Corrective Action Plans

Finding 48242 (2022-002)

Significant Deficiency 2022

NJ

Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.320 § 200.326

Finding No. 2022-002 Compliance Requirement ? Procurement ? Significant Deficiency and Noncompliance Planned Corrective Action The University will ensure that all procurement decisions comply with the Stevens Procurement Policy and are properly documented, including the procurement method used (e.g....

Finding No. 2022-002 Compliance Requirement ? Procurement ? Significant Deficiency and Noncompliance Planned Corrective Action The University will ensure that all procurement decisions comply with the Stevens Procurement Policy and are properly documented, including the procurement method used (e.g., competitive bidding or sole source justification). The Director of Procurement will ensure that all Stevens employees responsible for making purchasing decisions at the University are familiar with the Procurement Policy and the need to ensure full compliance even when making purchasing decisions during emergency situations (e.g., COVID pandemic). The Director of Procurement will ensure compliance with the Stevens Procurement Policy. Timing of Completion This corrective action has been implemented in FY23. Responsible for Corrective Action Joseph Cassidy, Associate Vice President for Finance (201) 216-5287 and Brian Seabold, Director of Procurement (201) 216-8722.

View Audit 42638

Finding 48240 (2022-001)

Significant Deficiency 2022

Stevens Institute of Technology

NJ

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding No. 2022-001 Compliance Requirement ? Reporting ? Significant Deficiency and Noncompliance Planned Corrective Action The University will ensure that each report submission that is required to support spending under each of the Higher Education Emergency Relief Funds and other related fundi...

Finding No. 2022-001 Compliance Requirement ? Reporting ? Significant Deficiency and Noncompliance Planned Corrective Action The University will ensure that each report submission that is required to support spending under each of the Higher Education Emergency Relief Funds and other related funding programs has formal supporting documentation to evidence appropriate review of the report. This issue of how eligible students were determined and how the amounts distributed were determined was identified on the Q4 2021 Report due to the timing of the test work in the prior year Single Audit. This issue was corrected in the Q1 2022 Report and all available funding has been spent. The Assistant Vice President for Financial Aid has ensured that the total number of students eligible to receive a grant and the total number of students who receive grants is properly reviewed and documented. The Manager of Financial Planning, Budgeting and Analysis will ensure that all submitted Institutional Aid Reports are properly reconciled to actual expenditures rather than anticipated expenditures. The Q4 2021 Report was revised and reposted to reflect that expenditures were related to other costs rather than lost revenue. Each Student Aid Report and Institutional Aid Report will be reviewed and approved by the Associate Vice President for Finance. This review and approval will be documented in the file. The submitted Reports will also be provided to the CFO, Vice President for Finance and Treasurer. Timing of Completion This corrective action was implemented in FY22 and FY23.

View Audit 42638

Finding 48236 (2022-001)

Material Weakness 2022

Kaleidoscope Charter School

MN

Procurement, Suspension & Debarment

2022-001 Material Weakness in Internal in Internal Control and Material Noncompliance - Procurement Recommendation: We recommend the School review its procedures to ensure it retains documentation sufficient to detail the history of all procurements in accordance with the Uniform Guidance. We also ...

2022-001 Material Weakness in Internal in Internal Control and Material Noncompliance - Procurement Recommendation: We recommend the School review its procedures to ensure it retains documentation sufficient to detail the history of all procurements in accordance with the Uniform Guidance. We also recommend the School review its procedures over procurement controls to ensure all controls are also sufficiently documented with records that include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The School will review the procurement procedure policy including procurement controls to ensure sufficient documentation is retained in accordance with the Uniform Guidance. Names of the contact persons responsible for corrective action: Wendi Foss, Director of Business Operations, is the official responsible for ensuring the corrective action plan. Planned Completion date for corrective action plan: 6/30/2023

View Audit 42690

Finding 48234 (2022-002)

Significant Deficiency 2022

Monument Health, Inc.

SD

Allowable Costs / Cost Principles Cash Management Significant Deficiency § 200.303

Finding: 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 HRSA Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund Federal Financial Assistance Listing #: #93.461 Finding Summary: Audit testing identified one instance ...

Finding: 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 HRSA Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund Federal Financial Assistance Listing #: #93.461 Finding Summary: Audit testing identified one instance in which health services provided to a patient were reimbursed under the federal program, and the health services provided did not meet the terms and conditions of the federal program. Through the coding process, an incorrect diagnosis code was included in the system, and therefore, the patient?s health services flowed into Monument Health?s Uninsured Program workflow which resulted in $3,563 of health services being reimbursed under the federal program. As part of the audit, a sample of 60 patients were selected for testing, accounting for $1,659,497 of $4,344,728 of monies received from the federal agency. Responsible Individuals: Austin Willuweit, Vice President of Finance Jen Schmaltz, Corporate Controller Corrective Action Plan: Monument Health will develop a review process to identify claims that could have a diagnosis coding issue. A return of any excess reimbursement will be completed. Anticipated Completion Date: June 30, 2023

View Audit 40813

Finding 48233 (2022-001)

Material Weakness 2022

Monument Health, Inc.

SD

Reporting Cash Management Material Weakness

Finding: 2022-001 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution, COVID-19 HRSA Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund Federal Financial Assis...

Finding: 2022-001 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution, COVID-19 HRSA Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund Federal Financial Assistance Listing #: #93.498, 93.461 Finding Summary: Management prepared the schedule of expenditures of federal awards for the year ended June 30, 2022. During testing, the auditors decreased the amount reported for the COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution program (PRF) to the amounts reported within the Department of Health and Human Services (HHS) for Period 2 and Period 3 Special Report. In addition, adjustments were made to decrease the amount reported for the COVID-19 HRSA Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (Uninsured Program) to total receipt of monies received from the federal agency during the year ended June 30, 2022. Finding 2022-001 relates solely to which period expenditures are included in the schedule of expenditures of federal awards as compared to periods deposited from the Uninsured Program and to periods in which they are included in Period 2 and Period 3 reports. Responsible Individuals: Austin Willuweit, Vice President of Finance Jen Schmaltz, Corporate Controller Corrective Action Plan: Monument Health will review future schedules of expenditures of federal awards to ensure period reporting consistent with agency filings and deposit periods. Anticipated Completion Date: June 30, 2023

View Audit 40813

Finding 48232 (2022-002)

Significant Deficiency 2022

Rosalind & Joseph Gurwin Jewish Geriatric Ctr of Long Island Dba Gurwi

NY

Reporting Internal Control / Segregation of Duties

Finding 2022-002 a. Comments on the Finding and Each Recommendation. Management agrees with the finding. Management also agrees with the recommendation, please see below for action taken. b. Action Taken on the Finding. ...

Finding 2022-002 a. Comments on the Finding and Each Recommendation. Management agrees with the finding. Management also agrees with the recommendation, please see below for action taken. b. Action Taken on the Finding. The infection control expenses were correctly reported in the Period 3 Provider Relief Fund Reporting Period. In the Period 4 Provider Relief Fund Reporting Period, the facility inadvertently failed to report infection control expenses utilized in their correct years. Management will review their internal control procedures to enhance the review process of portal submissions. There is not a mechanism to amend the portal submission and if given the opportunity management will correct it in a subsequent reporting period. Management has utilized lost revenues and infection control expenses in excess of the funding received in 2020 and 2021 and has maintained documentation of all eligible expenses and lost revenue calculations to support this assertion.

View Audit 46943

Finding 48231 (2022-001)

Significant Deficiency 2022

Rosalind & Joseph Gurwin Jewish Geriatric Ctr of Long Island Dba Gurwi

NY

Reporting Internal Control / Segregation of Duties

Finding 2022-001 a. Comments on the Finding and Each Recommendation. Management agrees with the finding. Management also agrees with the recommendation, please see below for action taken. b. Action Taken on the Finding. ...

Finding 2022-001 a. Comments on the Finding and Each Recommendation. Management agrees with the finding. Management also agrees with the recommendation, please see below for action taken. b. Action Taken on the Finding. Due to a prior finding, 2021-001, internal control procedures were updated and the FEMA assistance received was correctly reported in the Period 3 Provider Relief Fund Reporting Period. Even though the facility updated their internal control procedures they inadvertently failed to report the total amount of FEMA assistance received when reporting in the Period 4 Provider Relief Fund Reporting Period. It is noted that there is not a mechanism to amend the portal submission. Management will review their internal control procedures to enhance the review process of portal submissions. The facility did not inappropriately utilize funds and should not be at risk of having any funds returned to the Department of Health and Human Services. Management has maintained documentation of all eligible expenses and lost revenue calculations to support this assertion.

View Audit 46943

Finding 48222 (2022-004)

Significant Deficiency 2022

Catholic Charities, Inc.

MS

Internal Control / Segregation of Duties Reporting

Management has engaged an external consultant to perform bookkeeping and financial reporting services. In addition, management will schedule its external audit within a timeframe that ensures its completion before the Single Audit reporting deadline.

View Audit 46940

Finding 48221 (2022-003)

Significant Deficiency 2022

Catholic Charities, Inc.

MS

Matching / Level of Effort / Earmarking Subrecipient Monitoring Reporting

Management has engaged an external consultant to perform bookkeeping and financial reporting services.

View Audit 46940

Finding 48220 (2022-002)

Significant Deficiency 2022

Catholic Charities, Inc.

MS

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Management has engaged an external consultant to perform bookkeeping and financial reporting services.

View Audit 46940

Finding 48219 (2022-001)

Significant Deficiency 2022

Catholic Charities, Inc.

MS

Reporting Matching / Level of Effort / Earmarking Subrecipient Monitoring

Management has engaged an external consultant to perform bookkeeping and financial reporting services.

View Audit 46940

Finding 48214 (2022-002)

Significant Deficiency 2022

Raleigh County Community Action Association, Inc.

WV

Reporting Matching / Level of Effort / Earmarking § 200.303

2022-002 REPORTING Recommendation: We recommend that RCCAA revisit controls over the report submission process. At a minimum, such controls should include a documented review and approval process that ensures reported amounts agree with supporting documentation. We recommend that the review be perf...

2022-002 REPORTING Recommendation: We recommend that RCCAA revisit controls over the report submission process. At a minimum, such controls should include a documented review and approval process that ensures reported amounts agree with supporting documentation. We recommend that the review be performed by an individual independent of the data entry process. Additionally, management should maintain supporting documentation for the amounts reported in the reports. Action taken: The report submission process has been reviewed and additional controls have been implemented to ensure that, going forward, supporting documentation agrees with the amounts being reported. This documentation will be filed with the report. The report will be reviewed by a staff member who is not a part of the data entry process.

View Audit 46935

Finding 48213 (2022-005)

Material Weakness 2022

Winner Regional Healthcare Center

SD

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Finding 2022-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution FFAL #93.498 Finding Summary: The review process for the Period 4 HHS report submitted did not detect the error reported regard...

Finding 2022-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution FFAL #93.498 Finding Summary: The review process for the Period 4 HHS report submitted did not detect the error reported regarding the actual reported revenues for 2019 that were incorrectly keyed into the portal submission. Additionally, the revenues for 2022 were reported based upon actual revenue billed and reported within the electronic medical records (EMR) system which does not include monthly or quarterly adjustments posted to the general ledger. Responsible Individuals: Amanda Soesbe, Chief Finance Officer Corrective Action Plan: There are no further PRF Portal submissions. The control aspect implemented to involve review of the portal submission will be expanded if further submissions are warranted. An expanded control would require the CFO to review in detail with the reviewer how the numbers were obtained and provide all supporting documentation for cross reference against the requirements. This may require extra time to educate and inform the reviewer of the PRF program and requirements. Anticipated Completion Date: 12-31-2023

View Audit 46933

Finding 48210 (2022-007)

Significant Deficiency 2022

Winner Regional Healthcare Center

SD

Student Financial Aid Reporting Significant Deficiency § 200.303

Finding 2022-007 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: The fiscal year 2021 audit report was requited to be submitted to the federal agency by September 30th, 2022. We did not provide the 2021 audit report wi...

Finding 2022-007 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: The fiscal year 2021 audit report was requited to be submitted to the federal agency by September 30th, 2022. We did not provide the 2021 audit report within the timeframe requested by the federal agency representative. Responsible Individuals: Amanda Soesbe, Chief Finance Officer Corrective Action Plan: The CFO will send the audited financial statements to USDA by the deadline. Anticipated Completion Date: 9-30-2023

View Audit 46933

Finding 48209 (2022-006)

Material Weakness 2022

Winner Regional Healthcare Center

SD

Special Tests & Provisions Subrecipient Monitoring Material Weakness

Finding 2022-006 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: We elected to make a withdrawal and subsequent replenishment on the reserve account. There was no documented secondary review of the monthly reserve fund...

Finding 2022-006 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: We elected to make a withdrawal and subsequent replenishment on the reserve account. There was no documented secondary review of the monthly reserve fund account reconciliations as compared to the required minimum balance. Responsible Individuals: Amanda Soesbe, Chief Finance Officer Corrective Action Plan: An automatic transfer to fund the debt reserve account was established in January 2023 and repeats each month until the fund has been properly funded. Additionally the finance packets presented to the governing board will include monthly oversight of debt reserve balances and whether or not the facility is in compliance. Anticipated Completion Date: 9-30-2023

View Audit 46933

Finding 48206 (2022-001)

None 2022

St. Martin De Porres, Inc. (wellington Place Apartments)

TX

Questioned Costs Cash Management HUD Housing Programs

Finding Reference Number: 2022-001 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. The property has requested reimbursement from Villa Santa Maria. Completion Date: March 13, 2023

View Audit 41998 Questioned Costs: $1

Finding 48205 (2022-001)

Material Weakness 2022

Clearfield Jefferson Drug and Alcohol Commission

PA

Reporting

Clearfield-Jefferson Drug and Alcohol Commission Corrective Action Plan Contact Person: Christopher Grunthaner, Executi...

Clearfield-Jefferson Drug and Alcohol Commission Corrective Action Plan Contact Person: Christopher Grunthaner, Executive Director Finding No. 2022-001 The Organization concurs with the auditor's recommendation. We will ensure SF-SAC and the Single Audit reporting package(s) are filed within thirty (30) days of the report date or nine (9) months of June 30, in accordance with the Single Audit Act Amendments of 1996, and the Uniform Guidance. The Organization was unable to meet the SF-SAC and the Single Audit reporting submission deadlines due to employee turnover in the Fiscal Department. Clearfield-Jefferson Drug and Alcohol Commission has corrected any department issues and will institute control over the reporting and submission of the Data Collection Form and reporting packages when applicable to ensure the Organization is in compliance with all guidelines set forth by the Single Audit Act Amendments of 1996 and the Uniform Guidance. The Executive Director will be the responsible official to ensure that timely submissions are made in the future where applicable.

View Audit 41948

Finding 48203 (2022-005)

Significant Deficiency 2022

Catholic Charities West Michigan

MI

Special Tests & Provisions Eligibility Significant Deficiency

The Program Coordinator will complete the Volunteer File Master Checklist for each new volunteer including the income verification and background checks as well as other required steps. The Program Coordinator will sign and date the form. The Program Supervisor will review the checklist for comple...

The Program Coordinator will complete the Volunteer File Master Checklist for each new volunteer including the income verification and background checks as well as other required steps. The Program Coordinator will sign and date the form. The Program Supervisor will review the checklist for completeness and sign and date the form. The completed form will be filed in the volunteer?s file. This practice is being implemented currently.

View Audit 41510

Finding 48199 (2022-003)

Significant Deficiency 2022

Catholic Charities West Michigan

MI

Reporting Significant Deficiency

Catholic Charities West Michigan agrees that a separate review of both semi-annual reports and the quarterly Payment Management Services reports for Foster Grandparents/Senior Companion Cluster needs to occur and we have made those changes June 2022 as noted in the recommendations for this item.

View Audit 41510

Finding 48198 (2022-002)

Significant Deficiency 2022

Catholic Charities West Michigan

MI

Subrecipient Monitoring Cash Management Reporting

An Administrative Financial Management Policy is being written to address proper identification, grant relationship, and allowable costs of federal grants. This policy should be in place by June 2023. Catholic Charities West Michigan adopted a cash management policy in February 2023 supporting pro...

An Administrative Financial Management Policy is being written to address proper identification, grant relationship, and allowable costs of federal grants. This policy should be in place by June 2023. Catholic Charities West Michigan adopted a cash management policy in February 2023 supporting procedures to follow to assure timely draw and expenditures of federal dollars.

View Audit 41510

Finding 48197 (2022-004)

None 2022

Catholic Charities West Michigan

MI

Reporting

Timely reporting is very important to Catholic Charities West Michigan and we agree that we must file reports due by their deadline. Every effort is made to assure deadlines for the Foster Grandparent/Senior Companion Cluster and all of our other deadlines are met. We have implemented a process in...

Timely reporting is very important to Catholic Charities West Michigan and we agree that we must file reports due by their deadline. Every effort is made to assure deadlines for the Foster Grandparent/Senior Companion Cluster and all of our other deadlines are met. We have implemented a process including monthly meetings with the program supervisor and the Finance Accountant to review activity and close the month. All reporting is now filed timely based on a due date schedule provided by the funding entity.

View Audit 41510

Finding 48191 (2022-001)

Material Weakness 2022

Prairie Ridge Integrated Behavioral Healthcare

IA

Internal Control / Segregation of Duties

We are aware of the condition and will review procedures to make changes when appropriate and cost effective.

View Audit 53323

Finding 48190 (2022-002)

Significant Deficiency 2022

Watertown School District No. 14-4

SD

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Finding 2022-002 Federal Agency Name: Department of Education Program Name: Student Financial Aid Cluster CFDA # 84.268 - Federal Direct Student Loans Special Tests and Provisions ? Return of Title IV Funds Finding Summary: 1 of 30 students tested for return of Title IV had a withdrawal determina...

Finding 2022-002 Federal Agency Name: Department of Education Program Name: Student Financial Aid Cluster CFDA # 84.268 - Federal Direct Student Loans Special Tests and Provisions ? Return of Title IV Funds Finding Summary: 1 of 30 students tested for return of Title IV had a withdrawal determination date outside of the 30-day requirement. For a student who withdraws without providing notification from a school that is not required to take attendance, the school much determine the withdrawal date no later than 30 days after the end of the earlier of 1) the payment period or the period of enrollment, 2) the academic year, or 3) the student?s educational program. Responsible Individuals: Eric Schultz, Director of Enrollment and Marlene Seeklander, Director of Financial Aid Corrective Action Plan: The Registrar?s Office will take the following action: For all programs that have SOE/Internship/Clinical experiences, a roster will be generated, and the instructors will be required to verify that the student has been placed and is actively participating in the SOE/Internship/Clinical. Moving forward, this will be a reminder that is emphasized on a regular basis. At the instructor in-service sessions in August, the Director or Enrollment and Director of Financial Aid present a session which is a series of reminders and other important information that instructors need to know. While we already address the need to notify the Registration Office that a student is no longer attending, we plan to expand on that topic. We will include a slide with the audit finding as outlined so they can see the audit ramifications it has on LATC. We will also explain that this is an institutional responsibility, which includes all staff, all program instructors and all adjuncts. Anticipated Completion Date: Ongoing

View Audit 53320

Finding 48187 (2022-003)

Material Weakness 2022

Prairie Valley Community School District

IA

Internal Control / Segregation of Duties

COMMENT COMMENT CORRECTIVE ACTION PLAN CONTACT PERSON, TITLE, ANTICIPATED DATE REFERENCE TITLE PHONE NUMBER OF COMPLETION 2022-001 SEGREGATION S...

COMMENT COMMENT CORRECTIVE ACTION PLAN CONTACT PERSON, TITLE, ANTICIPATED DATE REFERENCE TITLE PHONE NUMBER OF COMPLETION 2022-001 SEGREGATION SEE RESPONSE AND CORRECTIVE LISA WILLARDSON N/A OF DUTIES ACTION PLAN AT 2022-001. BUSINESS MANAGER 515-352-5571 2022-002 PREPARATION OF SEE RESPONSE AND CORRECTIVE LISA WILLARDSON N/A FINANCIAL ACTION PLAN AT 2022-002. BUSINESS MANAGER STATEMENTS 515-352-5571

View Audit 52118

Finding 48184 (2022-002)

Material Weakness 2022

Black River Local School District

OH

Procurement, Suspension & Debarment § 200.318 § 200.319 § 200.320 § 200.324 § 200.327

Finding Number: 2022-002 Planned Corrective Action: See Below Anticipated Completion Date: 01/05/2023 Responsible Contact Person: Brian Haines, Treasurer 1. The Treasurer will educate all responsible parties (Director of Curriculum, Assistant Superintendent, Accounts Payable, Superintendent) in ...

Finding Number: 2022-002 Planned Corrective Action: See Below Anticipated Completion Date: 01/05/2023 Responsible Contact Person: Brian Haines, Treasurer 1. The Treasurer will educate all responsible parties (Director of Curriculum, Assistant Superintendent, Accounts Payable, Superintendent) in the District regarding to Federal Procurement requirements. 2. The Treasurer will ensure that all requests follow the Districts Purchasing Procedures, as well as the Federal Procurement Requirements.

View Audit 51847

Corrective Action Plans

Filters