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Corrective Action Plans

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Finding 480347 (2023-001)
Significant Deficiency 2023
Carearc, INC
KS
Special Tests & Provisions Subrecipient Monitoring Eligibility
Finding 2023.001 - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken CareArc was notified of the 2023 annual audit...
Finding 2023.001 - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken CareArc was notified of the 2023 annual audit finding related to Sliding Fee Discounts being applied incorrectly according to the Health Center Program Compliance Manual and out of compliance with our sliding fee policy. CareArc's CFO was aware of the incorrect slide adjustments during the sampling process of the audit. The two patients on Slide B that should have received 50% discount, only received 49% ($3.00 miscalculation) as our electronic medical records did not identify an internal lab as being all inclusive of the same-day office visit. The corrective action plan was to have the Electronic Medical Records system recognize internal labs as being all inclusive of the same-day office visit. This issue was identified by CareArc through an internal audit in September 2023 and we began working with Health Choice Network (HCN). HCN is our vendor that helps program our electronic medical records system. HCN has helped CareArc correct the system going forward. CareArc is working with HCN on creating a report on historical slide applications to correct accounts earlier in 2023. CareArc was able to manually correct the two identified patient accounts. The corrective action plan is still in process of being implemented by CareArc with the assistance of HCN/EPIC with an estimated completion in September 2024. If there are any question regarding this plan, please e-mail Seresa Howe at showe@carearc.org.
View Audit 316606
Clermont County
OH
Reporting § 200.329
The Auditor’s office with work with the Department of Job and Family Services and provide training on the importance of grant reporting and tracking. We will also explain and show how using the ERP system can aid in the tracking of expenses and help to ensure better accounting for grants. The Aud...
The Auditor’s office with work with the Department of Job and Family Services and provide training on the importance of grant reporting and tracking. We will also explain and show how using the ERP system can aid in the tracking of expenses and help to ensure better accounting for grants. The Auditor’s office will implement an additional level of control for this department’s grant award, reporting, and reimbursements to be reviewed by our office for accuracy. Use online state and federal agency websites to verify grant awards amounts and disbursements.
View Audit 316600
Asi - Reno, Inc.
MN
Questioned Costs HUD Housing Programs Cash Management
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ASI-Reno, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audi...
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ASI-Reno, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit Period: December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS - FINANCIAL STATEMENT AUDIT - NONE; FINDINGS - FEDERAL AWARD PROGRAMS AUDIT - DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT; FINDING 2023-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 The Project withdrew funds from the replacement reserve account that were subsequently reimbursed by the insurance company. Recommendation: The Project should deposit $5,500 into the replacement reserve account. Action Taken: The Project agrees with the finding. Management will deposit $5,500 into the replacement reserve account. If the Department of Housing and Urban Development has questions regarding this plan, please call Chuck Reuter at 651-645-7271.
View Audit 316599 Questioned Costs: $1
Asi - Billings, Inc.
MN
Questioned Costs HUD Housing Programs
ASI Billings, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit Period: December 31, 2023; The finding...
ASI Billings, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit Period: December 31, 2023; The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS - FINANCIAL STATEMENT AUDIT - None, FINDINGS - FEDERAL AWARD PROGRAMS AUDIT - None; DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2023-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 In 2 of 25 cash disbursements tested, the Project paid the expense of another project under common management. Recommendation: The Project should carefully review invoices before payment to make sure it only pays the proper amount. Action Taken: The Project agrees with the finding. The accounts payable staff will be reminded to be careful when entering invoices for payment. The finding was corrected in January 2024. If the Department of Housing and Urban Development has questions regarding this plan, please call Chuck Reuter at 651-645-7271.
View Audit 316598 Questioned Costs: $1
Asi Capitola, Inc.
MN
Questioned Costs HUD Housing Programs
FINDING 2023-001: SECTION 811, FEDERAL ASSISTANCE LISTING NUMBER 14.181 Condition: One of the tenant files tested contained a mathematical error in computing household income in the process of computing the tenant share of monthly rent. Recommendation: The Project should recompute the HUD subsidy a...
FINDING 2023-001: SECTION 811, FEDERAL ASSISTANCE LISTING NUMBER 14.181 Condition: One of the tenant files tested contained a mathematical error in computing household income in the process of computing the tenant share of monthly rent. Recommendation: The Project should recompute the HUD subsidy and tenant rent for this tenant and adjust a future monthly billing. Project managers should be aware of the importance of computing the tenant's household income correctly. Action taken: The Project agrees with the finding. Tenant rent was recomputed in January 2024 and management adjusted the April 2024 HUD billing. If the Department of Housing and Urban Development has questions regarding this plan, please call Chuck Reuter at 651-645-7271.
View Audit 316587 Questioned Costs: $1
Asi - Minot, Inc.
MN
Questioned Costs
Condition: In 1 of 25 cash disbursements tested, the Project paid the expense of another project under common management. Recommendation: The Project should carefully review invoices before payment to make sure it only pays the proper amount. Action Taken: The Project agrees with the finding. The ac...
Condition: In 1 of 25 cash disbursements tested, the Project paid the expense of another project under common management. Recommendation: The Project should carefully review invoices before payment to make sure it only pays the proper amount. Action Taken: The Project agrees with the finding. The accounts payable staff will be reminded to be careful when entering invoices for payment. The finding was corrected in January 2024. If the Department of Housing and Urban Development has questions regarding these plans, please call Chuck Reuter at 651-645-7271.
View Audit 316560 Questioned Costs: $1
Asi - Minot, Inc.
MN
Questioned Costs HUD Housing Programs
Condition: One of the tenant files tested contained a mathematical error in computing household income in the process of computing the tenant share of monthly rent. Recommendation: The Project should recompute the HUD subsidy and tenant rent for this tenant and adjust a future monthly billing. Proje...
Condition: One of the tenant files tested contained a mathematical error in computing household income in the process of computing the tenant share of monthly rent. Recommendation: The Project should recompute the HUD subsidy and tenant rent for this tenant and adjust a future monthly billing. Project managers should be aware of the importance of computing the tenant's household income correctly. Action taken: The Project agrees with the finding. Tenant rent was recomputed in January 2024. If the Department of Housing and Urban Development has questions regarding these plans, please call Chuck Reuter at 651-645-7271.
View Audit 316560 Questioned Costs: $1
Finding 480326 (2023-005)
Significant Deficiency 2023
Bethany Manor, Inc. and Affiliates Dba: Bethany Life
IA
Questioned Costs Allowable Costs / Cost Principles Significant Deficiency
FINDINGS—FEDERAL AWARD PROGRAMS AUDITS USDA Rural Development 2023-005 Community Facilities Loan – Assistance Lising Number: 10.766 Recommendation: We recommend management implement process of transfer and review for reserve fund payments to ensure adequacy of reserve account balance per loan agreem...
FINDINGS—FEDERAL AWARD PROGRAMS AUDITS USDA Rural Development 2023-005 Community Facilities Loan – Assistance Lising Number: 10.766 Recommendation: We recommend management implement process of transfer and review for reserve fund payments to ensure adequacy of reserve account balance per loan agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As of May 2024, management is reviewing with their banks to set up ACH for future transfers. The balance as of December 31, 2023 was $671,066 and deposits will continue until reaching the required amount of $928,800. Name(s) of the contact person(s) responsible for corrective action: Heather Uthoff, CFO Planned completion date for corrective action plan: December 31, 2024 If the USDA Rural Development has questions regarding this plan, please call Heather Uthoff at (515) 733-3030.
View Audit 316554 Questioned Costs: $1
Finding 480325 (2023-007)
Significant Deficiency 2023
City of Banning
CA
Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.302
2023-007 – Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing Number: 21.027 Federal Grantor: U.S. Department of Treasury Award No. and Year: 2021 Finding Summary: Compliance Requirement: Allowable Costs/Cost Principles Type of Finding: Significa...
2023-007 – Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing Number: 21.027 Federal Grantor: U.S. Department of Treasury Award No. and Year: 2021 Finding Summary: Compliance Requirement: Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control and Instance of Non-Compliance Corrective Action Plan: The city is in the process of updating its Purchasing Policy and will include language on allowable costs and cost principles that are compliant with 2 C.F.R. 200. The Purchasing Policy requires updates at least every five years and will be taken to City Council before the end of 2024 for approval by Resolution. Responsible Individual(s): Lincoln Bogard, Administrative Services Director; A’ja Wallace, Deputy Finance Director; and Barbara Mason, Purchasing Manager Anticipated Completion Date: December 2024
View Audit 316551
Finding 480324 (2023-006)
Material Weakness 2023
City of Banning
CA
Procurement, Suspension & Debarment § 200.214 § 200.303
2023-006 – Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing Number: 21.027 Federal Grantor: U.S. Department of Treasury Award No. and Year: 2021 Finding Summary: Compliance Requirements: Procurement and Suspension and Debarment Type of Finding:...
2023-006 – Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing Number: 21.027 Federal Grantor: U.S. Department of Treasury Award No. and Year: 2021 Finding Summary: Compliance Requirements: Procurement and Suspension and Debarment Type of Finding: Material Weakness in Internal Control over Compliance Corrective Action Plan: The City’s Purchasing Department has taken two steps to address this finding. First, the Purchasing Manager is currently checking for debarment and suspension prior to contract issuance. Second, the city’s standard contract is being revised to include language that requires contractors to affirm that they are not debarred or suspended. Responsible Individual(s): Lincoln Bogard, Administrative Services Director; A’ja Wallace, Deputy Finance Director; and Barbara Mason, Purchasing Manager Anticipated Completion Date: December 2024
View Audit 316551
Finding 480322 (2023-002)
Significant Deficiency 2023
Baptist Health Deaconess Madisonville, Inc.
KY
Allowable Costs / Cost Principles Cash Management Significant Deficiency § 200.303
Finding 2023-002 Federal Agency Name: Department of the Treasury Program Name: COVID-19 Claims Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing #21.027 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: B...
Finding 2023-002 Federal Agency Name: Department of the Treasury Program Name: COVID-19 Claims Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing #21.027 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: BHD, LLC calculated their indirect cost rate based on the total grant budget and took an equal amount of that per month instead of calculating the indirect cost rate percentage of direct expenditures for each month. Responsible Individuals: Kim Ashby, Vice President of Finance Corrective Action Plan: Indirect costs for some grants were allocated based on a percentage of the grant budget. Management has changed the policy for allocation of indirect costs for all grants to require allocation based on a percentage of actual grant expenditures. Anticipated Completion Date: August 1, 2024
View Audit 316547
Finding 480321 (2023-001)
Material Weakness 2023
Baptist Health Deaconess Madisonville, Inc.
KY
Reporting Material Weakness
Finding 2023-001 Federal Agency Name: Department of the Treasury Program Name: COVID-19 Claims Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing #21.027 Compliance Requirement: Preparation of Schedule of Expenditures of Federal Awards Finding Summary: Management ...
Finding 2023-001 Federal Agency Name: Department of the Treasury Program Name: COVID-19 Claims Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing #21.027 Compliance Requirement: Preparation of Schedule of Expenditures of Federal Awards Finding Summary: Management prepared the Schedule for the year ended August 31, 2023. During the audit process, changes were proposed to include the COVID‐19 Claims Coronavirus State and Local Fiscal Recovery Funds, which were not originally included on the Schedule. Responsible Individuals: Kim Ashby, Vice President of Finance Corrective Action Plan: When funds for this grant were initially awarded in fiscal year 2021, the grant was state funded and not subject to A-133 audit. During fiscal year 2022, a portion of the grant became federally funded and subject to A-133 audit, but this was not discovered until the current fiscal year 2023 audit. Management has implemented a procedure to check the funding status of grants at the beginning of each fiscal year. Anticipated Completion Date: August 1, 2024
View Audit 316547
Finding 480320 (2023-002)
Significant Deficiency 2023
Klamath Watershed Partnership
OR
Reporting
Views of responsible officials and planned corrective actions: Management agrees that the reports had inaccuracies that were created by including information that is listed as optional in SF-425 instructions. The staff will avoid reporting optional information in the future.
Views of responsible officials and planned corrective actions: Management agrees that the reports had inaccuracies that were created by including information that is listed as optional in SF-425 instructions. The staff will avoid reporting optional information in the future.
View Audit 316546
Finding 480319 (2023-001)
Significant Deficiency 2023
Klamath Watershed Partnership
OR
Views of responsible officials and planned corrective actions: Management agrees with the finding and have updated their procurement policy to align with the requirements of 2 CFR 200.318.
Views of responsible officials and planned corrective actions: Management agrees with the finding and have updated their procurement policy to align with the requirements of 2 CFR 200.318.
View Audit 316546
Endeavors, Inc.
TX
Questioned Costs Allowable Costs / Cost Principles Cash Management
Finding 2023-001 Responsible Individual: Steve Lefever Endeavors obtained verbal approval to include the activities related to utilities and facility services on requests for reimbursement from the official who reviewed and approved billings. Endeavors submits all invoices with attached detailed sup...
Finding 2023-001 Responsible Individual: Steve Lefever Endeavors obtained verbal approval to include the activities related to utilities and facility services on requests for reimbursement from the official who reviewed and approved billings. Endeavors submits all invoices with attached detailed support for each expenditure. All requests for reimbursement to date have been paid for utilities and facility services without exception. Corrective Action Plan (CAP) Endeavors will review each grant at inception and list out requirements related to budget and billings. Grant requirements will also be reviewed with the Grant/Contract Accountant and Program Officials at the start of any subsequent grant years. Endeavors will not submit billings without documented approval from the funder of budget changes from the original award. Anticipated Completion date 8/1/24
View Audit 316543 Questioned Costs: $1
Finding 480317 (2023-001)
Significant Deficiency 2023
Corewell Health & Affiliates
MI
Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303
Finding 2023-001 Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) Pass-Throug...
Finding 2023-001 Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) Pass-Through Grantor: Not applicable Pass-Through Award Number: Not applicable Pass-Through Award Period: 1/1/2020-12/31/2023 (Periods 5 and 6) Summary of Finding: The “Total Lost Revenues for the Period of Availability (January 1, 2020 to June 30, 2023)” line in the HRSA PRF portal for Spectrum Health System (the Parent), TIN 383382353, General Distribution HRSA PRF report in Reporting Period 5 was $108,697,843. The correct amount of lost revenue reported for Period 5 should have been $107,045,743. The difference represents a $1.6M error in adjusting for targeted funds to determine the Parent lost revenue for period 5. Corrective Action Plan: No further lost revenue reporting is required on the HRSA PRF Portal. Management will implement more robust internal controls in preparation for similar future filings. Individuals responsible for corrective action: Cindy Brink, Director, System Accounting and Reporting Timing of corrective action: July 1, 2024 and going forward.
View Audit 316542
Finding 480316 (2023-004)
Material Weakness 2023
Mount Vernon Community School District
IA
Cash Management Reporting Internal Control / Segregation of Duties
1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding Administration will add additional internal controls where the benefit exceeds the cost. 3. Official Responsible for Ensuring CAP Michael Marshall, Board Secre...
1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding Administration will add additional internal controls where the benefit exceeds the cost. 3. Official Responsible for Ensuring CAP Michael Marshall, Board Secretary/Treasurer, is the official responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP The planned completion date for the CAP is June 30, 2024. 5. Plan to Monitor Completion of CAP The School Board will be monitoring this CAP.
View Audit 316541
Finding 480313 (2023-001)
Significant Deficiency 2023
Middleborough Housing Authority
MA
HUD Housing Programs Subrecipient Monitoring Reporting
The Authority had a change in Executive Director and Fee Accountant, which resulted in delayed access to the FASPHA system. The Authority will ensure timely submissions going forward.
The Authority had a change in Executive Director and Fee Accountant, which resulted in delayed access to the FASPHA system. The Authority will ensure timely submissions going forward.
View Audit 316534
Finding 480310 (2023-001)
Significant Deficiency 2023
City of Springfield
MN
Auditor Prepared Financial Statements
Auditor Prepared Financial Statements
View Audit 316524
Finding 480310 (2023-001)
Significant Deficiency 2023
City of Springfield
MN
Name of Contact Person: Amber Dale, City Manager
Name of Contact Person: Amber Dale, City Manager
View Audit 316524
Finding 480310 (2023-001)
Significant Deficiency 2023
City of Springfield
MN
Correction Action: The City Manager will continue to review GASB pronouncements and GASB disclosure checklists to ensure she is aware of financial statement requirements and new pronouncements.
Correction Action: The City Manager will continue to review GASB pronouncements and GASB disclosure checklists to ensure she is aware of financial statement requirements and new pronouncements.
View Audit 316524
Finding 480310 (2023-001)
Significant Deficiency 2023
City of Springfield
MN
Proposed Completion Date: The City Council will implement the above procedures immediately.
Proposed Completion Date: The City Council will implement the above procedures immediately.
View Audit 316524
Finding 480308 (2023-004)
Material Weakness 2023
Blue Rivers Area Agency on Aging
NE
Allowable Costs / Cost Principles Material Weakness Internal Control / Segregation of Duties
View of Responsible Officials and Planned Corrective Actions: Management will implement procedures to reconcile expenditures of federal awards to ensure expenditures can be accurately tracked and reported.
View of Responsible Officials and Planned Corrective Actions: Management will implement procedures to reconcile expenditures of federal awards to ensure expenditures can be accurately tracked and reported.
View Audit 316523
Finding 480307 (2023-001)
Significant Deficiency 2023
City of Valley, Nebraska
NE
Procurement, Suspension & Debarment
Instance in which procurement for engineering services which exceeded the simplified acquisition threshold (SAT), or a lower threshold established by a non-Federal entity was not obtained. The Uniform Guidance for Federal Awards required competitive bids to be obtained when over the SAT threshold. T...
Instance in which procurement for engineering services which exceeded the simplified acquisition threshold (SAT), or a lower threshold established by a non-Federal entity was not obtained. The Uniform Guidance for Federal Awards required competitive bids to be obtained when over the SAT threshold. Transaction testing found procurement was not obtained for engineering services. The City of Valley has communicated proper procurement guidelines to the appropriate departments and outside agencies, moving forward the City of Valley shall be placing public notice for all available service contracts that involve Federal Awards to comply with the guidelines set forth under the Uniform Guidance of Federal Funds, including but not limited to Engineering services. Reasonable completion date: August 2024 Responsible Party: City Clerk and Treasurer will work together going forward to ensure all proper paperwork is completed and public notices are placed for all available service contracts.
View Audit 316519
Finding 480306 (2023-003)
Significant Deficiency 2023
City of Miami
OK
Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.318 § 200.320
Inadequate Records Retention Condition: In our procurement testing for CSLFRF funding, the City was unable to provide evidence that demonstrates public notice was published according to (2 CFR § 200.320(b)) for 1 of the 5 projects selected. In conjunction with our FY2023 audit, please see the City’...
Inadequate Records Retention Condition: In our procurement testing for CSLFRF funding, the City was unable to provide evidence that demonstrates public notice was published according to (2 CFR § 200.320(b)) for 1 of the 5 projects selected. In conjunction with our FY2023 audit, please see the City’s corrective action plan below: Management Response: The Finance Director is initiating conversations with department heads regarding updating procurement policies and procedures. We are taking steps to ensure all procurement documents are stored centrally in order for these items to be readily available moving forward. Expected completion date: In regards to procurement documents corrective action has already been taken for FY 23-24; regarding updating procurement policies and procedures expected completion date 6.30.25. Party Responsible: Jennifer Watts, Finance Director Contact Information: jwatts@miamiokla.net
View Audit 316516
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