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Corrective Action Plans

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Finding 10227 (2023-005)
Significant Deficiency 2023
Veterans Memorial Hospital
IA
Allowable Costs / Cost Principles Eligibility Reporting § 200.303
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 4 TIN#421030129 Federal Financial Assistance Listing #93.498 Compliance Requirement: Acti...
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 4 TIN#421030129 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Finding Summary: The Hospital did not retain evidence of the review and approval of the expenditure listing and lost revenue calculation by a separate individual outside of the preparer. In addition, the Hospital's special report submitted to the Department of Health and Human Services for Period 4 TIN #421030129 did not have evidence that it was reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Michael Coyle, CEO Corrective Action Plan: Management agrees with the finding. Controls will be put into place to ensure review and approval by a separate individual outside of the preparer is retained. Anticipated Completion Date: November 30, 2023
View Audit 13879
Finding 10226 (2023-004)
Material Weakness 2023
Veterans Memorial Hospital
IA
Material Weakness Reporting Internal Control / Segregation of Duties § 200.303
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 4 TIN#421030129 Federal Financial Assistance Listing #93.498 Compliance Requirement: Repo...
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 4 TIN#421030129 Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Hospital 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 Hospital did not have a budget for the entire reporting period that was approved prior to March 27, 2020. For the periods that the client did not have an approved budget, $0 was entered for net patient revenues even though there were patient revenues for this period. Responsible Individuals: Michael Coyle, CEO Corrective Action Plan: Management agrees with the finding and notes that there was no impact to the calculation or end results. Should this type of calculation be required in the future, controls will be put into place to ensure the reporting is complete. Anticipated Completion Date: November 30, 2023
View Audit 13879
Finding 10223 (2023-001)
Significant Deficiency 2023
Someplace Safe
MN
Item 2023-001. Inadequate Segregation of Duties
Item 2023-001. Inadequate Segregation of Duties
View Audit 13868
Finding 10223 (2023-001)
Significant Deficiency 2023
Someplace Safe
MN
Recommendation – Although it may not be economically feasible for the Organization to attain an ideal segregation of duties environment, the Organization can periodically observe and evaluate its current structure so as to make improvements when considered necessary.
Recommendation – Although it may not be economically feasible for the Organization to attain an ideal segregation of duties environment, the Organization can periodically observe and evaluate its current structure so as to make improvements when considered necessary.
View Audit 13868
Finding 10223 (2023-001)
Significant Deficiency 2023
Someplace Safe
MN
Action Planned – The Organization has determined the benefit of adequately segregating duties is less than the cost. Based on the assessment, the Organization is accepting the risk posed by the deficiency while also evaluating mitigating controls that will help reduce the risk of material misstateme...
Action Planned – The Organization has determined the benefit of adequately segregating duties is less than the cost. Based on the assessment, the Organization is accepting the risk posed by the deficiency while also evaluating mitigating controls that will help reduce the risk of material misstatement of the financial statements. Management attempts to mitigate the associated risks by doing the following:
View Audit 13868
Finding 10223 (2023-001)
Significant Deficiency 2023
Someplace Safe
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 13868
Finding 10223 (2023-001)
Significant Deficiency 2023
Someplace Safe
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 13868
Finding 10223 (2023-001)
Significant Deficiency 2023
Someplace Safe
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 13868
Finding 10223 (2023-001)
Significant Deficiency 2023
Someplace Safe
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 13868
Inter-Church Council Housing Corporation
NC
HUD Housing Programs
The property made a payment on October 18, 2023 to correct the amount in the reserve for replacement account and will keep track of required payments each month.
The property made a payment on October 18, 2023 to correct the amount in the reserve for replacement account and will keep track of required payments each month.
View Audit 13863
Finding 10217 (2023-001)
Significant Deficiency 2023
Laramie County School District #1
WY
Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.208 § 200.318 § 200.339
2023-001: Special Education Cluster – Procurement Context/Condition - Of the four procurement transactions subjected to testing, there were two professional service contracts that the District did not have documentation supporting the sole source procurement method. Corrective Action Plan – Laramie ...
2023-001: Special Education Cluster – Procurement Context/Condition - Of the four procurement transactions subjected to testing, there were two professional service contracts that the District did not have documentation supporting the sole source procurement method. Corrective Action Plan – Laramie County School District No. 1 (LCSD1) appreciates the thorough review conducted by the auditing team, identifying the lack of documentation for two sole source contracts for special education trainers hired in response to the Wyoming Department of Education’s monitoring review. In response, LCSD1 has undertaken a comprehensive corrective action plan to rectify the identified issues and prevent future occurrences. Immediate steps include a detailed review of the existing contract, identification of missing documentation, engagement with legal counsel to ensure compliance, and the development of clear procedures for documenting sole source justifications. To address potential gaps in staff understanding, LCSD1 has implemented additional training programs and reviews by procurement staff. LCSD1 will also evaluate federal, state and district procurement policies and initiate additional internal monitoring requirements for special education contracts. LCSD1 does not dispute the finding and will continue to improve processes and procedures with a focus on periodic reviews to enhance procurement practices. Contact Person – Jed Cicarelli, Chief Financial Officer Anticipated Completion Date – Immediately
View Audit 13858
Village at Hickory Glen Apartments
TX
HUD Housing Programs Reporting
Finding 2023-001 – Surplus cash should be funded to the residual receipts account within 60 days of year end. Management inadvertently deposited $6,268 into the reserve for replacement account on November 29, 2022 instead of depositing $6,269 into the residual receipts account. When management rea...
Finding 2023-001 – Surplus cash should be funded to the residual receipts account within 60 days of year end. Management inadvertently deposited $6,268 into the reserve for replacement account on November 29, 2022 instead of depositing $6,269 into the residual receipts account. When management realized the mistake, they made another deposit of $6,268 into the residual receipts account in February 2023, however they have an additional deposit in the reserve for replacement account as of September 30, 2023.Response: Management plans to withdraw the extra deposit in the reserve for replacement account and will calculate surplus cash and fund the residual receipts account with the required amount on a timely basis.
View Audit 13824
Fairfield Public School District No. 112
IL
Questioned Costs Reporting
SEE SEFA REPORT FOR CAP ON FINDING 2023-001
SEE SEFA REPORT FOR CAP ON FINDING 2023-001
View Audit 13808 Questioned Costs: $1
Finding 10181 (2023-001)
Significant Deficiency 2023
Independence Place Cooperative of Willmar
MN
Reporting Internal Control / Segregation of Duties
Housing and Urban Development Independence Place Cooperative respectfully submits the following corrective action plan for the year ended December 31, 2023. Westberg Eischens, PLLP 2630 1st Street South P.O. Box 362 Willmar, MN 56201 Audit Period: December 31, 2023 The finding from the December 31, ...
Housing and Urban Development Independence Place Cooperative respectfully submits the following corrective action plan for the year ended December 31, 2023. Westberg Eischens, PLLP 2630 1st Street South P.O. Box 362 Willmar, MN 56201 Audit Period: December 31, 2023 The finding from the December 31, 2023 schedule of findings and questioned costs and the summary schedule of prior audit findings is discussed below. The finding is numbered consistently with the number assigned in the schedules. Summary of audit results does not include findings and is not addressed. Finding 2023-001 Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles.
View Audit 13778
Finding 10176 (2023-002)
Significant Deficiency 2023
Oregon City School District No. 62
OR
School Nutrition Programs
The district will provide a clear segregation of duties between the preparer and the approver by documenting written approval prior to submission of the student counts through the CNPWeb.
The district will provide a clear segregation of duties between the preparer and the approver by documenting written approval prior to submission of the student counts through the CNPWeb.
View Audit 13775
Finding 10171 (2023-001)
Significant Deficiency 2023
Oregon City School District No. 62
OR
Cash Management School Nutrition Programs Internal Control / Segregation of Duties
The district has already implemented the corrective action plan by submitting the PLE for the 2023-24 school year. The district will continue to submit the PLE on an annual basis.
The district has already implemented the corrective action plan by submitting the PLE for the 2023-24 school year. The district will continue to submit the PLE on an annual basis.
View Audit 13775
Odessa-Montour Central School District
NY
Cash Management School Nutrition Programs Equipment & Real Property Management
Finding: 2023-002 School Food Account - Net Cash Resources (ALN #10.553/10.555/10.559) Corrective Action Plan: The School District has begun taking action to address this issue, as follows: Equipment Improvement - School Food Service Director, Joe Kilmer, Food Service Manager, Ann Overhiser, and ...
Finding: 2023-002 School Food Account - Net Cash Resources (ALN #10.553/10.555/10.559) Corrective Action Plan: The School District has begun taking action to address this issue, as follows: Equipment Improvement - School Food Service Director, Joe Kilmer, Food Service Manager, Ann Overhiser, and the School Business Administrator have plans to improve and replace cafeteria equipment. The replacement plan will be completed in conjunction with the School District’s upcoming Capital Project. This work was originally expected to be included in a prior project but due to scheduling issues, is now included in the upcoming project which is expected to be completed by June 30, 2025. Retained Balance for Pending Settlements - Wages will increase into 2023 and beyond. The minimum wage in New York State is expected to continue to rise over the next several years according to legislation. The rate will rise to $15 per hour by the end of 2023. Annual increases will continue until the rate reaches $16 per hour in 2026. Annual increases will be published by the Commissioner of Labor and based on a number of economic factors. Due to the critical labor shortage, the School District recently increased hourly wages for food service helpers and cooks in order to attract additional workers to maintain operations. Enhanced Meals - The Food Service Director and Food Service Manager continue to take steps to improve food options. They include making improvements to center of the plate options and improving local food options as well. In addition, the School District plans to spend a portion of the School Lunch excess cash on cafeteria equipment as a part of its upcoming Capital Project which is expected to be completed by June 30, 2025. Anticipated Correction Date: June 30, 2024
View Audit 13773
Finding 10143 (2023-005)
Significant Deficiency 2023
Mater Academy of Nevada
NV
Allowable Costs / Cost Principles School Nutrition Programs Significant Deficiency § 200.303
Finding Number: 2023-005 Approval Of Expense Transactions Corrective Action Plan: A process was put in place in May 2023 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be run, nor grant...
Finding Number: 2023-005 Approval Of Expense Transactions Corrective Action Plan: A process was put in place in May 2023 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be run, nor grants submitted, until proper approval is received. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2024
View Audit 13766
Finding 10114 (2023-004)
Significant Deficiency 2023
Mater Academy of Nevada
NV
Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303
Finding Number: 2023-004 and 2022-005 – Review and Approval of the Schedule of Expenditures of Federal Awards (SEFA) Corrective Action Plan: While there was a review of the SEFA, the documentation of said review did not occur properly. Management has put in place a process to document preparation/r...
Finding Number: 2023-004 and 2022-005 – Review and Approval of the Schedule of Expenditures of Federal Awards (SEFA) Corrective Action Plan: While there was a review of the SEFA, the documentation of said review did not occur properly. Management has put in place a process to document preparation/review of the SEFA evidenced by signature and date. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2024
View Audit 13766
Dauphin County Voa Living Center, INC (creekside Village)
VA
Cash Management HUD Housing Programs
Management agrees with the finding. The residual receipts account deficiency will be funded in the amount of $18,738, $1,515, and $10,164. Management will ensure that the residual receipts account is properly funded in the future
Management agrees with the finding. The residual receipts account deficiency will be funded in the amount of $18,738, $1,515, and $10,164. Management will ensure that the residual receipts account is properly funded in the future
View Audit 13735
Dauphin County Voa Living Center, INC (creekside Village)
VA
HUD Housing Programs Cash Management
Management agrees with the finding. The excess funds were accrued to submit to HUD.
Management agrees with the finding. The excess funds were accrued to submit to HUD.
View Audit 13735
Finding 10095 (2023-002)
Significant Deficiency 2023
Glen Oaks Community College
MI
Subrecipient Monitoring Eligibility Significant Deficiency
2023-02 – Gramm Leach Bliley Missing Elements. Auditor Description of Conditional and Effect. The most recent written security policy fails to address how the College will evaluate and adjust its information security program for any changes in the College's operations or the results of risk assessme...
2023-02 – Gramm Leach Bliley Missing Elements. Auditor Description of Conditional and Effect. The most recent written security policy fails to address how the College will evaluate and adjust its information security program for any changes in the College's operations or the results of risk assessments. Auditor Recommendation. We recommend that the College implement procedures to ensure that all Gramm Leach Bliley policies are met and confirmed by a second individual. Corrective Action. GOCC will require all procedures and policies are updated and reviewed on an annual basis to make sure we are incompliance with the requirements. Responsible Party. Chief Financial Officer/Controller and IT Director. Anticipated Completion Date. June 30, 2024.
View Audit 13719
Finding 10091 (2023-001)
Significant Deficiency 2023
Glen Oaks Community College
MI
Eligibility Significant Deficiency Internal Control / Segregation of Duties
2023-001 – Satisfactory Academic Progress. Auditor Description of Conditional and Effect. One student out of the 40 tested received federal aid, but did not meet the criteria for satisfactory academic progress, but did not receive a warning. The College's SAP policy published on its website is not b...
2023-001 – Satisfactory Academic Progress. Auditor Description of Conditional and Effect. One student out of the 40 tested received federal aid, but did not meet the criteria for satisfactory academic progress, but did not receive a warning. The College's SAP policy published on its website is not based on how the College determines whether students meet the College's SAP requirements. Auditor Recommendation. We recommend the College implement stronger procedures around awarding federal aid to ensure that students receive a warning letter from the College when they didn't meet SAP. We recommend that the College correct its SAP policy to match how they are currently evaluating whether students meet the requirements to continue receiving financial aid. Corrective Action. The school has edited the SAP policy on the College's website. The school will implement additional controls to address the failure to notify a student after they fail to meet the College's SAP policy. Responsible Party. Director of Financial Aid. Anticipated Completion Date. August 8, 2023
View Audit 13719
Finding 10087 (2023-002)
Significant Deficiency 2023
Green Bay Area Public Schools
WI
Procurement, Suspension & Debarment § 200.214
U.S. Department of Education 2023-002 IDEA Procurement, Suspension and Debarment Assistance Listing Nos. 84.027 and 84.173 Recommendation: CLA recommends that the District review its Uniform Guidance policies with all staff to ensure procurement requirements are understood and implement controls to ...
U.S. Department of Education 2023-002 IDEA Procurement, Suspension and Debarment Assistance Listing Nos. 84.027 and 84.173 Recommendation: CLA recommends that the District review its Uniform Guidance policies with all staff to ensure procurement requirements are understood and implement controls to help ensure the proper procurement method was followed and procurement history is documented. We also recommend the District review and update policies and procedures over review of certain transactions to ensure that all federal grants with covered transactions have vendors reviewed for suspension and debarment status. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have implemented and communicated a process where all contracts and orders that exceed $25,000 require a Purchas Order to be created. The creation of the Purchase Order then alerts the Director of Procurement to perform the suspension and debarment checks. This will be done for all agreements exceeding $25,000, including repeat contracts. Name(s) of the contact person(s) responsible for corrective action: Jake Alverson, Director of Procurement Planned completion date for corrective action plan: 12/15/2023 If the U.S. Department of Education and Wisconsin Department of Public Instruction has questions regarding this plan, please call Sara Noah at (920)448-2200.
View Audit 13713
Finding 10063 (2023-002)
Material Weakness 2023
Otto-Eldred School District
PA
Internal Control / Segregation of Duties Cash Management
Adjusting Journal Entries, Required Disclosures, and Draft Financial Statements Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and, in the future, under the new pronouncement, the District should continue to review and accept both proposed adjusting jour...
Adjusting Journal Entries, Required Disclosures, and Draft Financial Statements Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and, in the future, under the new pronouncement, the District should continue to review and accept both proposed adjusting journal entries and footnote disclosures, along with the draft financial statements. School District’s Response: Jodi Flexman, Business Manager, has received, reviewed and accepted all journal entries, footnote disclosures and draft financial statements proposed for the current year audit and will continue to review similar information for the year ending June 30, 2024 and in future years. Further, the District believes it has a thorough understanding of these financial statements and the ability to make informed judgments based on these financial statements.
View Audit 13695
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