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Corrective Action Plans

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Finding 575078 (2024-104)
Significant Deficiency 2024
Pancare of Florida, INC
FL
Internal Control / Segregation of Duties Subrecipient Monitoring HUD Housing Programs § 200.303
2024-104 Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hired a new Chie...
2024-104 Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal controls and facilitate segregation of duties best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review was also implemented in 2025 Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented
View Audit 365222
Finding 575077 (2024-101)
Material Weakness 2024
Pancare of Florida, INC
FL
Special Tests & Provisions Subrecipient Monitoring HUD Housing Programs § 200.303
2024-101 Lack of Internal Controls over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale...
2024-101 Lack of Internal Controls over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Billing and Collections Policy was updated to waive co-pays for students in the School-Based Program. The Billing Department is in the process of auditing and implementing quarterly feedback & training sessions for the Operations Department for training and compliance for the Sliding Fee Discount Program. This process was implemented in 2025. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: October 2025
View Audit 365222
Finding 575071 (2024-002)
Significant Deficiency 2024
Neighborhood Health Association of Toledo, Inc.
OH
Special Tests & Provisions Eligibility HUD Housing Programs
U.S. Department of Health and Human Services (HHS) SIGNIFICANT DEFICIENCY 2024-002 93.224/93.527 - Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center...
U.S. Department of Health and Human Services (HHS) SIGNIFICANT DEFICIENCY 2024-002 93.224/93.527 - Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center Program) Recommendation: We recommend that management hold additional training for front desk staff regarding the collection and verification of patient information for each patient. We also recommend enhancing your sliding fee status feature in your billing system to be completed for all patients to identify if the patient is insured, an application is pending, an application was received, an application was approved by finance for adjustment, and if an application was waived, to enable better tracking of the eligibility of each patient. We also recommend reviewing outstanding patient balances over 180 days to determine if follow up with a patient is required to collect the outstanding balance or to see if something has been collected by the front desk but not communicated to the finance team. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management agrees with the recommendations identified above. During April 2025, NHA started a project to review Self Pay balances with service dates prior to January 1, 2025 to follow up on why the balance is still outstanding. This would have caught the error identified above. In addition to this project, they have held additional trainings for front desk staff and will continue to do so and will continue to improve their methods of tracking patient eligibility. Name(s) of the contact person(s) responsible for corrective action: Doni Miller Planned completion date for corrective action plan: November 30, 2025 If the Department of Health and Human Services has questions regarding this plan, please call Doni Miller, CEO at 419-720-7883.
View Audit 365213
Finding 575069 (2024-001)
Material Weakness 2024
Saint Michael's Clinics, Inc.
NJ
Internal Control / Segregation of Duties Eligibility Subrecipient Monitoring
Clinic management team acknowledges that from the audit selection made of 60 patients, 14 were not recertified during the six-month period and the supporting documentation was not always obtained or retained related to income verification, household size, residency, and health insurance status. The ...
Clinic management team acknowledges that from the audit selection made of 60 patients, 14 were not recertified during the six-month period and the supporting documentation was not always obtained or retained related to income verification, household size, residency, and health insurance status. The corrective action plan as developed for CY 2023 will be continued to be reinforced and followed. The plan did result in lower findings than in prior years. A new bullet was added in the fourth quarter of 2024 to further assist in meeting the compliance guidance. The addition is the last bullet listed below. • Revamped the job titles and description to encourage better return on recruitment efforts of medical case manager positions. • A position of Certified Case Counselor (CCC) – Lead, was created and filled to provide direct oversight over the medical case managers that perform the bi-annual certifications, and other daily tasks. • Added a quality management process, where Clinic clients are called ahead of time to notify them of their recertification requirements. • Data Analyst(s) generate a report of patients due for recertification 60 days in advance of the due date. The CCC-Lead is directly accountable to review the progress of the re-certification, and the process is monitored by the Assistant Manager of the clinic. The CCC-Lead and Assistant Manager monitor retention of all patients required supporting documentation in the patients’ medical records. • Patients that do not provide the required supporting documentation showing compliance with program eligibility as outlined in the grant agreement or are otherwise not able to be recertified six months after certification will be classified as inactive in the database used to submit invoices to the Ryan White HIV/AIDS Program. • CCC-Lead has been assigned to preview charts on the daily appointment book in EPIC and sending a list of the documentation required via email to case management staff as they meet with the patients. Contact Person: Mark Brown, Office Manager, Peter Ho Memorial Clinic Expected Completion Date: September 30, 2025
View Audit 365210
Finding 575067 (2024-003)
Significant Deficiency 2024
Catholic Community Services of Western Washington
WA
Allowable Costs / Cost Principles § 200.1 § 200.414
Type of Finding: Significant deficiency in internal controls over the calculation of Modified Total Direct Costs puts CCS at risk of an overallocation indirect costs to federal programs. View of Responsible Officials: Management accepts this finding. Effective internal control over the calculation of...
Type of Finding: Significant deficiency in internal controls over the calculation of Modified Total Direct Costs puts CCS at risk of an overallocation indirect costs to federal programs. View of Responsible Officials: Management accepts this finding. Effective internal control over the calculation of Modified Total Direct Costs ensures that costs are allocated correctly to programs. Training of staff and increased review over allocations would likely have prevented this error. Corrective Action: CCS will be setting up a new form to calculate the Modified Indirect Cost Rate that each division will be required to use for all contract billings that are using the de minimis indirect cost method. The indirect costs charged to each contract will be reviewed semi-annually for accuracy and consistency.
View Audit 365205
Finding 575041 (2024-002)
Significant Deficiency 2024
Catholic Community Services of Western Washington
WA
Allowable Costs / Cost Principles § 200.430
Type of Finding: Significant deficiency in Internal Control over Compliance relating to inadequate allocation of wages to federal programs may result in noncompliance with grant regulations. Views of Responsible Officials: Management accepts this finding. Effective internal control over the allocati...
Type of Finding: Significant deficiency in Internal Control over Compliance relating to inadequate allocation of wages to federal programs may result in noncompliance with grant regulations. Views of Responsible Officials: Management accepts this finding. Effective internal control over the allocation of wages to federal programs ensures we remain in compliance with allowable costs. In one region, two employees in ADP were not set up correctly to ensure the proper allocation of hours worked per the timesheets to the associated job cost centers. Training of staff along with additional supervision over allocations would likely have prevented this error. Corrective Action: The set up of all employees has been reviewed and now corrected. In addition, new employee set up will be reviewed by a designated staff member to ensure consistency. A new report has been developed that will be reviewed for each pay period to ensure all employees, allocating their time are set up properly.
View Audit 365205
Finding 575026 (2024-001)
Significant Deficiency 2024
Catholic Community Services of Western Washington
WA
Procurement, Suspension & Debarment
Type of Finding: Significant deficiency in internal controls over compliance relating to suspension and debarment checks and maintenance of documentation puts CCS at risk of noncompliance with the standards of Procurement. Views of Responsible Officials: Management accepts this finding. Effective in...
Type of Finding: Significant deficiency in internal controls over compliance relating to suspension and debarment checks and maintenance of documentation puts CCS at risk of noncompliance with the standards of Procurement. Views of Responsible Officials: Management accepts this finding. Effective internal control over the documentation of suspension and debarment checks, which can be attributed to the documentation not being retained documenting the suspension and debarment check. Additional training and review of suspension and debarment check requirements would likely have prevented these errors. Corrective Action: A staff member has been assigned to do suspension and debarment checks on all vendors that CCS purchased more than $10,000 in goods or services in the prior year at the beginning of the next fiscal year. In addition, CCS is working on including a suspension and debarment clause in procurement contracts. Continued training will be done for purchases exceeding the micro-purchase limit to include a suspension and debarment check.
View Audit 365205
Cift
OH
Subrecipient Monitoring Reporting Program Income
State of Condition:During the year ended June 30, 2024, the Center had unexpended program income for the 5 year term of the cooperative agreement. Corrective Action: Resolved. The Center made restitution for the unexpended amount as well as implemented new procedures to track program income and ex...
State of Condition:During the year ended June 30, 2024, the Center had unexpended program income for the 5 year term of the cooperative agreement. Corrective Action: Resolved. The Center made restitution for the unexpended amount as well as implemented new procedures to track program income and expenses to ensure the issue does not occur in the future
View Audit 365198
Finding 575012 (2024-001)
Significant Deficiency 2024
St. Johns County Airport Authority
FL
Equipment & Real Property Management Procurement, Suspension & Debarment Significant Deficiency § 200.313
Finding Number: 2024-001 ...
Finding Number: 2024-001 Equipment and Real Property Management (Internal Control and Compliance) Condition Our testing of the expenditures of Airport Improvement Program funds identified $192,000 of equipment purchased as part of the rehabilitation of the air traffic control tower. This equipment was recorded in the Authority's property records. However, the property records did not contain the required data elements noted above. Response/Planned Corrective Action We agree with the auditor’s findings and have already taken corrective measures to ensure compliance. Specifically, we conducted a full review of the Authority’s property records and updated the equipment entries associated with this project to include all required data elements. To strengthen compliance moving forward, we have created a Standard Operating Procedure (SOP) that mandates completion of all required data elements before any asset record is finalized. In addition, the SOP establishes a protocol for conducting periodic internal audits of property records to confirm accuracy, completeness, and adherence to federal requirements. These corrective actions have already been implemented, and the Authority will maintain ongoing oversight to prevent recurrence. Responsible Contact Person: Courtney K. Pittman Interim Executive Director, St. Johns County Airport Authority
View Audit 365194
Finding 575011 (2024-001)
Significant Deficiency 2024
Housing Authority of the City of Anderson
SC
HUD Housing Programs Eligibility Significant Deficiency
Finding 2024-001 - Housing Choice Voucher Tenant Files - Eligibility- Rent Calculations Noncompliance & Significant Deficiency Section 8 Housing Choice Voucher Cluster - ALN 14.871 Corrective Plan: 1. Income Verification Vanette Greer (please state tenant in audit for privacy act) - Stated that she...
Finding 2024-001 - Housing Choice Voucher Tenant Files - Eligibility- Rent Calculations Noncompliance & Significant Deficiency Section 8 Housing Choice Voucher Cluster - ALN 14.871 Corrective Plan: 1. Income Verification Vanette Greer (please state tenant in audit for privacy act) - Stated that she did not have one of her weekly check stubs due to being out with Covid. The Specialist processed the following: She totaled three (3) check stubs, then divided by 4 with one being at zero. She then annualized. Upon further review, it was determined that the YTD included an additional pay week (which she stated that she was out with Covid). An interim will be completed with a Retroactive Agreement offered. 2. Income Verification Lola Garrett (please state tenant in audit for privacy act) -A student credit was given but failed to acquire the necessary source document. No retro necessary. 3. Late Reexaminations (4). Four reexaminations were processed late due to insufficient information provided. The Executive Director approved the late reexams to preserve and grow the lease-up rate (at 86%} prior to HUD's declaration of insufficient funds (May 2025} for the remaining calendar year of 2025. 4. Inspections - We did have one inspection overlooked at an elderly site since 2020. The other tenants within the complex did receive inspections including SEMAP. We are now utilizing the PIC report going forward (instead of in-house system) to prevent such an oversight again. Person Responsible: Jeff Trahan, Executive Director Anticipated Completion Date: July 14, 2025 Note: It is the Auditee's position that such an oversight constitutes a "deficiency" (oversight flaw) rather than a Significant Deficiency leading to a Material Weakness in Internal Control.
View Audit 365191
Leadership, Education, and Athletics in Partnership
CT
§ 200.512
Planned Corrective Action: 1. While LEAP was not solely responsible for delays in filing the Single Audit Report, it recognizes that it is ultimately the entity required to file timely and will do so. 2. At the beginning of the audit process, LEAP will establish an agreed timeline with its auditors ...
Planned Corrective Action: 1. While LEAP was not solely responsible for delays in filing the Single Audit Report, it recognizes that it is ultimately the entity required to file timely and will do so. 2. At the beginning of the audit process, LEAP will establish an agreed timeline with its auditors and LEAP will produce documentation consistent with that timeline. Planned Implementation Date of Corrective Action: September 1st, 2025. Person Responsible for Corrective Action: Shadine Alveranga, Managing Director of Finance
View Audit 365189
Finding 574979 (2024-005)
Significant Deficiency 2024
Leadership, Education, and Athletics in Partnership
CT
Internal Control / Segregation of Duties Reporting
Planned Corrective Action: 1. Quarterly financial and performance reports were consistently reviewed by multiple senior individuals in the finance, development and executive offices prior to submission; however, this was not fully documented. LEAP will fully document said reviews. 2. LEAP will add t...
Planned Corrective Action: 1. Quarterly financial and performance reports were consistently reviewed by multiple senior individuals in the finance, development and executive offices prior to submission; however, this was not fully documented. LEAP will fully document said reviews. 2. LEAP will add this requirement to its financial procedures' manual. Planned Implementation Date of Corrective Action: September 1st, 2025 . Person Responsible for Corrective Action: Shadine Alveranga, Managing Director of Finance Rachel Kline-Brown, Director of Development and Communications
View Audit 365189
Finding 574978 (2024-004)
Significant Deficiency 2024
Leadership, Education, and Athletics in Partnership
CT
Allowable Costs / Cost Principles
Planned Corrective Action: LEAP will hire a local CPA firm with expertise in nonprofit accounting inclusive of federal reporting requirements to support the updating of the finance manual to more fully include federal reporting requirements and applicable procedures. Planned Implementation Date of C...
Planned Corrective Action: LEAP will hire a local CPA firm with expertise in nonprofit accounting inclusive of federal reporting requirements to support the updating of the finance manual to more fully include federal reporting requirements and applicable procedures. Planned Implementation Date of Corrective Action: Implementation to begin September 1st, 2025, with completion by December 31 , 2025. Person Responsible for Corrective Action: Shadine Alveranga, Managing Director of Finance Henry Fernandez, Executive Director
View Audit 365189
Finding 574977 (2024-001)
Significant Deficiency 2024
Borough of Kennett Square
PA
Procurement, Suspension & Debarment
BOROUGH OF KENNETT SQUARE, PENNSYLVANIA CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2024 Finding 2024-001 Procurement and Suspension and Debarment AL #21.027 Coronavirus State and Local Fiscal Recovery Funds The Borough has updated its procurement procedures to ensure that a provider...
BOROUGH OF KENNETT SQUARE, PENNSYLVANIA CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2024 Finding 2024-001 Procurement and Suspension and Debarment AL #21.027 Coronavirus State and Local Fiscal Recovery Funds The Borough has updated its procurement procedures to ensure that a provider is neither suspended nor debarred prior to entering into a contract. The Borough will add appropriate language to mitigate the risk of entering a contract with a suspended or debarred entity. Responsible Official: Kyle Coleman, Borough Manager Contact Information: 610-444-6020 Anticipated Resolution Date: Immediately
View Audit 365185
Finding 574976 (2024-001)
Significant Deficiency 2024
The Houston Methodist Hospital System Dba Houston Methodist
TX
Questioned Costs Procurement, Suspension & Debarment § 200.303 § 200.318
Methodist recognizes the current gap between Supply Chain Services and the Research Institute related to retaining documents for procurement activities. Supply Chain Services will develop processes to retain written documentation for procurement activities in accordance with regulatory standards. ...
Methodist recognizes the current gap between Supply Chain Services and the Research Institute related to retaining documents for procurement activities. Supply Chain Services will develop processes to retain written documentation for procurement activities in accordance with regulatory standards. As Methodist is in transition to a new ERP system in Quarter 1, 2026, Supply Chain Services will include strategies to address the needs in both the short term and long term.
View Audit 365182 Questioned Costs: $1
Kankakee School District 111
IL
Reporting
The District will implement a process to track the submission tine of the data collection form and audit package.
The District will implement a process to track the submission tine of the data collection form and audit package.
View Audit 365176
Kankakee School District 111
IL
Reporting
The District will assign the appropriate personnel to complete the reconciliations on a timely basis.
The District will assign the appropriate personnel to complete the reconciliations on a timely basis.
View Audit 365176
Finding 574905 (2024-001)
Significant Deficiency 2024
Embrace Families Solutions, Inc.
FL
Reporting Significant Deficiency § 200.512
Corrective Action Plan Year Ended June 30, 2024 Identifying Number: 2024-001- Late Audit Reporting Finding: The audit, data collection form and reporting package for the Organization for the year ended June 30, 2024, should have been submitted to the Federal Audit Clearinghouse by March 31, 2025. Co...
Corrective Action Plan Year Ended June 30, 2024 Identifying Number: 2024-001- Late Audit Reporting Finding: The audit, data collection form and reporting package for the Organization for the year ended June 30, 2024, should have been submitted to the Federal Audit Clearinghouse by March 31, 2025. Corrective Actions Planned or Taken: The Organization will schedule and complete future external audits in a manner that will allow timely reporting. Responsible Official: Rebecca Leininger, Executive Director Anticipated Completion Date: March 31, 2026
View Audit 365168
Finding 574901 (2024-005)
Significant Deficiency 2024
Jackson County, Il
IL
Questioned Costs Reporting Allowable Costs / Cost Principles
The County agrees with this finding. The questioned costs are related to eligible payroll costs that were reported on the current year SEFA in error, rather than in the fiscal year in which they were incurred. The County recommends training for payroll and accounting staff related to proper recognit...
The County agrees with this finding. The questioned costs are related to eligible payroll costs that were reported on the current year SEFA in error, rather than in the fiscal year in which they were incurred. The County recommends training for payroll and accounting staff related to proper recognition of expenses on the SEFA and documentation standards of the COVID-19 Coronavirus State and Local Fiscal Recovery Funds program.
View Audit 365155 Questioned Costs: $1
Finding 574900 (2024-004)
Significant Deficiency 2024
Jackson County, Il
IL
Procurement, Suspension & Debarment
The Jackson County Board has and will continue to adhere to the state of Illinois procurement policy. Additionally, the Jackson County Board has created a procurement policy that addresses the federal compliance requirements as outlined in the Federal Uniform Guidance.
The Jackson County Board has and will continue to adhere to the state of Illinois procurement policy. Additionally, the Jackson County Board has created a procurement policy that addresses the federal compliance requirements as outlined in the Federal Uniform Guidance.
View Audit 365155
Finding 574896 (2024-007)
Material Weakness 2024
Kinston Community Health Center, Inc.
AL
Cash Management § 200.305
In Finding 2024-007, a condition was noted in which the Organization did not maintain proper documentation of qualifying expenditures prior to making drawdowns of federal funds. Management recognizes the importance of complying with federal cash management guidelines. In response to Finding 2024-00...
In Finding 2024-007, a condition was noted in which the Organization did not maintain proper documentation of qualifying expenditures prior to making drawdowns of federal funds. Management recognizes the importance of complying with federal cash management guidelines. In response to Finding 2024-007, procedures will be implemented to ensure that federal grant expenditures are documented prior to drawdowns of federal funds so that advance draws of federal funds do not occur.
View Audit 365147
Finding 574892 (2024-006)
Material Weakness 2024
Kinston Community Health Center, Inc.
AL
Reporting
In Finding 2024-006, it was reported that the Organization did not comply with federal award requirements to submit an annual Federal Data Collection Form to the Federal Audit Clearinghouse, including audited financial statements, no later than nine months after the fiscal year ended November 30, 20...
In Finding 2024-006, it was reported that the Organization did not comply with federal award requirements to submit an annual Federal Data Collection Form to the Federal Audit Clearinghouse, including audited financial statements, no later than nine months after the fiscal year ended November 30, 2023. Management recognizes the importance of complying with federal grant requirement guidelines. In response to Finding 2024-006, Management concurs. The Organization has made a change in service providers for the completion of future audits.
View Audit 365147
Finding 574888 (2024-005)
Material Weakness 2024
Kinston Community Health Center, Inc.
AL
Procurement, Suspension & Debarment
In Finding 2024-005, a condition was noted in which the Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. In response to Finding 2024-005, Management...
In Finding 2024-005, a condition was noted in which the Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. In response to Finding 2024-005, Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
View Audit 365147
Finding 574884 (2024-004)
Material Weakness 2024
Kinston Community Health Center, Inc.
AL
Allowable Costs / Cost Principles
In Finding 2024-004, it was reported that time and activity reports and/or I-9 forms were not maintained for certain employees. Although the Organization’s policies require that time records be maintained by employees, current operating procedures are not in place to ensure the time records are comp...
In Finding 2024-004, it was reported that time and activity reports and/or I-9 forms were not maintained for certain employees. Although the Organization’s policies require that time records be maintained by employees, current operating procedures are not in place to ensure the time records are completed. In response to Finding 2024-004, Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
View Audit 365147
Finding 574883 (2024-002)
Significant Deficiency 2024
Communities in Schools of Georgia, Inc.
GA
Internal Control / Segregation of Duties Cash Management Reporting § 200.303
Communities In Schools of Georgia acknowledges the audit recommendation and is committed to strengthening internal controls related to journal entries and supporting documentation.Under the leadership of our newly hired CFO, we are continuing to improve our finance processes by implementing the foll...
Communities In Schools of Georgia acknowledges the audit recommendation and is committed to strengthening internal controls related to journal entries and supporting documentation.Under the leadership of our newly hired CFO, we are continuing to improve our finance processes by implementing the following measures: Internal Controls for Journal Entries Segregation of Duties Workflow Approvals Training and Process Standardization During fiscal year 2025, we took the following actions to improve the integrity of our finance processes and controls over compliance with federal grant requirements: Engaged Senior Finance Contractor Completed Search for Permanent full-time CFO Initiated and Completed Search for an Accounting Manager
View Audit 365140
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