Corrective Action Plans

Finding 371305 (2021-007)

Significant Deficiency 2021

AK

Reporting § 200.303

Finding 2021‐007 Late Reporting – Significant Deficiency in Internal Control over Compliance Corrective Action Plan Management will carefully review report deadlines and ensure that submission of reports is made before they are due. Expected Completion Date Fiscal Year 2025.

View Audit 292985

Finding 371304 (2021-006)

Material Weakness 2021

City of Bethel, Alaska

AK

Allowable Costs / Cost Principles § 200.303 § 200.430

Finding 2021‐006 Payroll Documentation – Activities Allowed and Unallowed, Allowable Costs/Cost Principles – Noncompliance and Material Weakness in Internal Control over Compliance Corrective Action Plan Management will review current employee pay rates within the payroll module and ensure that rate...

Finding 2021‐006 Payroll Documentation – Activities Allowed and Unallowed, Allowable Costs/Cost Principles – Noncompliance and Material Weakness in Internal Control over Compliance Corrective Action Plan Management will review current employee pay rates within the payroll module and ensure that rates agree to the most current pay rate as is specified in the employee’s current personnel action form. Expected Completion Date Fiscal Year 2025.

View Audit 292985

Finding 370512 (2021-004)

Material Weakness 2021

Elmore County Commission

AL

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303

The County also produced reimbursement requests well in excess of not only the subject amount referenced above, but also well over the state allocated CARES Act funds the County was eligible to receive in reimbursement. Regardless, the County will increase efforts to provide internal review of these...

The County also produced reimbursement requests well in excess of not only the subject amount referenced above, but also well over the state allocated CARES Act funds the County was eligible to receive in reimbursement. Regardless, the County will increase efforts to provide internal review of these type items to ensure clarity of reimbursement s and/or costs moving forward on state and federally funded projects.

View Audit 292133 Questioned Costs: $1

Finding 370141 (2021-005)

Material Weakness 2021

Town of Livermore Falls

ME

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303

The Treasurer, Town Manager and Select Board will take the following actions to address finding 2021-005 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted a new Procurement Poli...

The Treasurer, Town Manager and Select Board will take the following actions to address finding 2021-005 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted a new Procurement Policy that addresses this deficiency. The Select Board will review this draft at their meeting in January 2024, edits will be made and then it will be sent to legal for final review before adoption. Additionally, Department Heads are required to turn in no later than Thursday by noon, invoices to be paid on that week’s warrant. The Treasurer has been given authority by the Town Manager to contact Department Heads and request that they come to the office weekly to turn in invoices. All invoices must have the appropriate expense code and be signed by the Department Head.

View Audit 291678

Finding 370139 (2021-003)

Material Weakness 2021

Town of Livermore Falls

ME

Allowable Costs / Cost Principles § 200.303

The Treasurer, Town Manager and Select Board will take the following actions to address finding 2021-003 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager that has implemented training for the ...

The Treasurer, Town Manager and Select Board will take the following actions to address finding 2021-003 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager that has implemented training for the Treasurer and the Select Board. She has implemented a process of having the Treasurer complete a warrant each week. The Select Board meets bi-monthly and the Town Manager has the Select Board review and approve all warrants as a regular action item in their meeting. Additionally, Department Heads are required to turn in no later than Thursday by noon, invoices to be paid on that week’s warrant. The Treasurer has been given authority by the Town Manager to contact Department Heads and request that they come to the office weekly to turn in invoices. All invoices must have the appropriate expense code and be signed by the Department Head.

View Audit 291678

Finding 370053 (2021-008)

Material Weakness 2021

Delaware County

OK

Allowable Costs / Cost Principles Period of Performance Matching / Level of Effort / Earmarking § 200.303

The Board of County Commissioners will work with all Count Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.

View Audit 291562

Finding 369744 (2021-008)

Material Weakness 2021

New Vision Foundation

MN

Matching / Level of Effort / Earmarking Cash Management Material Weakness § 200.303

Child and Adult Care Food Program - Assistance Listing No. 10.558 Recommendation Auditor recommends the Organization retain clear documentation of meal count sheets, including labeling of the particular month they relate to. We also recommend the Organization reconcile the meal count sheets with the...

Child and Adult Care Food Program - Assistance Listing No. 10.558 Recommendation Auditor recommends the Organization retain clear documentation of meal count sheets, including labeling of the particular month they relate to. We also recommend the Organization reconcile the meal count sheets with the clicker reports, and retain specific documentation as to the variances. Explanation of disagreement with audit finding The Child and Adult Care Food Program was created as an emergency response during the COVID-19 pandemic. In such an emergent situation, management believes the federal government acted in good faith to meet the needs of the country by contracting with regional sponsoring organizations. New Vision Foundation was selected by the sponsoring organization to be a community-based food provider to culturally-specific populations. All activities related to the program were expressly approved by the sponsoring organization. The finding of material noncompliance is overstated. Management followed all guidelines and fulfilled all obligations outlined by Feeding Our Future. Documentation of meal count sheets and clicker reports were accepted and approved by the sponsoring organization. Additional documentation was not requested nor were any changes to management’s practices. Action taken in response to finding The program noted was discontinued at the end of 2021. If the Organization enters into any other federal funding, we will consult with experts on compliance requirements from the start of the grant. Name of the contact person responsible for corrective action Hussein Farah, Executive Director Planned completion date for corrective action plan N/A

View Audit 291230

Finding 369742 (2021-006)

Material Weakness 2021

New Vision Foundation

MN

Questioned Costs Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment § 200.303

Child and Adult Care Food Program - Assistance Listing No. 10.558 Recommendation Auditor recommends the Organization attend training, review federal requirements, and fully understand the documentation and meal requirements of the program if they apply for funding with this program again. Explanatio...

Child and Adult Care Food Program - Assistance Listing No. 10.558 Recommendation Auditor recommends the Organization attend training, review federal requirements, and fully understand the documentation and meal requirements of the program if they apply for funding with this program again. Explanation of disagreement with audit finding The Child and Adult Care Food Program was created as an emergency response during the COVID-19 pandemic. In such an emergent situation, management believes the federal government acted in good faith to meet the needs of the country by contracting with regional sponsoring organizations. New Vision Foundation was selected by the sponsoring organization to be a community-based food provider to culturally-specific populations. All activities related to the program were expressly approved by the sponsoring organization. The auditor was provided meal logs, invoices and documents signed by program participants as evidence of meals delivered. However, this documentation was not accepted by the auditor even though it had been approved by the sponsor organization. The auditor requested delivery driver schedules and/or volunteer assignments for specific deliveries which were not available since the sponsor organization never requested such documents be kept. The finding of material noncompliance is overstated. Management followed all guidelines and fulfilled all obligations outlined by Feeding Our Future. Action taken in response to finding The program noted was discontinued at the end of 2021. If the Organization enters into any other federal funding, we will consult with experts on compliance requirements from the start of the grant. Name of the contact person responsible for corrective action Hussein Farah, Executive Director Planned completion date for corrective action plan N/A

View Audit 291230 Questioned Costs: $1

Finding 369354 (2021-004)

Material Weakness 2021

Legacy Senior Services

MN

Allowable Costs / Cost Principles Material Weakness § 200.303

Finding Summary: During our testing, there was no documentation for a portion of the sample selected. Responsible Individuals: Stephanie Schmidt, Director, Financial Planning & Analysis Corrective Action Plan: Management will enhance internal control policies to ensure all expenditures are supported...

Finding Summary: During our testing, there was no documentation for a portion of the sample selected. Responsible Individuals: Stephanie Schmidt, Director, Financial Planning & Analysis Corrective Action Plan: Management will enhance internal control policies to ensure all expenditures are supported to ensure that all payments are necessary, correct, and meet the requirements of the federal program. The unsupported invoices were damaged in a flood. The support was available at the time the expenditures were being recognized. The organization has gone to an electronic accounts payable system in 2021 so invoices are being stored electronically and that will assist in making sure that all expenditures are supported. Anticipated Completion Date: Ongoing

View Audit 290581

Finding 369353 (2021-003)

Material Weakness 2021

Legacy Senior Services

MN

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Finding Summary: The Organization selected option ii to calculate lost revenue which consists of a comparison of actual results during the period of availability to the approved budget. The Organization did not have a budget for the entire reporting period that was approved prior to March 27, 2020. ...

Finding Summary: The Organization selected option ii to calculate lost revenue which consists of a comparison of actual results during the period of availability to the approved budget. The Organization did not have a budget for the entire reporting period that was approved prior to March 27, 2020. Responsible Individuals: Stephanie Schmidt, Director, Financial Planning & Analysis Corrective Action Plan: The organization thought it was calculating lost revenue appropriately and later realized the budget needed to be approved prior March 27, 2020. The lost revenue calculation was revised to Option i in Period 4 reporting. Anticipated Completion Date: March 2023

View Audit 290581

Finding 369352 (2021-002)

Significant Deficiency 2021

Legacy Senior Services

MN

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Finding Summary: The Organization’s final expenditure listing and lost revenue identified as eligible and claimed under the Provider Relief Fund program did not have documented review and approval by a separate individual outside of the preparer. In addition, the Organization’s special reports submi...

Finding Summary: The Organization’s final expenditure listing and lost revenue identified as eligible and claimed under the Provider Relief Fund program did not have documented review and approval by a separate individual outside of the preparer. In addition, the Organization’s special reports submitted to the Department of Health and Human Services (HHS) for Period 1 and Period 2 were not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Stephanie Schmidt, Director, Financial Planning & Analysis Corrective Action Plan: When summarizing eligible costs and lost revenue for submission, a secondary review of the summary spreadsheet prepared from the underlying supporting expense records will be documented. Before reports are submitted to the federal agency, documented approval of this submission will be acquired. Anticipated Completion Date: 2/1/2024

View Audit 290581

Finding 11925 (2021-003)

Material Weakness 2021

Coastal Harvest

WA

Special Tests & Provisions Subrecipient Monitoring Cash Management § 200.303

Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024

View Audit 15891

Finding 11002 (2021-001)

Material Weakness 2021

Cornwall Manor

PA

Questioned Costs Allowable Costs / Cost Principles § 200.303

The Manor agrees with the finding. The Manor reported expenses in its period 1 submission of $798,256 which included all skilled nursing supplies expenses and an allocation of dining supplies which all of which were not necessarily used to prevent, prepare for, and respond to coronavirus. The Mano...

The Manor agrees with the finding. The Manor reported expenses in its period 1 submission of $798,256 which included all skilled nursing supplies expenses and an allocation of dining supplies which all of which were not necessarily used to prevent, prepare for, and respond to coronavirus. The Manor was able to provide direct costs used to prevent, prepare for, and respond to coronavirus that totaled $908,131 of which $266,251 were reported in period 2, thus $156,376 was over reported in period 1. Cornwall Manor agrees with the finding and misinterpreted the guidance but was able to substantiate $641,880 of expenses reported in period 1 as direct costs used to prevent, prepare for, and respond to coronavirus. Additionally, the Manor reported $740,727 of lost revenues in the period 1 report that could be applied against the PRF payments. Procedures have been implemented to ensure that all future reporting will only include direct costs used to prevent, prepare for, and respond to coronavirus.

View Audit 14852 Questioned Costs: $1

Finding 10111 (2021-005)

Material Weakness 2021

Hill & Dales General Hospital and Subsidiary

MI

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.303

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

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

View Audit 13756 Questioned Costs: $1

Finding 10110 (2021-004)

Material Weakness 2021

Hill & Dales General Hospital and Subsidiary

MI

Subrecipient Monitoring Material Weakness Reporting § 200.303

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

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

View Audit 13756

Finding 10109 (2021-003)

Material Weakness 2021

Hill & Dales General Hospital and Subsidiary

MI

Allowable Costs / Cost Principles Eligibility Material Weakness § 200.303

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

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

View Audit 13756

Finding 8802 (2021-011)

Material Weakness 2021

The Center for Black Women's Wellness, Inc.

GA

Procurement, Suspension & Debarment § 200.303

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. We implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and p...

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. We implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and procedures in 2022 to include procurement, suspension and debarment procedures and implemented a procedure for ensuring compliance with obtaining required bids, etc. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022

View Audit 12076

Finding 8801 (2021-010)

Significant Deficiency 2021

The Center for Black Women's Wellness, Inc.

GA

Questioned Costs Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.303 § 200.320

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal polic...

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and procedures in 2022 to include procurement and implemented a procedure for ensuring compliance with obtaining required bids, etc. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022

View Audit 12076 Questioned Costs: $1

Finding 8800 (2021-009)

Material Weakness 2021

The Center for Black Women's Wellness, Inc.

GA

Cash Management Internal Control / Segregation of Duties § 200.303 § 200.305

concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2023, we implemented additional procedures to more efficiently review drawdowns and supporting documentation. We updated our fiscal policies and procedures in 2023 to document a standardiz...

concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2023, we implemented additional procedures to more efficiently review drawdowns and supporting documentation. We updated our fiscal policies and procedures in 2023 to document a standardized process for review and approval of drawdowns before request for reimbursement by the Fiscal Office and CEO. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022

View Audit 12076

Finding 8799 (2021-008)

Significant Deficiency 2021

The Center for Black Women's Wellness, Inc.

GA

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303 § 200.308 § 200.309 § 200.403

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. We mplemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and pr...

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. We mplemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and procedures in 2022 to document a standardized process for documenting expenditures and retaining receipts. For instance, invoices cannot be processed without adequate documentation. Additionally, credit card holders are responsible for submitting electronic credit card receipts to the fiscal office monthly. In 2022, an updated credit card policy was provided to all employees. The adherence to the credit card policy is monitored by the Fiscal Office and CEO. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022

View Audit 12076 Questioned Costs: $1

Finding 8798 (2021-007)

Significant Deficiency 2021

The Center for Black Women's Wellness, Inc.

GA

Questioned Costs Internal Control / Segregation of Duties § 200.303

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. We implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and p...

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. We implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and procedures in 2022 to document a standardized process for documenting expenditures and retaining receipts. For instance, invoices cannot be processed without adequate documentation. Additionally, credit card holders are responsible for submitting electronic credit card receipts to the fiscal office monthly. In 2022, an updated credit card policy was provided to all employees. The adherence to the credit card policy is monitored by the Fiscal Office and CEO. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022

View Audit 12076 Questioned Costs: $1

Finding 8450 (2021-002)

Material Weakness 2021

Veterans Transition Center of California

CA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303

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

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

View Audit 11397 Questioned Costs: $1

Finding 8248 (2021-007)

Material Weakness 2021

Round Valley Indian Tribes

CA

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303

The Tribes will ensure compliance with future program allowable costs and allowable activities requirements, such as documentation review and enhanced controls to ensure accurate recognition of expenditures.

View Audit 10880 Questioned Costs: $1

Finding 8247 (2021-006)

Material Weakness 2021

Round Valley Indian Tribes

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

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

View Audit 10880

Finding 8246 (2021-005)

Material Weakness 2021

Round Valley Indian Tribes

CA

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

The Tribes commit to a comprehensive corrective action plan, including a thorough review of document processes, implementing additional controls for disbursement transactions, ensuring proper documentation review in the future, enhancing controls over the timing of expenditure recognition, and provi...

The Tribes commit to a comprehensive corrective action plan, including a thorough review of document processes, implementing additional controls for disbursement transactions, ensuring proper documentation review in the future, enhancing controls over the timing of expenditure recognition, and providing additional training to personnel involved in disbursement processes.

View Audit 10880

Corrective Action Plans

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