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Corrective Action Plans

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Finding 401688 (2023-001)
Material Weakness 2023
Memorial Health and Subsidiaries
IL
Subrecipient Monitoring Allowable Costs / Cost Principles Eligibility § 200.303
• Finding 2023-001 – The FEMA submission request was submitted by management in 2021, which occurred prior to management’s implementation of its corrective action plan to address Finding 2022-004. Management performed an independent review of the expenditure for FEMA eligibility as part of an iterat...
• Finding 2023-001 – The FEMA submission request was submitted by management in 2021, which occurred prior to management’s implementation of its corrective action plan to address Finding 2022-004. Management performed an independent review of the expenditure for FEMA eligibility as part of an iterative review process with its FEMA consultants and FEMA representatives. This review was also documented in management’s representation on the FEMA online portal when the submission was made. However, management’s process did not include internal documentation to evidence an independent review had occurred prior to submission. The process has been corrected for any future FEMA submissions in October 2022. o Responsible Party: Amanda Zentefis
View Audit 309641
Finding 401664 (2023-002)
Material Weakness 2023
Troy University
AL
Questioned Costs Student Financial Aid Eligibility
Corrective Action Plan The University will establish processes and policies to pull attendance reports after census date of each term/semester for any students who receive Title IV aid and are identified as non-attendance. We will use this information to recalculate Federal Pell Grant and Federal Di...
Corrective Action Plan The University will establish processes and policies to pull attendance reports after census date of each term/semester for any students who receive Title IV aid and are identified as non-attendance. We will use this information to recalculate Federal Pell Grant and Federal Direct Student Loan awards based on enrollment or change in enrollment status. At the end of each term/semester, the University will review F/FA grades for any student who receives Title IV aid and will adjust their aid accordingly to comply with Title 34 of the Code of Federal Regulations, Part 690.80. In addition, we are currently reviewing F/FA grades for the 2023-2024 academic year. Anticipated Completion Date: June 2024 Contact Person(s): Alicia Bookout Associate Vice Chancellor, Financial Aid
View Audit 309623 Questioned Costs: $1
Finding 401662 (2023-001)
Significant Deficiency 2023
Troy University
AL
Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking
Corrective Action Plan The University will consistently follow established procedures used to perform Title IV refund calculations for students who withdraw after the 60 percent point that comply with Title 34 of the Code of Federal Regulations, Part 668.22. Anticipated Completion Date; June 2024 Co...
Corrective Action Plan The University will consistently follow established procedures used to perform Title IV refund calculations for students who withdraw after the 60 percent point that comply with Title 34 of the Code of Federal Regulations, Part 668.22. Anticipated Completion Date; June 2024 Contact Person(s): Alicia Bookout Associate Vice Chancellor, Financial Aid
View Audit 309623
Finding 401661 (2023-001)
Significant Deficiency 2023
Southeasthealth System, Inc.
MO
Cash Management § 200.305
Views of Responsible Officials and Planned Corrective Actions – We have since developed an organization policy for cash management for federally sponsored grant programs. SEH has provided and will continue to provide staff education on this policy in the future.
Views of Responsible Officials and Planned Corrective Actions – We have since developed an organization policy for cash management for federally sponsored grant programs. SEH has provided and will continue to provide staff education on this policy in the future.
View Audit 309622
Finding 401659 (2023-002)
Material Weakness 2023
City of Livonia, Michigan
MI
Subrecipient Monitoring HUD Housing Programs Material Weakness
Condition: Tiered environmental reviews were not completed for the City’s emergency and minor home rehabilitation activities. The environmental review for major rehabilitation activities was incomplete and was not submitted in the HEROS system. Planned Corrective Action: This finding was partly due ...
Condition: Tiered environmental reviews were not completed for the City’s emergency and minor home rehabilitation activities. The environmental review for major rehabilitation activities was incomplete and was not submitted in the HEROS system. Planned Corrective Action: This finding was partly due to the staff members' need for more training. HUD mandated that staff undergo training on the HERO system as part of the resolution. The extra training enabled staff to revisit and finalize previous environmental reviews, ensuring compliance with environmental review regulations. After a follow-up with HUD, the agency considers the issue resolved. Going forward, environmental reviews will be conducted once every five years, which is in compliance with HUD regulations. Tiered reviews will be added as projects are completed. Our rehab specialist will be responsible for entering HEROs, and the division director will be responsible for public notices and hearings. Contact person responsible for corrective action: Madison Bjertness Anticipated Completion Date: 5/22/2024
View Audit 309614
Finding 401658 (2023-001)
Material Weakness 2023
Indiana Public Broadcasting Stations, Inc.
IN
Reporting Internal Control / Segregation of Duties
Views of Responsible Officials and Planned Corrective Actions: We agree with the auditor's findings and subsequent adjustment. Due to the change in accounting software and lack of experience utilizing the new software, the Accounting Director made a data entry error when recording a payable and di...
Views of Responsible Officials and Planned Corrective Actions: We agree with the auditor's findings and subsequent adjustment. Due to the change in accounting software and lack of experience utilizing the new software, the Accounting Director made a data entry error when recording a payable and did not realize it on subsequent reporting. The recommended adjustment is legitimate and in accordance with GAAP accounting policy. It was an isolated incident and has been corrected. As there will be a change in accounting services and software for the upcoming fiscal year, we do not expect this to be an issue going forward.
View Audit 309609
City of Salem School District
NJ
Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.320
The School District should be in compliance with the NJ DOE purchasing guidelines.
The School District should be in compliance with the NJ DOE purchasing guidelines.
View Audit 309606
Finding 401648 (2023-003)
Material Weakness 2023
City of Salem School District
NJ
Cash Management Reporting Internal Control / Segregation of Duties
The School District should always reconcile its reimbursement requests with documented workpapers.
The School District should always reconcile its reimbursement requests with documented workpapers.
View Audit 309606
Finding 401635 (2023-004)
Significant Deficiency 2023
North Border School District #100
ND
Reporting Internal Control / Segregation of Duties
2023-004 Finding 1. Correcting Plan School District personnel will establish a policy for completion of audits on a timely basis. 2. Explanation of Disagreement with the Audit Findings There is essentially no disagreement with the finding. 3. Official Responsible for Insuring CAP The Superintendent,...
2023-004 Finding 1. Correcting Plan School District personnel will establish a policy for completion of audits on a timely basis. 2. Explanation of Disagreement with the Audit Findings There is essentially no disagreement with the finding. 3. Official Responsible for Insuring CAP The Superintendent, Seth Engelstad, is responsible for carrying out the corrective action plan. 4. Planned Completion Date for CAP School district personnel will attend training annually effective March 31, 2025. 5. Plan to Monitor Completion of CAP The Superintendent will monitor the completion of the CAP, with reports to the Board of Education, on an annual basis.
View Audit 309600
Finding 401598 (2023-006)
Material Weakness 2023
Refugee & Immigrant Self-Empowerment, Inc.
NY
Procurement, Suspension & Debarment HUD Housing Programs Reporting
Name of Auditee: Refugee & Immigrant Self-Empowerment, Inc. Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended September 30, 2023 CAP Prepared by: Haji Adan, Executive Director Phone: 315-214-4480 (A) Current Finding on the Schedule of Findings and Responses (6) Audit...
Name of Auditee: Refugee & Immigrant Self-Empowerment, Inc. Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended September 30, 2023 CAP Prepared by: Haji Adan, Executive Director Phone: 315-214-4480 (A) Current Finding on the Schedule of Findings and Responses (6) Audit Finding 2023-006 (a) Comments on the finding and recommendation: Refugee & Immigrant Self-Empowerment, Inc. acknowledges the need for documenting credit card usage. (b) Actions Taken: Refugee & Immigrant Self-Empowerment, Inc. will establish a clear process requiring verification of identity and purpose for each transaction. We will implement strict controls, such as mandatory receipts, detailed transaction logs, and periodic audits. Additionally, we will provide comprehensive training to all employees on the proper use and accountability of credit cards, emphasizing the importance of adherence to established protocols. We will regularly review and update these procedures to adapt to evolving risks and maintain effective internal controls. (c) Anticipated Completion Date: August 31, 2024
View Audit 309599
Finding 401597 (2023-005)
Material Weakness 2023
Refugee & Immigrant Self-Empowerment, Inc.
NY
Procurement, Suspension & Debarment Reporting Internal Control / Segregation of Duties
Name of Auditee: Refugee & Immigrant Self-Empowerment, Inc. Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended September 30, 2023 CAP Prepared by: Haji Adan, Executive Director Phone: 315-214-4480 (A) Current Finding on the Schedule of Findings and Responses (5) Audit...
Name of Auditee: Refugee & Immigrant Self-Empowerment, Inc. Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended September 30, 2023 CAP Prepared by: Haji Adan, Executive Director Phone: 315-214-4480 (A) Current Finding on the Schedule of Findings and Responses (5) Audit Finding 2023-005 (a) Comments on the finding and recommendation: Refugee & Immigrant Self-Empowerment, Inc. acknowledges the need for the approval of purchases within the organization. (b) Actions Taken: Refugee & Immigrant Self-Empowerment, Inc. will conduct a thorough review of current expenditure review and approval processes to identify gaps and weaknesses. Clear documentation standards and procedures will be developed, outlining roles, responsibilities, and methods for maintaining expenditure review and approval records. Staff members will receive comprehensive training on these new standards, and compliance will be regularly monitored. (c) Anticipated Completion Date: August 31, 2024
View Audit 309599
Refugee & Immigrant Self-Empowerment, Inc.
NY
Internal Control / Segregation of Duties Reporting Matching / Level of Effort / Earmarking
Name of Auditee: Refugee & Immigrant Self-Empowerment, Inc. Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended September 30, 2023 CAP Prepared by: Haji Adan, Executive Director Phone: 315-214-4480 (A) Current Finding on the Schedule of Findings and Responses (4) Audit...
Name of Auditee: Refugee & Immigrant Self-Empowerment, Inc. Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended September 30, 2023 CAP Prepared by: Haji Adan, Executive Director Phone: 315-214-4480 (A) Current Finding on the Schedule of Findings and Responses (4) Audit Finding 2023-004 (a) Comments on the finding and recommendation: Refugee & Immigrant Self-Empowerment, Inc. acknowledges improvement in the process of recognizing the allowable matching requirements is needed. (b) Actions Taken: Refugee & Immigrant Self-Empowerment, Inc. will ensure training for relevant program staff and implement robust procedures to accurately monitor and fulfill matching requirements stipulated in grant agreements. This will involve establishing clear guidelines for tracking and documenting matching contributions, assigning responsibility for oversight, implementing regular reviews, and conducting internal audits to ensure compliance. (c) Anticipated Completion Date: August 31, 2024
View Audit 309599
Refugee & Immigrant Self-Empowerment, Inc.
NY
Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties
Name of Auditee: Refugee & Immigrant Self-Empowerment, Inc. Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended September 30, 2023 CAP Prepared by: Haji Adan, Executive Director Phone: 315-214-4480 (A) Current Finding on the Schedule of Findings and Responses (3) Audit...
Name of Auditee: Refugee & Immigrant Self-Empowerment, Inc. Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended September 30, 2023 CAP Prepared by: Haji Adan, Executive Director Phone: 315-214-4480 (A) Current Finding on the Schedule of Findings and Responses (3) Audit Finding 2023-003 (a) Comments on the finding and recommendation: Refugee & Immigrant Self-Empowerment, Inc. acknowledges the need for enhanced internal controls to track grant reporting requirements. (b) Actions Taken: RISE has introduced a bookkeeper position within our finance department to alleviate the workload of the Finance Director and ensure timely submission of required grant reports. The Executive Director will oversee the submission of grant financial reports, ensuring they meet contracting deadlines. (c) Anticipated Completion Date: The position is already added and recruited on April 22, 2024.
View Audit 309599
Finding 401555 (2023-001)
Material Weakness 2023
Clarion Goldfield Dows Csd
IA
Internal Control / Segregation of Duties
SEE RESPONSE AND CORRECTIVE ACTION PLAN AT 2023-001
SEE RESPONSE AND CORRECTIVE ACTION PLAN AT 2023-001
View Audit 309592
Finding 401554 (2023-002)
Material Weakness 2023
Ikm-Manning Community School District
IA
Internal Control / Segregation of Duties Reporting
As a small district we have added an employee that is shared between our district and another to help review and delegate. As a small district I believe we are doing a good job of internal controls. Would it be nice to hire additional people, yes but financially it is not responsible. (we review eve...
As a small district we have added an employee that is shared between our district and another to help review and delegate. As a small district I believe we are doing a good job of internal controls. Would it be nice to hire additional people, yes but financially it is not responsible. (we review every year our procedures and make sure we obtain the maximum internal control possible for our district under the circumstances).
View Audit 309591
Finding 401553 (2023-002)
Material Weakness 2023
Gadsden City Board of Education
AL
Questioned Costs Procurement, Suspension & Debarment Special Tests & Provisions
Funds from COVID-19 Education Stabilization Fund (ESF) were used to fund construction contracts in excess of $2,000 without the inclusion of prevailing wage rate clauses as required by Title 29, U.S. Code of Federal Regulations, Part 5, Sub-Part A Davis Bacon and Related Acts Provisions and Procedur...
Funds from COVID-19 Education Stabilization Fund (ESF) were used to fund construction contracts in excess of $2,000 without the inclusion of prevailing wage rate clauses as required by Title 29, U.S. Code of Federal Regulations, Part 5, Sub-Part A Davis Bacon and Related Acts Provisions and Procedures (the “Davis-Bacon Act”). The Board did not have controls in place to ensure the Davis-Bacon Act wage rate requirements were included in construction contracts. Therefore, the construction project contract awarded during the fiscal year did not include prevailing wage rate clauses nor did the contractors submit weekly certified payrolls to the Board. Response: Management will implement controls to ensure future contracts funded with COVID-19 Education Stabilization Funds (ESF) in excess of $2,000 specify applicability of wage rate requirements.
View Audit 309587 Questioned Costs: $1
Finding 401552 (2023-008)
Significant Deficiency 2023
The Housing Authority of East Baton Rouge Parish
LA
Questioned Costs HUD Housing Programs Significant Deficiency
Special Tests – Formula Income – Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend the Authority reviews their controls over submitting forms to HUD to ensure they contain accurate information. Explanation of disagreement with audit finding: There is no disagre...
Special Tests – Formula Income – Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend the Authority reviews their controls over submitting forms to HUD to ensure they contain accurate information. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: New CFO is preparing a Subsidy Calculation procedure so new staff will be aware of what is eligible and non-eligible transactions for preparing forms. Name(s) of the contact person(s) responsible for corrective action: Shannon Sterling and/or Carlton Brown
View Audit 309583 Questioned Costs: $1
Finding 401551 (2023-007)
Significant Deficiency 2023
The Housing Authority of East Baton Rouge Parish
LA
HUD Housing Programs Significant Deficiency Matching / Level of Effort / Earmarking
Allowable Costs – Operating Fund – Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend the Authority establishes procedures to properly reconcile the revolving fund cash account to ensure that cash and interprogram accounts are properly reported at the program lev...
Allowable Costs – Operating Fund – Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend the Authority establishes procedures to properly reconcile the revolving fund cash account to ensure that cash and interprogram accounts are properly reported at the program level. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: There are procedures in place to settle interfunds if possible. Name(s) of the contact person(s) responsible for corrective action: J Daniels and Shannon Sterling
View Audit 309583
Finding 401549 (2023-006)
Significant Deficiency 2023
The Housing Authority of East Baton Rouge Parish
LA
HUD Housing Programs Reporting Significant Deficiency
Reporting – PIC – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that the person assigned to submit the 50058s to PIC assures a quality control review is performed on the submissions to ensure timely and accurate reporting. Explanation of disagreement with au...
Reporting – PIC – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that the person assigned to submit the 50058s to PIC assures a quality control review is performed on the submissions to ensure timely and accurate reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Following CLA’s recommendation, SVP of Housing Choice will audit a random sample of 50058 submissions to PIC each month to ensure that all submissions are accurate in PIC. Additionally, the Agency is transitioning to Yardi software which should eliminate many of the submission issues caused by current enterprise software. Name(s) of the contact person(s) responsible for corrective action: Janie Anderson, VP Housing Voucher Cluster Planned completion date for corrective action plan: September 30, 2023
View Audit 309583
Finding 401547 (2023-005)
Material Weakness 2023
The Housing Authority of East Baton Rouge Parish
LA
Questioned Costs HUD Housing Programs Subrecipient Monitoring
Eligibility – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: CLA recommends management should designate one person to review a sample of the files that have been recertified each month. The purpose of the review is to determine if the tenant files were prepared in accordanc...
Eligibility – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: CLA recommends management should designate one person to review a sample of the files that have been recertified each month. The purpose of the review is to determine if the tenant files were prepared in accordance with internal policies and verify the compliance deficiencies have been corrected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: : Following CLA’s recommendation, SVP of Housing Choice will audit a random sample of 10 files on a monthly basis. Agency working with Human Resources contractor to fill open staff positions Name(s) of the contact person(s) responsible for corrective action: Janie Anderson, VP Housing Voucher Cluster Planned completion date for corrective action plan: September 30, 2023
View Audit 309583 Questioned Costs: $1
Finding 401545 (2023-004)
Significant Deficiency 2023
The Housing Authority of East Baton Rouge Parish
LA
HUD Housing Programs Eligibility Significant Deficiency
Special Tests – Top of the Waiting List – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that the Authority reviews their standard procedures to ensure requests for informal reviews are granted and notified to the applicant within 30 days of the receipt of the ...
Special Tests – Top of the Waiting List – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that the Authority reviews their standard procedures to ensure requests for informal reviews are granted and notified to the applicant within 30 days of the receipt of the request. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Agency hired a dedicated Hearing Officer following last year’s audit. Unfortunately, during the period in question, the Hearing Officer went on maternity leave and then subsequently left the position resulting in a delay in completing hearings and reviews. The Agency has since contracted with a 3rd party to conduct hearings and reviews in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Janie Anderson, VP Housing Voucher Cluster Planned completion date for corrective action plan: September 30, 2023
View Audit 309583
Finding 401543 (2023-003)
Significant Deficiency 2023
The Housing Authority of East Baton Rouge Parish
LA
HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties
Special Tests – Annual HQS and Quality Control Inspections – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that management review their controls for conducting HQS biennial and quality control re-inspections and ensure compliance standards are met. Explanatio...
Special Tests – Annual HQS and Quality Control Inspections – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that management review their controls for conducting HQS biennial and quality control re-inspections and ensure compliance standards are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Previously, staff used a 90-day window to select Quality Control samples. Doing so caused some QC inspections to be completed past the regulatory time period. Going forward, staff are selecting the sample size from a 45-day window. This allows sufficient time to complete the QC inspection within the regulatory time period. Name(s) of the contact person(s) responsible for corrective action: Janie Anderson, VP Housing Voucher Cluster Planned completion date for corrective action plan: September 30, 2023
View Audit 309583
Finding 401542 (2023-002)
Significant Deficiency 2023
Goodwill Industries of Greater Cleveland and East Central, Ohio, Inc.
OH
Questioned Costs Allowable Costs / Cost Principles Significant Deficiency
In 2024 the manual component of the calculations has been eliminated and all calculations of billing units are now completed using an Excel spreadsheet.
In 2024 the manual component of the calculations has been eliminated and all calculations of billing units are now completed using an Excel spreadsheet.
View Audit 309574 Questioned Costs: $1
Finding 401538 (2023-003)
Significant Deficiency 2023
Goodwill Industries of Greater Cleveland and East Central, Ohio, Inc.
OH
Questioned Costs Allowable Costs / Cost Principles
In 2024, all contracts / grants have been updated to current year budgeted fringe and payroll tax rates. These will be updated annually with any changes going forward.
In 2024, all contracts / grants have been updated to current year budgeted fringe and payroll tax rates. These will be updated annually with any changes going forward.
View Audit 309574 Questioned Costs: $1
Finding 401531 (2023-003)
Material Weakness 2023
Community Action Services and Food Bank
UT
Allowable Costs / Cost Principles Eligibility Material Weakness
Finding 2023-003 Finding Summary: The Organization did not have adequate controls to document the review and approval of qualified invoices prior to payment. Responsible Individuals: CFO (Amanda Moon), CEO (Karen McCandless) Corrective Action Plan: Ensure that all invoices are approved as eligible p...
Finding 2023-003 Finding Summary: The Organization did not have adequate controls to document the review and approval of qualified invoices prior to payment. Responsible Individuals: CFO (Amanda Moon), CEO (Karen McCandless) Corrective Action Plan: Ensure that all invoices are approved as eligible program costs prior to issuing payment. Anticipated Completion Date: 7/1/2024
View Audit 309571
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