: U.S. Department of the Treasury Organization's Response: DRC agrees with the finding. Views of Responsible Officials: DRC agre...

CORRECTIVE ACTION PLAN For the Year Ended September 30, 2022 Finding 2022-001 Program: Coronavirus State and Local Fiscal Recovery Funds CFDA No.: 21.027 Federal Agency: U.S. Department of the Treasury Organization's Response: DRC agrees with the finding. Views of Responsible Officials: DRC agrees with the finding and has taken steps to rectify the finding. The schedule of expenditures of federal awards has been updated to include the $1,114,429 federal expenditures for the Coronavirus State and Local Fiscal Recovery Funds. The total federal expenditures were updated from $17,824,221 to $18,938,650. The schedule of expenditures of state awards has been updated to not include the $1,114,429 federal expenditures. The total state expenditures were updated from $19,710,395 to $18,595,966. DRC is monitoring and performing evaluations of individual grants to ensure expenditures are accurately captured and reported on the schedule of expenditures of federal awards. In addition, DRC maintains a thorough review process for the preparation of the schedule of expenditures of federal awards. Name of Responsible Person: Karen Keene, Associate Executive Director of Finance and Administration Anticipated Completion Date: September 4, 2024

View Audit 323803

Finding 499601 (2022-004)

Material Weakness 2022

Ronin Institute for Independent Scholarship

NJ

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.403 § 200.430

Corrective Action: Management of the Institute did not provide any planned corrective actions for this finding. Person Responsible: Management of the Institute did not identify an individual responsible for corrective action for this finding. Completion Date: Management of the Institute has not esta...

Corrective Action: Management of the Institute did not provide any planned corrective actions for this finding. Person Responsible: Management of the Institute did not identify an individual responsible for corrective action for this finding. Completion Date: Management of the Institute has not established a completion date for corrective action for this finding.

View Audit 322455 Questioned Costs: $1

Finding 499595 (2022-003)

Material Weakness 2022

Ronin Institute for Independent Scholarship

NJ

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.317 § 200.318 § 200.327

Corrective Action: Management of the Institute did not provide any planned corrective actions for this finding. Person Responsible: Management of the Institute did not identify an individual responsible for corrective action for this finding. Completion Date: Management of the Institute has not esta...

Corrective Action: Management of the Institute did not provide any planned corrective actions for this finding. Person Responsible: Management of the Institute did not identify an individual responsible for corrective action for this finding. Completion Date: Management of the Institute has not established a completion date for corrective action for this finding.

View Audit 322455

Finding 499589 (2022-002)

None 2022

Ronin Institute for Independent Scholarship

NJ

Reporting Subrecipient Monitoring § 200.512

Corrective Action: Management of the Institute did not provide any planned corrective actions for this finding. Person Responsible: Management of the Institute did not identify an individual responsible for corrective action for this finding. Completion Date: Management of the Institute has not esta...

Corrective Action: Management of the Institute did not provide any planned corrective actions for this finding. Person Responsible: Management of the Institute did not identify an individual responsible for corrective action for this finding. Completion Date: Management of the Institute has not established a completion date for corrective action for this finding.

View Audit 322455

Finding 499580 (2022-002)

Material Weakness 2022

Solidaridad North America

CA

Subrecipient Monitoring Allowable Costs / Cost Principles

The Organization will implement procedures to guarantee the proper supervision for subgrantees in a timely manner.

View Audit 322438

Finding 499300 (2022-004)

Material Weakness 2022

Rmi Ports Authority

MH

Reporting Subrecipient Monitoring

1. Management will delegate temporarily to the CFO to oversee the reporting requirements with the Federal funded projects until the Deputy Director will be filled in. 2. Management will establish internal control policies and procedures to properly and systematically administer the reporting require...

1. Management will delegate temporarily to the CFO to oversee the reporting requirements with the Federal funded projects until the Deputy Director will be filled in. 2. Management will establish internal control policies and procedures to properly and systematically administer the reporting requirements of Federal Aviation Administration.

View Audit 322122

Finding 499020 (2022-001)

Material Weakness 2022

The Atlanta Botanical Garden, Inc.

GA

Reporting Subrecipient Monitoring Material Weakness § 200.512

The Garden’s Uniform Guidance Audit for the year ended December 31, 2022 was delayed as Garden management was unare that that their federal expenditures exceeded the audit requirement threshold for the first time. Going forward, Garden management will ensure the data collection form and reporting pa...

The Garden’s Uniform Guidance Audit for the year ended December 31, 2022 was delayed as Garden management was unare that that their federal expenditures exceeded the audit requirement threshold for the first time. Going forward, Garden management will ensure the data collection form and reporting package are submitted within the earlier of 30 calendar days after receipt of the auditor’s report or nine months after the end of the audit period.

View Audit 321803

Finding 498912 (2022-005)

Significant Deficiency 2022

Panthera Corporation

NY

Subrecipient Monitoring § 200.332

Panthera has now adopted the implementation of the Federal Assistance Listing Numbers on each agreement with subrecipients, and will ensure a formal approval is issued on all expenditure reports.

View Audit 321740

Finding 498581 (2022-221)

Significant Deficiency 2022

Congregation Oros Bais Yaakov Lakewood Inc.

NJ

Subrecipient Monitoring

Recommendation: To keep monitoring the net cash resources throughout the year to ensure I doesn’t exceed three months average expenditures. Action Taken: Since being made aware of the issue, the School’s administrator has begun to routinely monitor the net cash resources to ensure it does not exceed...

Recommendation: To keep monitoring the net cash resources throughout the year to ensure I doesn’t exceed three months average expenditures. Action Taken: Since being made aware of the issue, the School’s administrator has begun to routinely monitor the net cash resources to ensure it does not exceed three months of average expenditures. As such, the required correction actions have been implemented. Implementation Date: Corrective Action Plan has been implemented as of August 16, 2023. Person responsible for Implementation: Nechama Prager, the Administrator, is the responsible party for implementation of the CAP. Telephone Number: 732-730-6049

View Audit 321323

Finding 497560 (2022-004)

None 2022

Inspiration Ministries, Inc.

IN

Subrecipient Monitoring Reporting § 200.508

Schedule of Expenditures of Federal Awards Views of Responsible Officials and Planned Corrective Actions: Management concurs with the recommendation. Management has hired a compliance administrator to track all grants, including federal, state and county. Management and Butler CPA firm will ensure t...

Schedule of Expenditures of Federal Awards Views of Responsible Officials and Planned Corrective Actions: Management concurs with the recommendation. Management has hired a compliance administrator to track all grants, including federal, state and county. Management and Butler CPA firm will ensure training to establish procedures and the preparation of the Schedule of Expenditures of Federal Awards.

View Audit 320316

Finding 497070 (2022-004)

Material Weakness 2022

Bristol Bay Borough, Alaska

AK

Subrecipient Monitoring Material Weakness Reporting

Finding 2022-004: Reporting – Material Weakness in Internal Control Over Compliance and Material Noncompliance Name of Contact Person: Stephen Wilson, Finance Director Corrective Action Plan: New controls are being put into place to ensure that all subawards over $30,000 are properly and timely repo...

Finding 2022-004: Reporting – Material Weakness in Internal Control Over Compliance and Material Noncompliance Name of Contact Person: Stephen Wilson, Finance Director Corrective Action Plan: New controls are being put into place to ensure that all subawards over $30,000 are properly and timely reported. Completion Date : June 30, 2025

View Audit 319779

Finding 497069 (2022-003)

Significant Deficiency 2022

Bristol Bay Borough, Alaska

AK

Period of Performance Subrecipient Monitoring Allowable Costs / Cost Principles § 200.512

Federal Award Findings and Questioned Costs: Finding 2022-003: Reporting - Timely Submission of Financial Reports – Significant Deficiency in Internal Control over Compliance and Noncompliance Name of Contact Person: Stephen Wilson, Finance Director Corrective Action Plan: As the Borough is currentl...

Federal Award Findings and Questioned Costs: Finding 2022-003: Reporting - Timely Submission of Financial Reports – Significant Deficiency in Internal Control over Compliance and Noncompliance Name of Contact Person: Stephen Wilson, Finance Director Corrective Action Plan: As the Borough is currently behind on its audit’s we are aware that this will continue to be an issue until we are caught up. Completion Date: June 30, 2025

View Audit 319779

Corrective Action Plans

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