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Corrective Action Plans

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Finding 6537 (2023-004)
Material Weakness 2023
Sioux Center Health
IA
Allowable Costs / Cost Principles Eligibility Material Weakness § 200.303
Finding 2023-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Health Center's final expenditure listing identified as eligib...
Finding 2023-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Health Center's final expenditure listing identified as eligible and claimed under the federal program were not reviewed and approved by a separate individual outside of the preparer. Responsible individuals: Crystal Richter, Chief Financial Officer Corrective Action Plan: If future reports are required, a secondary review of the summary spreadsheet prepared from the underlying supporting spreadsheets will be documented. No further are reports anticipated relating to this federal program. Anticipated Complete Date: 11/30/2023.
View Audit 8497
Bridge House #11 Corporation
NY
HUD Housing Programs Cash Management Reporting
Actions Taken or Planned - Auditee agrees with this finding. Our policy has been to make surplus cash deposits after the final audit has been issued. Management has determined that making the required deposit will leave the entity with low funds to cover operation expenses. Management is currently i...
Actions Taken or Planned - Auditee agrees with this finding. Our policy has been to make surplus cash deposits after the final audit has been issued. Management has determined that making the required deposit will leave the entity with low funds to cover operation expenses. Management is currently in communication with HUD discussing options of a possible waiver for the required deposit or the possibility of making the deposit with promise of approval for immediate release
View Audit 8490
118 East 111th Street Corporation
NY
HUD Housing Programs Cash Management Reporting
Actions Taken or Planned - Auditee agrees with this finding. Our policy has been to make surplus cash deposits after the final audit has been issued. Management has determined that making the required deposit will leave the entity with low funds to cover operation expenses. Management is currently i...
Actions Taken or Planned - Auditee agrees with this finding. Our policy has been to make surplus cash deposits after the final audit has been issued. Management has determined that making the required deposit will leave the entity with low funds to cover operation expenses. Management is currently in communication with HUD discussing options of a possible waiver for the required deposit or the possibility of making the deposit with promise of approval for immediate release
View Audit 8487
Finding 6531 (2023-002)
Significant Deficiency 2023
Kandiyohi County Housing and Redevelopment Authority
MN
Finding 2023-002 Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The Authority will work with the bank to ensure deposits are covered by sufficient collateral. Officer Responsible for Ensuring CAP: Executi...
Finding 2023-002 Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The Authority will work with the bank to ensure deposits are covered by sufficient collateral. Officer Responsible for Ensuring CAP: Executive Director Planned Completion Date: December 2023
View Audit 8486
Finding 6530 (2023-001)
Material Weakness 2023
Kandiyohi County Housing and Redevelopment Authority
MN
Internal Control / Segregation of Duties Subrecipient Monitoring Reporting
Finding 2023-001 Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The Authority will continue to review internal controls and work to design modifications that will increase internal control and the ability t...
Finding 2023-001 Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The Authority will continue to review internal controls and work to design modifications that will increase internal control and the ability to detect material misstatements. Officer Responsible for Ensuring CAP: Executive Director Planned Completion Date: December 2023
View Audit 8486
Finding 6528 (2023-002)
Significant Deficiency 2023
Sma Healthcare, Inc.
FL
Allowable Costs / Cost Principles Eligibility
For ALN 93.959, a Financial Assessment Form was not properly completed for 1 of the 60 clients tested. Additionally, 1 of the 60 clients tested did not have the Financial Assessment Form properly signed. Finally, 1 of the 60 clients tested had an incorrect discount fee applied. Our internal tracking...
For ALN 93.959, a Financial Assessment Form was not properly completed for 1 of the 60 clients tested. Additionally, 1 of the 60 clients tested did not have the Financial Assessment Form properly signed. Finally, 1 of the 60 clients tested had an incorrect discount fee applied. Our internal tracking of completion of the financial assessment form indicates that compliance with this requirement occurs about 98% of the time. Obtaining the client signature on the form has been challenging, particularly during recent years as use of telehealth services has expanded. As a corrective action, SMA will include completion of the assessment form compliance results to be reviewed at the monthly Process Improvement Committee. Program managers are required to present a corrective action plan when results are out of compliance with the standard. In addition, SMA will develop a procedure to allow staff to document receipt of verbal approval of the completed financial assessment form when the client is unable to be present at service location site.
View Audit 8478
Finding 6527 (2023-001)
Significant Deficiency 2023
Sma Healthcare, Inc.
FL
Allowable Costs / Cost Principles
For ALN 93.958, the full seven-part comprehensive assessment required for FACT clients was not completed fully within 60 days of client admission into the program for 1 of the 60 clients tested. Additionally, 3 of the 60 clients tested did not have the discount fee that was shown on their comprehens...
For ALN 93.958, the full seven-part comprehensive assessment required for FACT clients was not completed fully within 60 days of client admission into the program for 1 of the 60 clients tested. Additionally, 3 of the 60 clients tested did not have the discount fee that was shown on their comprehensive assessment. Finally, 1 of the 60 clients tested had an incorrect discount fee applied. This appears to be the result of staff oversight. As a corrective action, all FACT team staff responsible for completion of the assessment will be retrained on a recurring basis. We feel as though the current process to review compliance is comprehensive. SMA’s internal clinical compliance department conducts routine audits. When conducting audits of the FACT program, the compliance staff members review charts for compliance with the comprehensive assessments. The results of those internal audits are reviewed at the Process Improvement Committee where program managers are required to present a corrective action plan if charts do not meet a pre-set compliance threshold. The clinical compliance results are also presented to the Quality Program Review subcommittee of the board. Furthermore, the FACT program directors are responsible for monitoring documentation timeframes to ensure that when new clients are admitted to the program, documentation is completed timely.
View Audit 8478
Finding 6504 (2023-004)
Material Weakness 2023
Jasper-Troupsburg Central School District
NY
Internal Control / Segregation of Duties
Adjusting Journal Entries and Required Disclosures to the Financial Statements Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and in the future, under the pronouncement, the District should continue to review and accept both proposed adjusting journal e...
Adjusting Journal Entries and Required Disclosures to the Financial Statements Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and in the future, under the 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: The District 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 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. The District Treasurer, Alexis Devine, will continue to review and work with the external auditors regarding all adjusting journal entries for the year ending June 30, 2024.
View Audit 8477
Finding 6503 (2023-001)
Material Weakness 2023
Tampa Family Health Centers, Inc.
FL
Reporting
To whom this may concern, I Sherry Hoback President and CEO of Tampa Family Health Centers state, we agree with the findings of the audit. We are currently working with HRSA to request additional reporting time to file the report.
To whom this may concern, I Sherry Hoback President and CEO of Tampa Family Health Centers state, we agree with the findings of the audit. We are currently working with HRSA to request additional reporting time to file the report.
View Audit 8476
Marshall Public Schools
MO
Questioned Costs Cash Management School Nutrition Programs
December 1, 2023 U.S. Department of Education Marshall Public Schools respectfully submits the following Corrective Action Plan for the year ended June 30, 2023. Contact information for the individual responsible for the corrective action: Caleb Petet, Superintendent Marshall Public Schools Independ...
December 1, 2023 U.S. Department of Education Marshall Public Schools respectfully submits the following Corrective Action Plan for the year ended June 30, 2023. Contact information for the individual responsible for the corrective action: Caleb Petet, Superintendent Marshall Public Schools Independent Public Accounting Firm: Gerding, Korte & Chitwood, P.C., 723 Main Street, Boonville, MO 65233 Audit Period: Year ended June 30, 2023 The findings from the June 30, 2023, Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Significant Deficiency
View Audit 8463 Questioned Costs: $1
Marshall Public Schools
MO
Questioned Costs Cash Management School Nutrition Programs
2023-002 Child Nutrition Cluster Recommendation: We recommend that fund balances should be monitored to ensure that balances remain in line with child nutrition compliance requirements. Action Taken: The district has in FY24 allocated much of the funds in excess from the child nutrition cluster to ...
2023-002 Child Nutrition Cluster Recommendation: We recommend that fund balances should be monitored to ensure that balances remain in line with child nutrition compliance requirements. Action Taken: The district has in FY24 allocated much of the funds in excess from the child nutrition cluster to invest in equipment. We have to date, spent the funds down on Freezers, cafeteria tables, coolers, and other such equipment as is allowable for the funds. After speaking with food and nutrition services at DESE, we understand that this surplus comes from the state reimbursements being higher during COVID than what they are post covid. Meaning the rate we were getting reimbursed for free/reduced was higher than the cost, which built the surplus. We are confident that this excess is going to continue being dwindled down, now that our reimbursements are less than the cost of the 3rd party vendors charges to us. However, we are not allowed to use it on unpaid lunch balances, so we have to continue running that surplus for at least another year. This excess is going to start coming down on its own through necessary investments in infrastructure. Completion Date: June 30, 2024 Sincerely, Caleb Petet, Superintendent Marshall Public Schools
View Audit 8463 Questioned Costs: $1
Finding 6488 (2023-001)
Significant Deficiency 2023
Family Pathways
MN
Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment
Family Pathways will correct this significant deficiency by establishing procedures to monitor purchaces and the exclusion of sales tax. The procedures will include monitoring of credit card statements and procurement of supplies.
Family Pathways will correct this significant deficiency by establishing procedures to monitor purchaces and the exclusion of sales tax. The procedures will include monitoring of credit card statements and procurement of supplies.
View Audit 8445 Questioned Costs: $1
Finding 6485 (2023-003)
Significant Deficiency 2023
Hamilton Health Center, Inc.
PA
Questioned Costs Allowable Costs / Cost Principles Cash Management
Corrective Action Planned: In September of 2022, the Chief Financial Officer left the health center, and a replacement was not hired until a month (February 20, 2023) before the end of the fiscal year on March 31, 2023. While the accounting staff have been with the health center for more than three ...
Corrective Action Planned: In September of 2022, the Chief Financial Officer left the health center, and a replacement was not hired until a month (February 20, 2023) before the end of the fiscal year on March 31, 2023. While the accounting staff have been with the health center for more than three years, they lacked guidance while the search for a replacement Chief Financial Officer was going on. The Chief Financial Officer who left the health center was the only one who was handling and administering the indirect cost rate to Federal grants but when he left the accounting staff had no clue that the new indirect cost rate needed to be administered. The new Chief Financial Officer has experience in the use and application of indirect cost rates and has cross trained the Controller in the use and application of indirect cost rates. This finding will never reoccur in future. Name(s) of Contact Person(s) Responsible for Corrective Action: Frackson Sakala Anticipated Completion Date: 12/31/2023
View Audit 8436 Questioned Costs: $1
Finding 6484 (2023-002)
Material Weakness 2023
Hamilton Health Center, Inc.
PA
Reporting Internal Control / Segregation of Duties
Corrective Action Planned: In September of 2022, the Chief Financial Officer left the health center, and a replacement was not hired until a month (February 20, 2023) before the end of the fiscal year on March 31, 2023. While the accounting staff have been with the health center for more than three ...
Corrective Action Planned: In September of 2022, the Chief Financial Officer left the health center, and a replacement was not hired until a month (February 20, 2023) before the end of the fiscal year on March 31, 2023. While the accounting staff have been with the health center for more than three years, they lacked guidance while the search for a replacement Chief Financial Officer was going on. The accounting staff were not trained in HRSA grant reporting and this led to missing the grant reporting due dates. The new Chief Financial Officer is experienced in HRSA grants reporting and has put in place a tracking system for all grants including HRSA Federal grants so that lapses in grants reporting do not happen again. Name(s) of Contact Person(s) Responsible for Corrective Action: Frackson Sakala Anticipated Completion Date: 12/31/2023
View Audit 8436
Finding 6473 (2023-003)
Significant Deficiency 2023
Detroit Transportation Corporation
MI
Subrecipient Monitoring Cash Management Significant Deficiency § 200.305
Federal funds payback has been completed as required by Federal Transit Authority, as of October 2023.
Federal funds payback has been completed as required by Federal Transit Authority, as of October 2023.
View Audit 8432
Finding 6472 (2023-002)
Material Weakness 2023
Detroit Transportation Corporation
MI
Reporting
DTC shall assign one responsible party to complete the Schedule of Expenditures of Federal Awards (SEFA). The SEFA shall be prepared and presented to auditors as required.
DTC shall assign one responsible party to complete the Schedule of Expenditures of Federal Awards (SEFA). The SEFA shall be prepared and presented to auditors as required.
View Audit 8432
Finding 6470 (2023-001)
Significant Deficiency 2023
Housing Authority of Kansas City Kansas
RI
HUD Housing Programs Subrecipient Monitoring Reporting
Finding 2023-001: Delay in submitting the unaudited FDS to HUD Corrective Action Plan: Management has hired a new qualified staff member to fill the gap left by the previous critical employee at the time of financial closing. Management will continue to closely monitor and review financial transa...
Finding 2023-001: Delay in submitting the unaudited FDS to HUD Corrective Action Plan: Management has hired a new qualified staff member to fill the gap left by the previous critical employee at the time of financial closing. Management will continue to closely monitor and review financial transaction recordings in a timely manner making sure the data is accurate and complete. Management will continue reviewing, comparing, and reconciling the financial data that will be used as an input for the FDS reporting. Name of Responsible Person: Worku Alem, Director of Finance Projected Completion Date: March 31, 2024
View Audit 8417
Finding 6469 (2023-005)
Material Weakness 2023
Paris Union School District No. 95
IL
Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303
2023-005 Internal Controls over Compliance of Federal Awards (Coronavirus State and Local Recovery Funds 21.027) Condition: 1) Five (5) instances where employees received pay rates in excess of three hundred percent of their normal pay rates received from unrestricted funds. 2) Fifteen (15) instance...
2023-005 Internal Controls over Compliance of Federal Awards (Coronavirus State and Local Recovery Funds 21.027) Condition: 1) Five (5) instances where employees received pay rates in excess of three hundred percent of their normal pay rates received from unrestricted funds. 2) Fifteen (15) instances were noted where salaries were allocated to this program without documentation of time and effort. Plan: The District will appoint an individual that is knowledgeable, or provide the appropriate training, of the federal compliance requirements set forth in the Code of Federal Regulation to oversee the District’s federal programs to ensure the District is in compliance with all applicable federal compliance requirements. Anticipated Date of Completion: Immediately upon learning of issue. Name of Contact Person: Lorraine Bailey, Superintendent
View Audit 8413
Finding 6465 (2023-004)
Material Weakness 2023
Paris Union School District No. 95
IL
Questioned Costs Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303
2023-004 Internal Controls over Compliance of Federal Awards (Education Stabilization Fund 84.425) Condition: 1) During testing of compliance over disbursements, we noted the following: a. Eight (8) transactions totaling $474,924 appeared to be for capital purchases that did not have prior approval ...
2023-004 Internal Controls over Compliance of Federal Awards (Education Stabilization Fund 84.425) Condition: 1) During testing of compliance over disbursements, we noted the following: a. Eight (8) transactions totaling $474,924 appeared to be for capital purchases that did not have prior approval by the SEA b. Six (6) transactions totaling $52,117 were incurred where the District appeared to be subject to Davis-Bacon prevailing wage requirements but no documentation was retained. Additionally, a formal policy for complying with Davis-Bacon requirements is not in place for individual expenditures less than $25,000. 2) During testing of compliance over reporting, we noted the following: a. Expenditure reports were completed based on budgeted amounts rather than actual expenditures. In total, expenditure reports exceeded amounts reported in the District’s general ledger by $726,653. Plan: The District will appoint an individual that is knowledgeable, or provide the appropriate training, of the federal compliance requirements set forth in the Code of Federal Regulation to oversee the District’s federal programs to ensure the District is in compliance with all applicable federal compliance requirements. Anticipated Date of Completion: Immediately upon learning of issue. Name of Contact Person: Lorraine Bailey, Superintendent
View Audit 8413 Questioned Costs: $1
Finding 6450 (2023-004)
Significant Deficiency 2023
Doral Academy of Nevada
NV
Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303
Finding Number: 2023-004 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 ...
Finding Number: 2023-004 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 8387
Converse University
SC
Student Financial Aid Subrecipient Monitoring Reporting
The finding was due in part to the lack of a process to correctly backdate administrative withdrawals when a student is awarded a grade of W after the stated date. This resulted in inconsistent dates reported to NSLDS and in the academic file. Management has met to address this issue. The Offices...
The finding was due in part to the lack of a process to correctly backdate administrative withdrawals when a student is awarded a grade of W after the stated date. This resulted in inconsistent dates reported to NSLDS and in the academic file. Management has met to address this issue. The Offices of Campus Technology, Financial Planning and Registrar have met to discuss processes in place and create new methods by which administrative withdrawals will be handled going forward. Additionally, management is working with Jenzabar to ensure the dates are consistent with the withdrawal option, specifically the awarding of W grades and the related date of last attendance. This process will assist the University in the following ways: students will be reported on the NSLDS report in the appropriate timeframe, a uniform withdrawal date will be recorded in the Offices of the Registrar and Financial Planning and students receive the appropriate grade as indicated by the official academic calendar. This action has been implemented for the final grading period ending on Monday, December 11, 2023. Management will continue to submit enrollment reports to the NSLDS on the schedule submitted annually, ensuring that any changes to student enrollment will be reported as required. The corrective action plan will be undertaken by the Office of the Registrar, under the supervision of the University Registrar and Director of Institutional Research and Effectiveness, Kendra Woodson (Kendra.woodson@converse.edu).
View Audit 8384
Finding 6443 (2023-002)
Significant Deficiency 2023
Breaking Free
MN
Program Income
Planned Action: The organization will review and revise all internal processes to ensure that there is proper accounting regarding this program and others. A review of policies and systems will be an important part of this process to ensure that revenue is recognized in the correct period.
Planned Action: The organization will review and revise all internal processes to ensure that there is proper accounting regarding this program and others. A review of policies and systems will be an important part of this process to ensure that revenue is recognized in the correct period.
View Audit 8383
Finding 6442 (2023-001)
Significant Deficiency 2023
Breaking Free
MN
Period of Performance
Planned Action: The organization will review and revise all internal processes to ensure that there is proper accounting regarding this program and others. A review of policies and systems will be an important part of this process to ensure that only expenses incurred during the period of performanc...
Planned Action: The organization will review and revise all internal processes to ensure that there is proper accounting regarding this program and others. A review of policies and systems will be an important part of this process to ensure that only expenses incurred during the period of performance are billed to the grants.
View Audit 8383
Finding 6438 (2023-001)
Significant Deficiency 2023
San Francisco Medical Center Outpatient Improvement Programs, Inc.
CA
Special Tests & Provisions Eligibility
2023-001 Sliding Fee Discount Determination Name of Contact Person: Interim Chief Financial Officer: Shigeyuki Murota, Patient Accounts Manager: George Ward Corrective Action: San Francisco Medical Center Outpatient Improvement Programs, Inc will: - Immediately retrain staff involved in Slid...
2023-001 Sliding Fee Discount Determination Name of Contact Person: Interim Chief Financial Officer: Shigeyuki Murota, Patient Accounts Manager: George Ward Corrective Action: San Francisco Medical Center Outpatient Improvement Programs, Inc will: - Immediately retrain staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing. - Train all new staff at new hire orientations, conduct an internal audit, and retrain current staff based on outcome as needed. - Perform periodic audits of sliding fee transactions Proposed Completion Date: December 31, 2023
View Audit 8376
Finding 6437 (2023-002)
Significant Deficiency 2023
Housing Authority of the City of Newport Rhode Island
RI
Questioned Costs Procurement, Suspension & Debarment
2023-002 – PROCUREMENT, SUSPENSION, AND DEBARMENT Auditee’s Response and Planned Corrective Action Based on the finding from the prior year’s report on internal control, the Authority implemented a Contract Register that is updated quarterly. The Contract Register lists all payments made year-to-dat...
2023-002 – PROCUREMENT, SUSPENSION, AND DEBARMENT Auditee’s Response and Planned Corrective Action Based on the finding from the prior year’s report on internal control, the Authority implemented a Contract Register that is updated quarterly. The Contract Register lists all payments made year-to-date to all vendors and is reviewed periodically for frequently recurring transactions with vendors that could exceed the threshold limits. In this way, the level of procurement required is reviewed and changed if necessary. The level and type of procurement is determined by the amount of the purchase and the aggregate of purchases from that vendor to date. In the situation cited by the auditors, the aggregate purchases for that vendor exceeded the $10,000 threshold (but not more than $250,000). The Authority relied on a matrix of services and comparison of pricing between the former provider and the current provider, but bids were not documented. This has been corrected subsequent to year-end and the proper documentation was provided to the auditors. Planned Implementation Date of Corrective Action: December 21, 2023 Person Responsible for Corrective Action: Stuart MacDonald, CFO
View Audit 8357 Questioned Costs: $1
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