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Corrective Action Plans

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Finding 479414 (2023-001)
Significant Deficiency 2023
Family Counseling Service of the Finger Lakes, Inc.
NY
Internal Control / Segregation of Duties
We feel this situation was an anomaly, as the employee’s original Supervisor had taken a new position and the hiring of a replacement Supervisor had not yet taken place. Normally, the Director of Therapeutic Services would have stepped in; however, they were out on medical leave. These special cir...
We feel this situation was an anomaly, as the employee’s original Supervisor had taken a new position and the hiring of a replacement Supervisor had not yet taken place. Normally, the Director of Therapeutic Services would have stepped in; however, they were out on medical leave. These special circumstances, while rare, do not negate the need for contingency plans. We will continue to require employees to complete OVS Functional Timecards each month and have their Supervisor review and approve. If the Supervisor is unavailable, the Director of the appropriate program will review and approve. If the Director of the appropriate program is unavailable, VP of Operations will review and approve the functional timecard. Specifically, employees will complete and sign their monthly functional timecards and submit for Supervisor review no later than the 15th of the month following their support of OVS. Supervisors (or if needed, Program Directors or VP of Operations) will review and approve via signature no later than end of the month following timecard timeframe. All completed and approved functional timecards will be sent by the supervisor to VP of Operations for review of completeness and filed for documentation purposes.
View Audit 315916
Finding 479413 (2023-003)
Material Weakness 2023
Southeast Iowa Regional Medical Center
IA
Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles
U.S. Department of Health and Human Services Great River Health System, Inc. and Subsidiaries respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 – June 30, 2023 The finding from the schedule of findings and questioned costs is discu...
U.S. Department of Health and Human Services Great River Health System, Inc. and Subsidiaries respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 – June 30, 2023 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING—FEDERAL AWARD PROGRAMS AUDITS MATERIAL WEAKNESS U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-003 Provider Relief Fund – Assistance Listing No. 93.498 Recommendation: We recommend the Organization put in place controls over compliance that mitigate the risk of errors in reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We added an additional management review for future submissions prior to filing and submission. Name(s) of the contact person(s) responsible for corrective action: Jeremy Alexander, CFO Planned completion date for corrective action plan: 7/01/2024 If the Department of Health and Human Services has questions regarding this plan, please call Jeremy Alexander at 319-768-3280.
View Audit 315911 Questioned Costs: $1
Finding 479412 (2023-001)
Significant Deficiency 2023
Child Guidance & Family Solutions
OH
Questioned Costs Allowable Costs / Cost Principles Cash Management
Management will review all draw down requests and tracking of overall payroll costs billed to the program to ensure employees are not billed more than once for the same period. The overpayment finding is being refunded to the funder.
Management will review all draw down requests and tracking of overall payroll costs billed to the program to ensure employees are not billed more than once for the same period. The overpayment finding is being refunded to the funder.
View Audit 315906 Questioned Costs: $1
Finding 479406 (2022-004)
Significant Deficiency 2023
Meadows Mental Health Policy Institute for Texas
TX
Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties
Develop a comprehensive policy outlining the procedures for reviewing the monthly payroll grant summary. Provide training and guidance to the designated reviewer on the policies and procedures outlined in the new policy. Maintain thorough documentation of the review activities conducted, including a...
Develop a comprehensive policy outlining the procedures for reviewing the monthly payroll grant summary. Provide training and guidance to the designated reviewer on the policies and procedures outlined in the new policy. Maintain thorough documentation of the review activities conducted, including any corrective actions taken in response to identified issues.
View Audit 315903
Finding 479405 (2022-003)
Significant Deficiency 2023
Meadows Mental Health Policy Institute for Texas
TX
Allowable Costs / Cost Principles Cash Management Period of Performance
Maintain detailed documentation of the review process, including any findings or discrepancies identified during the review of drawdowns. Establish clear review procedures for the drawdowns prepared by the Assistant Controller. Continuously monitor the effectiveness of the review process and identif...
Maintain detailed documentation of the review process, including any findings or discrepancies identified during the review of drawdowns. Establish clear review procedures for the drawdowns prepared by the Assistant Controller. Continuously monitor the effectiveness of the review process and identify areas for improvement. Implement any necessary changes or enhancements to the review procedures to ensure thorough compliance with grant requirements.
View Audit 315903
Finding 479403 (2023-003)
Significant Deficiency 2023
City of Green Bay
WI
Reporting Significant Deficiency
Condition The Quarter 2 and 4 Project and Expenditure Reports were tested. The Quarter 4 (Q4) report had a typo that resulted in the Q4 expenditures to be understated by $1,007,000 for project 2-6-001, but the cumulative expenditures were input correctly. Additionally, project 12-6-201 was understat...
Condition The Quarter 2 and 4 Project and Expenditure Reports were tested. The Quarter 4 (Q4) report had a typo that resulted in the Q4 expenditures to be understated by $1,007,000 for project 2-6-001, but the cumulative expenditures were input correctly. Additionally, project 12-6-201 was understated by $18,515 for the Q4 and cumulative expenditures due to excluding a transaction. Corrective Action Plan Corrective Action Planned: SLFRF Compliance reports will be reviewed and approved by the Grant Administrator, Assistant Finance Director and Finance Director. Query reports are now in place to capture all accounts and ensure accuracy. Name(s) of Contact Person(s) Responsible for Corrective Action: Susan House, Grant Administrator; Linda Chosa, Assistant Finance Director; Diana Ellenbecker, Finance Director Anticipated Completion Date: July 31, 2024
View Audit 315900
Finding 479402 (2023-002)
Significant Deficiency 2023
Mercer County
IL
Reporting
County management and County Board will ensure that ARPA interim reports are completed in a timely manner.
County management and County Board will ensure that ARPA interim reports are completed in a timely manner.
View Audit 315899
Finding 479401 (2023-001)
Significant Deficiency 2023
Mercer County
IL
County management will review employee timesheets.
County management will review employee timesheets.
View Audit 315899
Midland County
MI
Reporting Internal Control / Segregation of Duties
The County's system of internal control detected this error prior to commencement of audit procedures for 2023 and was corrected during the grant reporting process for the quarter ended March 31, 2024.
The County's system of internal control detected this error prior to commencement of audit procedures for 2023 and was corrected during the grant reporting process for the quarter ended March 31, 2024.
View Audit 315895
Finding 479382 (2023-003)
Significant Deficiency 2023
Wisconsin Health Care Association, Inc.
WI
Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.302 § 200.303 § 200.305
Management will implement the necessary changes to WHCA's policies and procedures.
Management will implement the necessary changes to WHCA's policies and procedures.
View Audit 315889
Columbia Opportunities, Inc.
NY
Reporting
Name of auditee: Columbia Opportunities, Inc. TIN: 14-1627038 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: November 1, 2022 - October 31, 2023 CAP prepared by: Tina Sharpe tsharpe@columbiaopportunities.org Finding 2023-001 Corrective Action Plan The Organization acknowledges a...
Name of auditee: Columbia Opportunities, Inc. TIN: 14-1627038 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: November 1, 2022 - October 31, 2023 CAP prepared by: Tina Sharpe tsharpe@columbiaopportunities.org Finding 2023-001 Corrective Action Plan The Organization acknowledges and is aware of this finding. Management and fiscal departments are responsible for timely reporting. Management will follow its comprehensive policies and procedures and complete reporting submissions on time for future periods.
View Audit 315886
Finding 479373 (2023-001)
Material Weakness 2023
Spyglass Ridge
OR
Allowable Costs / Cost Principles Material Weakness Internal Control / Segregation of Duties
Views of Responsible Officials and Planned Corrective Actions We agree with this finding. NWCH was successful in adding needed staff in 2023, but was unable to hire a degreed accountant or controller, or to contract with an accounting firm for oversight of the accounting function. Bookkeeper trainin...
Views of Responsible Officials and Planned Corrective Actions We agree with this finding. NWCH was successful in adding needed staff in 2023, but was unable to hire a degreed accountant or controller, or to contract with an accounting firm for oversight of the accounting function. Bookkeeper training was provided from Shelter Resources Financial Manager in February 2023. NWCH is researching CPA firms in order to contract a qualified controller with expertise in real estate holdings relevant to NWCH. NWCH has been actively searching for a qualified CPA to hire or contract with since 2021, however, due to capacity constraints and overwhelmed CPA firms, NWCH has been unsuccessful. Efforts to hire experienced accounting personnel continues.
View Audit 315878
Finding 479367 (2023-003)
Significant Deficiency 2023
Adams County, Colorado
CO
Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency § 200.303
COVID - 19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Condition: During our testing of nine covered transactions (three vendors and six subawards), we noted all three vendors did not have proper supporting documentation for suspension and debarment procedures for vendors. Recommendati...
COVID - 19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Condition: During our testing of nine covered transactions (three vendors and six subawards), we noted all three vendors did not have proper supporting documentation for suspension and debarment procedures for vendors. Recommendation: We recommend the County obtain certifications from vendors stating their organization is not suspended, debarred, or otherwise excluded from participation in federal assistance programs or document the procedures performed to verify the vendor is not identified as suspended or debarred on SAM, even if no formal agreement exists with a vendor. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Program will on a quarterly basis review all vendor expense and pull the suspension and debarment when the vendor is close to reaching $20,000 in expenses. Name of the contact person responsible for corrective action: Laura Garcia Planned completion date for corrective action plan: December 31, 2024
View Audit 315875
Finding 479363 (2023-001)
Significant Deficiency 2023
Regional Food Bank of Northeastern New York, Inc.
NY
Subrecipient Monitoring Allowable Costs / Cost Principles HUD Housing Programs
Finding, Reference Number: 2023-001 Federal Agency: Department of Agriculture (USDA) Description of Finding: Criteria: 7 CFR Section 250.1 9(a) identifies requirements related to record keeping for this major program. It is important to note the Food Bank appeared to maintain the appropriate suppo...
Finding, Reference Number: 2023-001 Federal Agency: Department of Agriculture (USDA) Description of Finding: Criteria: 7 CFR Section 250.1 9(a) identifies requirements related to record keeping for this major program. It is important to note the Food Bank appeared to maintain the appropriate supporting documents and required components, this finding relates to one component regarding the lack of a signoff not lack of documentation. Condition: During audit testing, we noted the following; the invoices created as a result of USDA orders being made were not consistently signed off on by the recipient agency representative upon pick up or delivery of the commodities. Statement of Concurrence or Nonconcurrence: The Food Bank agrees with this finding. Corrective Action: The Food Bank places a strong emphasis on ensuring accountability in the pickup process for agencies by requiring them to sign invoices upon receiving their orders. This practice is crucial for maintaining accurate records and verifying the receipt of products and other items. To strengthen this procedure, we will be reinforcing with our staff the absolute requirement for agencies to sign for their orders at the time of pickup. As of July 8, 2024 we will implement a new procedure mandating dual sign-offs on all orders by both the agency representative and a Food Bank staff member. Our Programs team will also conduct educational marketing raising awareness among the agencies about the importance of signing their invoices. These steps will not only enhance our operational efficiency but also uphold our commitment to transparency and accountability in distributing food resources to those in need. Name of Contact Person: Nicholas Pisani, Chief Operating Officer; phone number 518-786-3691 ext. 241; email NickP@Regionalfoodbank.net Projected completion date: July 8, 2024
View Audit 315870
Finding 479360 (2023-002)
Significant Deficiency 2023
City of Elizabeth
MN
Reporting Significant Deficiency
Preparation of Financial Statements and Related Footnotes
Preparation of Financial Statements and Related Footnotes
View Audit 315866
Finding 479360 (2023-002)
Significant Deficiency 2023
City of Elizabeth
MN
Reporting Significant Deficiency
Recommendation: This control deficiency is not unusual in a small city. However, it is the responsibility of management and the Council to decide whether to accept the degree of risk associated with this condition based on the cost of correction and other considerations.
Recommendation: This control deficiency is not unusual in a small city. However, it is the responsibility of management and the Council to decide whether to accept the degree of risk associated with this condition based on the cost of correction and other considerations.
View Audit 315866
Finding 479360 (2023-002)
Significant Deficiency 2023
City of Elizabeth
MN
Reporting Significant Deficiency
Management’s Response and Actions Planned: The City’s management is aware of this significant deficiency. Management reviews and approves the draft annual audited financial statements and distributes them to the users. For entities of this size, it generally is not practical to obtain the internal e...
Management’s Response and Actions Planned: The City’s management is aware of this significant deficiency. Management reviews and approves the draft annual audited financial statements and distributes them to the users. For entities of this size, it generally is not practical to obtain the internal expertise needed to handle all aspects of the external financial reporting. Management recognizes this and feels it is effectively handling its reporting responsibilities with the procedures described above.
View Audit 315866
Finding 479359 (2023-001)
Significant Deficiency 2023
City of Elizabeth
MN
Segregation of Duties
Segregation of Duties
View Audit 315866
Finding 479359 (2023-001)
Significant Deficiency 2023
City of Elizabeth
MN
Recommendation: While we recognize the City’s office staff is not large enough to permit an adequate segregation of duties in all respects for an effective internal control structure, it is important that the City be aware of this condition and look for opportunities to improve segregation of duties...
Recommendation: While we recognize the City’s office staff is not large enough to permit an adequate segregation of duties in all respects for an effective internal control structure, it is important that the City be aware of this condition and look for opportunities to improve segregation of duties or add mitigating controls to prevent material misstatement of the financial statements.
View Audit 315866
Finding 479359 (2023-001)
Significant Deficiency 2023
City of Elizabeth
MN
Management’s Response and Actions Planned: The City’s management is aware of this condition and believes that it is not economically feasible to attain the ideal segregation of duties. Management attempts to mitigate the associated risks by doing the following:
Management’s Response and Actions Planned: The City’s management is aware of this condition and believes that it is not economically feasible to attain the ideal segregation of duties. Management attempts to mitigate the associated risks by doing the following:
View Audit 315866
Finding 479359 (2023-001)
Significant Deficiency 2023
City of Elizabeth
MN
1.      Identifies areas where the lack of segregation of duties exists and where there are higher risks of errors or fraud occurring.
1.      Identifies areas where the lack of segregation of duties exists and where there are higher risks of errors or fraud occurring.
View Audit 315866
Finding 479359 (2023-001)
Significant Deficiency 2023
City of Elizabeth
MN
2.      Implements limited segregation to the extent possible to reduce risks without impairing efficiency.
2.      Implements limited segregation to the extent possible to reduce risks without impairing efficiency.
View Audit 315866
Finding 479359 (2023-001)
Significant Deficiency 2023
City of Elizabeth
MN
3.      Uses the knowledge that management and the Board of Directors have of operations by having them review certain accounting records and reports.
3.      Uses the knowledge that management and the Board of Directors have of operations by having them review certain accounting records and reports.
View Audit 315866
Finding 479359 (2023-001)
Significant Deficiency 2023
City of Elizabeth
MN
Monitors the effectiveness of the above actions and makes changes as considered appropriate.
Monitors the effectiveness of the above actions and makes changes as considered appropriate.
View Audit 315866
Chemung County Treasurer
NY
Eligibility
Views of Responsible Officials and Planned Corrective Actions: Please accept the following corrective action plan from Chemung County Department of Social Services (DSS) regarding the audit findings shared with Chemung County DSS. In this audit, it was identified Chemung DSS had 1 of 40 HEAP cases w...
Views of Responsible Officials and Planned Corrective Actions: Please accept the following corrective action plan from Chemung County Department of Social Services (DSS) regarding the audit findings shared with Chemung County DSS. In this audit, it was identified Chemung DSS had 1 of 40 HEAP cases where an incorrect eligibility determination was made causing a negative impact to a client denying their case when indeed they were eligible. Chemung County DSS will take the following actions to address this deficiency: The HEAP Supervisor will hold an inservice refresher training by August 15th for all eligibility workers. This training will include budgeting income and determining eligibility for HEAP benefits. The examiner who made the error on this audit finding will be scheduled to take the HEAP eligibility and certification training course again with a target completion date of August 31st. The County is confident these two actions will help prevent this type of incorrect determination from happening again in the future and it will support reinforcing program knowledge for all involved.
View Audit 315856
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