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Corrective Action Plans

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Finding 560138 (2022-013)
Material Weakness 2022
Oregon Coast Community Action
AL
Allowable Costs / Cost Principles Eligibility Period of Performance § 200.303
ORCCA's current process at the program level has improved to ensure proper documentation of eligibility. The Housing director and staff have implemented this internal control at the program level. The finance department's internal control (as noted earlier) is in place to ensure the payment requests...
ORCCA's current process at the program level has improved to ensure proper documentation of eligibility. The Housing director and staff have implemented this internal control at the program level. The finance department's internal control (as noted earlier) is in place to ensure the payment requests have sufficient supporting documentation. As for record retention, ORCCA hired additional temp workers to ensure completed transactions are filed timely with the goal of going paperless in the near future. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 2025
View Audit 356132
Finding 560137 (2022-012)
Material Weakness 2022
Oregon Coast Community Action
AL
Questioned Costs § 200.303
ORCCA's current process at the program level has improved to ensure proper documentation of eligibility. The Housing director and staff are implementing this internal control at the program level already. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 20...
ORCCA's current process at the program level has improved to ensure proper documentation of eligibility. The Housing director and staff are implementing this internal control at the program level already. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 2025
View Audit 356132 Questioned Costs: $1
Finding 560131 (2022-011)
Significant Deficiency 2022
Oregon Coast Community Action
AL
Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.303 § 200.32 § 200.330
ORCCA plans to utilize grant tracker system with the ability to send reminders for important dates to avoid future delinquent reporting that was experienced during the audit period. The system will be utilized by the program directors as well as the finance team (Finance Director, Accounting Manager...
ORCCA plans to utilize grant tracker system with the ability to send reminders for important dates to avoid future delinquent reporting that was experienced during the audit period. The system will be utilized by the program directors as well as the finance team (Finance Director, Accounting Manager, Program Fiscal Compliance Coordinator) working with grant directors. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 2025
View Audit 356132
Finding 560125 (2022-010)
Significant Deficiency 2022
Oregon Coast Community Action
AL
Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.303
ORCCA is aware of the lack of documentation and internal control during the audit period due to various reasons, mainly short staffing and staff turnover, and has been working hard to prevent such occurrences. The Finance staff (Finance Director, Accounting Manager, Program Fiscal Compliance Coordin...
ORCCA is aware of the lack of documentation and internal control during the audit period due to various reasons, mainly short staffing and staff turnover, and has been working hard to prevent such occurrences. The Finance staff (Finance Director, Accounting Manager, Program Fiscal Compliance Coordinator) have already started communicating with program directors if any such issues are observed. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 2025
View Audit 356132
Finding 560113 (2022-008)
Material Weakness 2022
Oregon Coast Community Action
AL
Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.403 § 200.404 § 200.405 § 200.430
The HS program has established an internal process of requester/approver in place to review the transaction requested. Documents then get reviewed again by HR or Finance staff based on the transaction type before getting processed. Responsible party: Bonnie Foroudi, Finance Director Estimated compl...
The HS program has established an internal process of requester/approver in place to review the transaction requested. Documents then get reviewed again by HR or Finance staff based on the transaction type before getting processed. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 2025
View Audit 356132 Questioned Costs: $1
Finding 555649 (2022-008)
Significant Deficiency 2022
Town of Coventry, Rhode Island
RI
Procurement, Suspension & Debarment Subrecipient Monitoring Eligibility § 200.213 § 200.303
Significant Deficiency in Internal Control over Compliance, Other Matters Description of Finding The Town does not have policies and procedures in place to ensure that they do not contract with or make subawards to parties that are suspended or debarred. Statement of Concurrence or Nonconcurrence ...
Significant Deficiency in Internal Control over Compliance, Other Matters Description of Finding The Town does not have policies and procedures in place to ensure that they do not contract with or make subawards to parties that are suspended or debarred. Statement of Concurrence or Nonconcurrence Management concurs with the finding. Corrective Action The Town will review the district’s suspension and debarment policy and make sure that it is following the criteria as set out in the 2 CFR sections 200.213. The policy will then be updated and communicated to all personnel involved in the procurement process. Name of Contact Person Robert J. Civetti, CPA, Finance Director Projected Completion Date June 30, 2025
View Audit 354246
Finding 555647 (2022-007)
Significant Deficiency 2022
Town of Coventry, Rhode Island
RI
Procurement, Suspension & Debarment § 200.1 § 200.303 § 200.318 § 200.319 § 200.320
Significant Deficiency in Internal Control over Compliance, Other Matters Description of Finding Coventry Public School’s procurement standards do not include the essential elements as outlined in 2 CFR sections 200.318 through 200.326. Statement of Concurrence or Nonconcurrence Management concurs...
Significant Deficiency in Internal Control over Compliance, Other Matters Description of Finding Coventry Public School’s procurement standards do not include the essential elements as outlined in 2 CFR sections 200.318 through 200.326. Statement of Concurrence or Nonconcurrence Management concurs with the finding. Corrective Action Coventry Public Schools will review the district’s current purchasing policy and make sure that it is following the criteria as set out in the 2 CFR sections 200.318 and 200.326. The policy will then be updated and communicated to all personnel involved in the procurement process. Name of Contact Person Christopher Deverna, CPA, Director of Finance, Coventry Public Schools Projected Completion Date June 30, 2025
View Audit 354246
Finding 555141 (2022-006)
Significant Deficiency 2022
Valencia Shelter for Victims of Domestic Violence
NM
Questioned Costs Matching / Level of Effort / Earmarking HUD Housing Programs § 200.303
Recommendation: We recommend that VSS reviews the current financial policies and procedures in order to better serve the organization in documenting compliance with federal and grantor requirements regarding the program requirements. Explanation of disagreement with audit finding: There is no disagr...
Recommendation: We recommend that VSS reviews the current financial policies and procedures in order to better serve the organization in documenting compliance with federal and grantor requirements regarding the program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: VSS agrees with CLA and has updated our financial policies. We have hired an accountant, in addition to our Finance Director and Finance Coordinator to create a system of posting and review. Fair Market Rents will be reviewed along with the HQS worksheet and Income Limits during annual recertification for active participants in the HUD program. Name(s) of the contact person(s) responsible for corrective action: Jessica Franco, Director of Finance Planned completion date for corrective action plan: XXX
View Audit 353736 Questioned Costs: $1
Finding 555131 (2022-004)
Material Weakness 2022
Valencia Shelter for Victims of Domestic Violence
NM
Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303
Recommendation: We recommend that VSS reviews the current financial policies and procedures in order to better serve the organization in documenting compliance with federal cost principals. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken ...
Recommendation: We recommend that VSS reviews the current financial policies and procedures in order to better serve the organization in documenting compliance with federal cost principals. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: VSS agrees with CLA and has updated our financial policies to include electronic approval of expenditures through Bill.com. Timesheets and supplements will be reviewed and approved by staff supervisors biweekly to ensure proper allocation of hours worked. Credit Card Expense reports will require Description of item purchased, as well as the funder and class allocation. Name(s) of the contact person(s) responsible for corrective action: Jessica Franco, Director of Finance Planned completion date for corrective action plan: 3/1/2023
View Audit 353736 Questioned Costs: $1
Finding 555092 (2022-007)
Significant Deficiency 2022
Saint Anthony Health Ministries and Subsidiaries
IL
Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management § 200.303
2022-007 Maintenance of Documentation of Internal Control Over Compliance Finding: Under Uniform Grant Guidance (2 CFR 200.303) requires nonfederal entities receiving Federal awards to establish and maintain internal controls designed to reasonably ensure compliance with Federal laws, regulations,...
2022-007 Maintenance of Documentation of Internal Control Over Compliance Finding: Under Uniform Grant Guidance (2 CFR 200.303) requires nonfederal entities receiving Federal awards to establish and maintain internal controls designed to reasonably ensure compliance with Federal laws, regulations, and program compliance requirements. Effective internal controls should include procedures to ensure that documentation to evidence the operation of internal controls, such as supervisory reviews. The Corporation did not have sufficient documentation that internal controls were in place and operating effectively for control activities required for assessment of activities allowed or unallowed and for allowable costs/cost principles. The Corporation also did not have sufficient documentation that internal controls were in place and operating effectively for monitoring procedures required for cash management and reporting compliance requirements. Corrective Actions Taken or Planned: Due to turnover of key positions responsible for grant submission, supporting documentation that was kept on these individuals’ computers was not saved, passed on, nor stored in a central storage location so that the new hires that were brought in to replace these individuals as well as others in the department could view them. In August 2023, the Corporation provided education and training to the staff regarding identifying documentation and files related to the annual SEFA as well as establishing a central departmental drive to store the documentations so that others can locate them when necessary. Name of contact person responsible for corrective action: Jamie Mack, Vice President of Finance
View Audit 353678
Finding 554493 (2022-013)
Material Weakness 2022
Washington County
OK
Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303
No corrective action taken.
No corrective action taken.
View Audit 353150
Finding 554492 (2022-012)
Material Weakness 2022
Washington County
OK
Procurement, Suspension & Debarment Subrecipient Monitoring Reporting § 200.303
No corrective action taken.
No corrective action taken.
View Audit 353150
Finding 540863 (2022-108)
Significant Deficiency 2022
Pancare of Florida, INC
FL
Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.328
2021-108 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 well as additional supporting staff within the finance ...
2021-108 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 well as additional supporting staff within the finance department. Source documentation for grant reporting is retained and maintained in grant folders on the shared drive for future reference. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer Anticipated Completion Date: Implemented
View Audit 350520
Finding 540862 (2022-105)
Material Weakness 2022
Pancare of Florida, INC
FL
Cash Management Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303
Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional support...
Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. 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 grant drawdown procedures to include 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: Joe Derry, Chief Financial Officer Anticipated Completion Date: Implemented
View Audit 350520
Finding 540861 (2022-102)
Significant Deficiency 2022
Pancare of Florida, INC
FL
Cash Management § 200.303
2022-102 Lack of Cash Management Documentation Condition: The Organization made drawdowns after month-end based on budgeted period expenditures and therefore could not be agreed to the actual approved wages paid prior to the reimbursement request. Insufficient documentation was kept to clearly docu...
2022-102 Lack of Cash Management Documentation Condition: The Organization made drawdowns after month-end based on budgeted period expenditures and therefore could not be agreed to the actual approved wages paid prior to the reimbursement request. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization’s policy and procedures related to support documentation retention has been evaluated and updated. Supporting documentation for all drawdown requests are retained by grant. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer Anticipated Completion Date: Implemented
View Audit 350520
Finding 540860 (2022-101)
Material Weakness 2022
Pancare of Florida, INC
FL
Subrecipient Monitoring Special Tests & Provisions Matching / Level of Effort / Earmarking § 200.303
2022-101 Lack of Internal Controls over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale ...
2022-101 Lack of Internal Controls over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization’s policies for the sliding fee scale were recently updated during fiscal year 2022, by management, based on findings during the monitoring by HRSA performed in 2022, but management will consider discussing potential improvements to their policy with the grantor to potentially update it to allow for certain exceptions. The Billing and Collections Policy will be updated to waive co-pays for students in the School-Based Program. The Billing Department will audit and implement periodic feedback & training sessions for the Operations Department for training and compliance for the Sliding Fee Discount Program. The Organization expects to have the corrective action implemented by May 1, 2025. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer Anticipated Completion Date: May 1, 2025
View Audit 350520
Finding 530120 (2022-004)
Material Weakness 2022
Healthsource Saginaw, Inc.
MI
Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303
Condition: HealthSource does not have a review process in place related to the lost revenue calculation used to input into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program and not having a review process in place over the fo...
Condition: HealthSource does not have a review process in place related to the lost revenue calculation used to input into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program and not having a review process in place over the forementioned required submissions. Planned Corrective Action: A review of all updates to Covid lost revenue will be performed with the CEO and President as indicated by new activity, and before any submissions are uploaded. Contact person responsible for corrective action: Sonja Martinez, Chief Financial Officer Anticipated Completion Date: 12/31/2024
View Audit 348199
Finding 530096 (2022-002)
Significant Deficiency 2022
Pasadena Symphony Association
CA
Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303
Corrective Action Plan: In the time since the initial audit was due at the end of 2022, the organization experienced a substantial turnover in its senior administrative leadership team. I was engaged as the new Chief Executive Officer in November 2023, and have since hired a new General Manager, Dir...
Corrective Action Plan: In the time since the initial audit was due at the end of 2022, the organization experienced a substantial turnover in its senior administrative leadership team. I was engaged as the new Chief Executive Officer in November 2023, and have since hired a new General Manager, Director of Development, and worked closely with our accounting firm, who was engaged to replace the original CFO, after her retirement in 2022. Since this new team has assumed leadership, we have transitioned to new accounting and billing software platforms and developed or renewed policies and procedures that have improved monitoring, tracking, approval, and reporting procedures for all expenditures and revenues, across the organization. We have also upgraded to a cloud-based server/filesharing system and reorganized the filing and archival systems and procedures to ensure that files and documents are organized more clearly and more accessibly for key staff members, current and into the future. Anticipated Completion Date: Already implemented.
View Audit 348149
Finding 530091 (2022-004)
Significant Deficiency 2022
South Big Horn Hospital District
WY
Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303
2022-004 - Required debt reserve compliance Corrective Action Plan: Management agrees with the finding and has committed the resources giving rise to the finding. Person(s) Responsible: M. Michael Garza Timing for Implementation: June 30, 20 5
2022-004 - Required debt reserve compliance Corrective Action Plan: Management agrees with the finding and has committed the resources giving rise to the finding. Person(s) Responsible: M. Michael Garza Timing for Implementation: June 30, 20 5
View Audit 348143
Muskogee County
OK
Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303
Assistance Listing Number 21.027 Noncompliance Over Reporting - Major Federal Program - Coronavirus State and Local Fiscal Recovery Funds Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will ...
Assistance Listing Number 21.027 Noncompliance Over Reporting - Major Federal Program - Coronavirus State and Local Fiscal Recovery Funds Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to ensure that all grant funds are properly expended and properly reported.
View Audit 345862
Finding 526801 (2022-015)
Material Weakness 2022
Muskogee County
OK
Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.303
Assistance Listing Number 21.027 Lack of Internal Controls Over Major Federal Programs - Coronavirus State and Local Fiscal Recovery Funds Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will...
Assistance Listing Number 21.027 Lack of Internal Controls Over Major Federal Programs - Coronavirus State and Local Fiscal Recovery Funds Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to ensure that all grant funds are properly expended.
View Audit 345862
Finding 526762 (2022-003)
Material Weakness 2022
Choctaw County City of Hugo Hospital Authority Dba Choctaw Memorial Hospital
OK
Internal Control / Segregation of Duties Eligibility Material Weakness § 200.303
Reporting - Material Weakness in Internal Control over Compliance and Noncompliance Deemed not Material Identification of the Federal Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution - 93.498. Finding Summary: The Authority tracked patiet care revenues intern...
Reporting - Material Weakness in Internal Control over Compliance and Noncompliance Deemed not Material Identification of the Federal Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution - 93.498. Finding Summary: The Authority tracked patiet care revenues internally within a spreadsheet. The calculations of revenue by payor within the spreadsheet and included in Period 2 report to HRSA, which are utilized to calculate lost revenues, contained errors. Responsible Individual: Dawn Ballard. Corrective Action Plan: While there were errors in the reported net patient revenue by payor for specific quarters, the total net patient service revenue, by quarter, was accurately reported and did not impact the calculated lost revenue. Management believes that the control process in place is sufficient to identify material errors in reported amounts. Anticipated Completion Date: January 15, 2025
View Audit 345762
Finding 526761 (2022-002)
Material Weakness 2022
Choctaw County City of Hugo Hospital Authority Dba Choctaw Memorial Hospital
OK
Allowable Costs / Cost Principles Material Weakness Reporting § 200.303
Reporting - Material Weakness in Internal Control over Compliance and Material Noncompliance Identification of the Federal Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution - 93.498. Finding Summary: The Authority selected Option 1, as defined by HRSA, to calc...
Reporting - Material Weakness in Internal Control over Compliance and Material Noncompliance Identification of the Federal Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution - 93.498. Finding Summary: The Authority selected Option 1, as defined by HRSA, to calculate lost revenue. This option consists of reporting actual revenues from relevant quarters in the period of availability with the system calculating the lost revenues because of deadlines. The fiscal year 2021 single audit identified unallowable expenses totaling $263,861. The Company utilized excess lost revenues at the time to cover this difference. To capture the use of these lost revenues from Period 1, the Authority should have used Option 3, as defined by HRSA, to calculate and report lost revenues. Within that calculation, lost revenues could then be reduced by the $263,861. Responsible Individual: Dawn Ballard. Corrective Action Plan: Due to the timing of completion of the single audit requirements and identification of questioned costs, the report for Period 2 was unable to properly reflect the identified questioned costs. Management will implement process and procedures to ensure all required reports are completed accurately, in the event similar funding is received in the future. Anticipated Completion Date: January 16, 2025
View Audit 345762
Finding 523338 (2022-003)
Significant Deficiency 2022
Mission Hospice & Home Care INC
CA
Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting § 200.303
Management Response and Corrective Action: The Agency agrees with the finding and acknowledges the need to improve controls and documentation processes related to federal grant reporting. The Agency will implement the following corrective actions: - By April 30, 2025, establish formal review and app...
Management Response and Corrective Action: The Agency agrees with the finding and acknowledges the need to improve controls and documentation processes related to federal grant reporting. The Agency will implement the following corrective actions: - By April 30, 2025, establish formal review and approval procedures for all federal grant reports submitted to HRSA. - Provide training to all relevant staff on the new procedures and federal compliance requirements by April 30, 2025. - Ensure that all future reports submitted to HRSA include traceable documentation of the review and approval process. Management will monitor the implementation of these procedures to ensure their effectiveness in addressing the deficiency.
View Audit 342609
Finding 522582 (2022-002)
Significant Deficiency 2022
Clayton County Community Services Authority, Inc.
GA
Eligibility Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303
Responsible Persons: Director of Community Support, Executive Director, Case Managers Anticipated Completion Date: February 1, 2025 / On-going Corrective Action: The management of Clayton County Community Services Authority, Inc. has reviewed the above referenced finding and fully agrees with the r...
Responsible Persons: Director of Community Support, Executive Director, Case Managers Anticipated Completion Date: February 1, 2025 / On-going Corrective Action: The management of Clayton County Community Services Authority, Inc. has reviewed the above referenced finding and fully agrees with the recommendation to enhance the design of our control activities to ensure that CSBG participant files are adequately maintained, and to strengthen controls surrounding management review of participant files during intake process. Case Managers are responsible for initiating and developing participant files for the purpose of determining eligibility for the CSBG Program. Once the file has been developed and the participant deemed eligible for assistance, the file is forwarded to the Director of Community Support for additional review and approval. Only after the file has been approved by the Director of Community Support or Executive Director will the payment request/transmittal be submitted to the Fiscal Department for processing of payment. The Fiscal Department will not process any transactions or transmitt als without the required signature approval from the Director of Community Support or Executive Director indicating the participant is eligible for benefits.
View Audit 341807
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