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Corrective Action Plans

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Finding 1155423 (2022-010)
Material Weakness 2022
Headquarters Kansas, Inc.
KS
Significant Deficiency Internal Control / Segregation of Duties § 200.512
2022-010 Timely Submission of Audit Reports (Significant Deficiency) Recommendation: We recommend the Organization become familiar with the requirements of Uniform Guidance and implement policies to ensure compliance. Action Taken (Unaudited): Management is working to update its control procedures t...
2022-010 Timely Submission of Audit Reports (Significant Deficiency) Recommendation: We recommend the Organization become familiar with the requirements of Uniform Guidance and implement policies to ensure compliance. Action Taken (Unaudited): Management is working to update its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. Dan Watkins is responsible for this corrective action. Implementation of updated policies related to audits was completed November 2024. The organization will complete an additional review of the policies compared to Uniform Guidance 1st Quarter 2026.
View Audit 367706
Finding 1155422 (2022-009)
Material Weakness 2022
Headquarters Kansas, Inc.
KS
Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.302 § 200.403
2022‐009 Cash Disbursements (Material Weakness) Recommendation: We recommend policies and procedures over the segregation of duties between the accounting and banking functions be strengthened. In addition, policies and procedures should be implemented to ensure support for expenditures is retained ...
2022‐009 Cash Disbursements (Material Weakness) Recommendation: We recommend policies and procedures over the segregation of duties between the accounting and banking functions be strengthened. In addition, policies and procedures should be implemented to ensure support for expenditures is retained and includes evidence of approval. Additional oversight should be provided by those charged with governance. Action Taken (Unaudited): Management has updated its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. Dan Watkins is responsible for this corrective action. Implementation of updated policies was completed November 2024. Accounting and banking functions are segregated.
View Audit 367706
Finding 1155421 (2022-008)
Material Weakness 2022
Headquarters Kansas, Inc.
KS
Cash Management Material Weakness Reporting § 200.302 § 200.400
2022‐008 Grant Expenditures (Material Weakness) Recommendation: The Organization’s accounting system should be modified to accommodate expense tracking by individual grant and policies and procedures should be implemented to require direct expenses be assigned to specific grants. A method should be ...
2022‐008 Grant Expenditures (Material Weakness) Recommendation: The Organization’s accounting system should be modified to accommodate expense tracking by individual grant and policies and procedures should be implemented to require direct expenses be assigned to specific grants. A method should be established to allocate indirect costs in accordance with federal regulations. Policies and procedures are also needed to provide appropriate oversight of all grant accounting including reporting. Action Taken (Unaudited): Management has updated its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. Dan Watkins is responsible for this corrective action. A review process and coding within the accounting system was completed in January 2025. All invoices and staff time are evaluated for the level of effort towards each grant.
View Audit 367706
Finding 1155420 (2022-007)
Material Weakness 2022
Headquarters Kansas, Inc.
KS
Material Weakness Reporting § 200.430
2022‐007 Payroll (Material Weakness) Recommendation: Procedures should be implemented to require appropriate contemporaneous documentation to support time and effort reporting under 2 CFR Part 200. In addition, procedures should also be implemented to require the review and approval of payroll. Acti...
2022‐007 Payroll (Material Weakness) Recommendation: Procedures should be implemented to require appropriate contemporaneous documentation to support time and effort reporting under 2 CFR Part 200. In addition, procedures should also be implemented to require the review and approval of payroll. Action Taken (Unaudited): Management has updated its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. Dan Watkins is responsible for this corrective action. The Organization hired a Human Resource Manager June of 2024, moved to ADP for payroll in January 2025 and updated policies and process for review in May 2025. Procedures are in place for review and approval of each payroll.
View Audit 367706
Finding 1155271 (2022-003)
Material Weakness 2022
Comanche County Medical Center
TX
Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303
We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting and Activities Allowed/Unallowed and Cost Principles. Management agrees with the finding. After correcting the calculation of expenses to include reimbursement from other sources, the Hosp...
We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting and Activities Allowed/Unallowed and Cost Principles. Management agrees with the finding. After correcting the calculation of expenses to include reimbursement from other sources, the Hospital still has sufficient lost revenues and expenses to cover the amount of provider relief funding received. Management will perform a detailed analysis of the reporting requirements in accordance with the final guidelines set by HRSA for future reporting periods. As deemed necessary, the Hospital will modify policies and procedures over federal grant reporting The CFO, Hong Wade, will be responsible to ensure this is accomplished. The corrective action plan will be implemented by December 31, 2025.
View Audit 367503 Questioned Costs: $1
Finding 1155242 (2022-008)
Material Weakness 2022
Defensewerx
FL
Allowable Costs / Cost Principles Cash Management Matching / Level of Effort / Earmarking § 200.403 § 200.412
We agree with the recommendations offered and will establish and implement a comprehensive indirect cost allocation policy that aligns with Uniform Guidance requirements.
We agree with the recommendations offered and will establish and implement a comprehensive indirect cost allocation policy that aligns with Uniform Guidance requirements.
View Audit 367461
Finding 1155241 (2022-007)
Material Weakness 2022
Defensewerx
FL
Special Tests & Provisions Matching / Level of Effort / Earmarking
We agree with the recommendations offered and have established updated policies and procedures to address the finding regarding the retention of evidence of the funders’ approval of any changes in identified key personnel. We have addressed this finding by creating a list of government partners and ...
We agree with the recommendations offered and have established updated policies and procedures to address the finding regarding the retention of evidence of the funders’ approval of any changes in identified key personnel. We have addressed this finding by creating a list of government partners and the key personnel identified in each PIA agreement. If it is not listed in the agreement, written documentation is provided from the government partners identifying the key personnel. When there are changes in the key personnel, verbal and written approval is obtained prior to changes and documentation is uploaded in the DEFENSEWERX SharePoint private site and a copy is added to the personnel file kept in the financial department.
View Audit 367461
Finding 1155240 (2022-006)
Material Weakness 2022
Defensewerx
FL
Procurement, Suspension & Debarment
We agree with the recommendations offered and have established more formal policies and procedures to address the findings while considering appropriate segregation of duties. We have established a procurement policy to conform to applicable federal law and regulations and standards identified by 2 ...
We agree with the recommendations offered and have established more formal policies and procedures to address the findings while considering appropriate segregation of duties. We have established a procurement policy to conform to applicable federal law and regulations and standards identified by 2 CFR Part 200. This policy has been shared with each location. A procurement checklist has also been created and will be shared with each location on procurement procedures.
View Audit 367461
Finding 1155239 (2022-005)
Material Weakness 2022
Defensewerx
FL
Equipment & Real Property Management
We agree with the recommendations offered and will establish updated policies and procedures to address the findings while considering appropriate measures to ensure compliance by the various locations. We have addressed this finding to each location. We have requested that they obtain an inventory ...
We agree with the recommendations offered and will establish updated policies and procedures to address the findings while considering appropriate measures to ensure compliance by the various locations. We have addressed this finding to each location. We have requested that they obtain an inventory system that uses a bar code to identify serial number, source, owner, acquisition date, cost, percentage allocated to federal funds, location, condition and any disposition date. There is a requirement that each site conducts an annual inventory count and document dates on the inventory count. There is also an annual year-end requirement to perform an inventory check as part of the annual year-end checklist.
View Audit 367461
Finding 1155238 (2022-004)
Material Weakness 2022
Defensewerx
FL
Cash Management
We agree with the recommendations offered and will establish updated policies and procedures to address the finding while considering appropriate measures for operating programs that are on a cost reimbursement basis. We have addressed this finding to our government partners. Specific government par...
We agree with the recommendations offered and will establish updated policies and procedures to address the finding while considering appropriate measures for operating programs that are on a cost reimbursement basis. We have addressed this finding to our government partners. Specific government partners have requested the continuation of cash advances in the manner which we have been operating. We have worked with the other government partners and have come up with an incremental funding plan based on needs that are appropriate in maintaining the operational requirements set forth by the awards. Periodically we updated the government partners on program funds that have been used or those funds that are excess.
View Audit 367461
Finding 1155086 (2022-004)
Material Weakness 2022
Hill Country Community Clinic, Inc.
CA
Cash Management
Current leadership and Management has implemented robust policies and procedures to ensure compliance with federal drawdown requirements. Currently, all drawdowns are based on 1/12th of the approved annual budget and are fully supported by actual expenditures recorded in the General Ledger. These ex...
Current leadership and Management has implemented robust policies and procedures to ensure compliance with federal drawdown requirements. Currently, all drawdowns are based on 1/12th of the approved annual budget and are fully supported by actual expenditures recorded in the General Ledger. These expenditures exceed the amount of the monthly drawdown, ensuring we are not drawing funds in advance. Previous acceleration of drawdowns in prior years was not aligned with best practices and stemmed from poor cash flow management and inadequate internal controls. Our corrective action plan directly addresses these issues through strengthened oversight and improved fiscal discipline. Furthermore, in alignment with the Department of Health and Human Services’ “Defend the Spend” (DOGE) initiative, all drawdowns are now required to be substantiated by actual, documented expenses reflected in the General Ledger.
View Audit 367389
Finding 1155085 (2022-003)
Material Weakness 2022
Hill Country Community Clinic, Inc.
CA
Special Tests & Provisions Eligibility
Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for ...
Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for applying discounts consistently. We will review and update our sliding fee discount policy to ensure clarity, consistency, and compliance with regulatory requirements. We will provide an annual review and obtain board approval of the Sliding Fee Discounting Program scheduled on an annual basis. Regular internal audits will be conducted to review the application of sliding fee discounts and identify any discrepancies before external audits. Results of internal audits will be shared with management, and corrective actions will be taken as necessary. We will assess the feasibility of implementing system controls or automated alerts within our electronic health record (EHR) and billing systems to reduce errors in discount applications. Additional oversight measures may be introduced to ensure all eligible patients receive the correct discount in accordance with policy guidelines. The above corrective actions are currently being implemented.
View Audit 367389
Finding 1155084 (2022-002)
Material Weakness 2022
Hill Country Community Clinic, Inc.
CA
Reporting
Management acknowledges the finding. We will enhance our internal policies and procedures to ensure accurate financial reporting and compliance with federal grant requirements. A detailed reporting checklist will be developed to prevent errors and improve the accuracy of UDS and FFR submissions. Add...
Management acknowledges the finding. We will enhance our internal policies and procedures to ensure accurate financial reporting and compliance with federal grant requirements. A detailed reporting checklist will be developed to prevent errors and improve the accuracy of UDS and FFR submissions. Additional layers of review will be implemented to verify the accuracy of financial data before submission. Designated personnel will cross-check program income and financial data to ensure proper classification and reporting. To mitigate the impact of staff turnover, we will implement a structured training program for all employees responsible for grant reporting. A documented succession plan will be established to ensure continuity in key financial and reporting roles. We will evaluate opportunities for automation and financial system improvements to reduce manual errors. Enhanced documentation and reconciliation procedures will be implemented to ensure accurate tracking of program income. Internal compliance reviews will be conducted quarterly to assess reporting accuracy and address potential issues before submission. Management will conduct periodic training sessions and refresher courses to keep staff informed of reporting requirements and best practices. The above corrective actions are currently being implemented.
View Audit 367389
Finding 1155016 (2022-009)
Material Weakness 2022
Ulster County Community Action Committee, Inc.
NY
Reporting Significant Deficiency § 200.508 § 200.510
UCCAC has retained services of an outside service provider who will ensure schedule of expenditures of federal awards is reconciled to general ledger and includes all federal and pass-through federal grants awarded. The schedule will also be reviewed by program director for accuracy and completeness...
UCCAC has retained services of an outside service provider who will ensure schedule of expenditures of federal awards is reconciled to general ledger and includes all federal and pass-through federal grants awarded. The schedule will also be reviewed by program director for accuracy and completeness. Responsible Person: Controller and program directors Timeline: 30-60 days
View Audit 367339
Finding 1155003 (2022-012)
Material Weakness 2022
Ulster County Community Action Committee, Inc.
NY
Procurement, Suspension & Debarment § 200.14
UCCAC will incorporate checklist to ensure that before entering into a contract or securing services with a vendor they are verified against SAM.gov exclusion database. Evidence of verification will be retained on file. Responsible Person: Executive Director, Program Directors and Controller Timelin...
UCCAC will incorporate checklist to ensure that before entering into a contract or securing services with a vendor they are verified against SAM.gov exclusion database. Evidence of verification will be retained on file. Responsible Person: Executive Director, Program Directors and Controller Timeline: 0-30 days
View Audit 367339
Finding 1155002 (2022-011)
Material Weakness 2022
Ulster County Community Action Committee, Inc.
NY
Reporting Subrecipient Monitoring Material Weakness
Due to recent turnovers at UCCAC, program and fiscal staff did not have proper access to the reporting application to timely complete the report. The report was submitted as soon as access to the application was obtained. In addition, UCCAC has given access to multiple staff administrative access to...
Due to recent turnovers at UCCAC, program and fiscal staff did not have proper access to the reporting application to timely complete the report. The report was submitted as soon as access to the application was obtained. In addition, UCCAC has given access to multiple staff administrative access to applications. Responsible Person: Executive Director Timeline: 30-60days
View Audit 367339
Finding 1155001 (2022-010)
Material Weakness 2022
Ulster County Community Action Committee, Inc.
NY
Reporting
Due to recent turnovers at UCCAC, program and fiscal staff did not have proper access to the reporting application to timely complete the report. The report was submitted as soon as access to the application was obtained. In addition, UCCAC has given access to multiple staff administrative access to...
Due to recent turnovers at UCCAC, program and fiscal staff did not have proper access to the reporting application to timely complete the report. The report was submitted as soon as access to the application was obtained. In addition, UCCAC has given access to multiple staff administrative access to applications. Responsible Person: Executive Director Timeline: 30-60days
View Audit 367339
Finding 1153884 (2022-001)
Material Weakness 2022
Monterey County Business Council
CA
Cash Management Reporting Significant Deficiency
Finding Reference: 2022-001 Description of Finding: Significant Deficiency in Internal Controls over Compliance. Identification of the Federal Program: U.S. Department of the Treasury CFDA 20.019 Criteria or Specific Requirement: Recipients of federal awards must establish internal controls over rep...
Finding Reference: 2022-001 Description of Finding: Significant Deficiency in Internal Controls over Compliance. Identification of the Federal Program: U.S. Department of the Treasury CFDA 20.019 Criteria or Specific Requirement: Recipients of federal awards must establish internal controls over reports that are prepared and submitted. Finding/Condition: Pursuant to the reporting requirement set forth by the Department of the Treasury, the Organization is required to submit the single audit to the Federal Audit Clearinghouse within 30 days of the issuance of the audit report or nine months after the end of the Organization’s fiscal year. During our reporting period we noted that the audit was not completed and filed timely. Cause: The Organization met the requirements for a single audit for the first time during the year ended December 31, 2022. Due to a lack of expertise in federal grant reporting requirements, the Organization overlooked the requirement to perform a single audit and file with the clearinghouse in a timely manner Corrective Action: In June 2025, Monterey County Business Council employed a CFO Consultant with 30+ years’ experience in finance and accounting who has performed a deep dive into the accounting framework. The Consultant has been engaged to assist the Organization in completing financial and single audits for the years ended December 31, 2022, 2023, and 2024. It is expected that the Organization will be caught up with federal clearinghouse filings by the end of 2025 or early 2026 at the latest. Under the consultant’s guidance, the Organization has made progress in financial reporting and will be filing the 2022 audit by August 30, 2025. Audits for subsequent years will be audited thereafter. Name of Responsible Person: Chris Steinbruner, CPA Questioned Cost: None Chris Steinbruner, CPA MCBC Board Member (831)-222-6111
View Audit 366960
Finding 1153700 (2022-004)
Material Weakness 2022
Vermont Seniors
CA
Questioned Costs HUD Housing Programs
Management should immediately reimburse the amount due to the project and establish procedures to ensure payments of this nature are not made in the future.
Management should immediately reimburse the amount due to the project and establish procedures to ensure payments of this nature are not made in the future.
View Audit 366836 Questioned Costs: $1
Finding 1153699 (2022-003)
Material Weakness 2022
Vermont Seniors
CA
Questioned Costs
Management should work with HUD to come to a resolution to this matter.
Management should work with HUD to come to a resolution to this matter.
View Audit 366836 Questioned Costs: $1
Finding 1153698 (2022-002)
Material Weakness 2022
Vermont Seniors
CA
§ 200.512
The Corporation should file the December 31, 2022 financial statements as soon as possible and should ensure the annual financial report is filed within 30 days after the date of the auditor’s report and within nine months of fiscal year end.
The Corporation should file the December 31, 2022 financial statements as soon as possible and should ensure the annual financial report is filed within 30 days after the date of the auditor’s report and within nine months of fiscal year end.
View Audit 366836
Finding 1153694 (2022-001)
Material Weakness 2022
Vermont Seniors
CA
HUD Housing Programs
The Corporation should file the December 31, 2022 financial statements as soon as possible and should ensure the annual financial report is filed within 90 days in future periods or within nine months of fiscal year end if an owner certified submission was furnished to HUD.
The Corporation should file the December 31, 2022 financial statements as soon as possible and should ensure the annual financial report is filed within 90 days in future periods or within nine months of fiscal year end if an owner certified submission was furnished to HUD.
View Audit 366836
Finding 1153400 (2022-001)
Material Weakness 2022
The Center in Hollywood
CA
The Center's payroll practices were found to not be in compliance with federal funding in two areas. a . The Center's time tracking software does not have the capacity to track employees' time by funding stream b. The Center has not b een auditing and signing off on bi-weekly payroll. This is an add...
The Center's payroll practices were found to not be in compliance with federal funding in two areas. a . The Center's time tracking software does not have the capacity to track employees' time by funding stream b. The Center has not b een auditing and signing off on bi-weekly payroll. This is an additional required step on -top of supervisors reviewing and approving timesheets . The Center has migrated to a new Payroll Processing System, Gusto, as of 5/15/24 and will be fully migrated by the start of the 24 -25 FY. Gusto will enable all employees who are billed to multiple funding streams tie their work activities to the appropriate funding streams and requires supervisor approval before payroll processing is complete. The Center continues to maintain a consistent Operations Department. Chase Weaver complet es additional audit and compliance trainings in his role of Compliance Manager. His scope includes the addition of payroll audits among additional internal agency compliance checks.
View Audit 366611
Finding 1153398 (2022-001)
Material Weakness 2022
Horizon Healthcare Partners
RI
Internal Control / Segregation of Duties Reporting
We agree with the recommendation and understand the required compliance responsibility to provide audited financial statements and major Federal program compliance reporting timely each fiscal year, in accordance with the Federal Single Audit Act. Because of past misunderstandings and incorrect assu...
We agree with the recommendation and understand the required compliance responsibility to provide audited financial statements and major Federal program compliance reporting timely each fiscal year, in accordance with the Federal Single Audit Act. Because of past misunderstandings and incorrect assumptions about major Federal program compliance requirements for fiscal 2019, 2020, 2021, and 2022, management failed to provide for timely audits. One critical assumption was that the Organization’s subrecipient, responsible for over ninety percent (90%) of grant distributions, fulfilled the audit requirement for the required Federal grant reporting under the Single Audit Act. However, upon recognizing this error, the Organization promptly engaged for the financial statement and major Federal program compliance audits spanning multiple years including up to last fiscal year and is on track to provide for timely filing with the current year. With this understanding and the expectation of financial statement and major Federal program compliance audits, the Organization replaced its contracted accountants by hiring its first Chief Financial Officer (CFO) in January of 2021 and a number of additional support accountants beginning in November of 2021 through January of 2024. Upon hire, and with the growth of the programming, the CFO and the accounting team focused extensively on enhancing the Organization’s financial reporting framework and data management systems to ensure continued compliance with federal and state guidelines and reporting requirements. This effort has been crucial in expediting the more recent audits and improving overall efficiencies in the day-to-day and monthly financial reporting and budgeting requirements. Further, the Organization must acknowledge the challenges posed by the transition of multiple Chief Executive Officers in a 2-year period as well as the impact of the pandemic on operations and reporting. These two factors affected operations and time lines as well as access to data files as many were in paper form. Despite these difficulties, management’s commitment to timely financial reporting and program compliance remains steadfast and are working diligently to get its timing back on track going forward.
View Audit 366610
Finding 1153050 (2022-003)
Material Weakness 2022
Michigan Ability Partners
MI
HUD Housing Programs Material Weakness
Michigan Ability Partners strives to maintain compliance with all HUD requirements, however due to the challenges of social distancing and the requirement of remote work during the COVID era, meeting in person with clients and landlords to obtain signed documents became much more difficult. Staff tr...
Michigan Ability Partners strives to maintain compliance with all HUD requirements, however due to the challenges of social distancing and the requirement of remote work during the COVID era, meeting in person with clients and landlords to obtain signed documents became much more difficult. Staff transitions also contributed to these challenges. The Voucher Manager position—responsible for verifying rent reasonableness and filling open HUD vouchers—was vacated in July 2022 after a brief tenure. Although the role was refilled quickly, the transition resulted in information gaps during lease renewal periods due to the disruption in continuity and knowledge transfer. To help support the growing difficulty of the work, a new position, Housing Administrative Team Lead, was created in November 2022 to have direct responsibility of the Voucher Manager, maintain compliance, and update systems and workflows. More recently, in August 2024, Michigan Ability Partners created an additional position, Sr. Manager of Programs to provide an additional level of review to ensure compliance. To recruit and retain qualified staff, the salaries for these three position have been adequately adjusted. Michigan Ability Partners (MAP) provides outstanding services to the unhoused population of Washtenaw County. Although many staffing disruptions have recently affected some of its operations, MAP is committed to continue to provide exceptional services and maintain a high standard of compliance. Going forward, MAP will continue to work diligently to complete Single Audit Packages in a timely manner
View Audit 366303
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