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Corrective Action Plans

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Finding 4420 (2022-002)
Material Weakness 2022
Community Counseling Solutions
OR
Reporting Internal Control / Segregation of Duties
Corrective Action Taken: The entity understands the importance of timely maintenance of the general ledger and has taken steps to document procedures, cross train the accounting team, and hire additional employees to assist with processing transactions.
Corrective Action Taken: The entity understands the importance of timely maintenance of the general ledger and has taken steps to document procedures, cross train the accounting team, and hire additional employees to assist with processing transactions.
View Audit 6868
Finding 4413 (2022-001)
Material Weakness 2022
Community Counseling Solutions
OR
Reporting Internal Control / Segregation of Duties
Corrective Action Taken: The entity understands the importance of timely maintenance of the general ledger and has taken steps to document procedures, cross train the accounting team, and hire additional employees to assist with processing transactions.
Corrective Action Taken: The entity understands the importance of timely maintenance of the general ledger and has taken steps to document procedures, cross train the accounting team, and hire additional employees to assist with processing transactions.
View Audit 6868
Finding 4407 (2022-002)
Material Weakness 2022
Central Decatur Community School District
IA
Internal Control / Segregation of Duties
The District reviews this audit finding internally on an annual basis, identifying control procedures and processes that would leverage movement toward the maximum internal control possible with available staffing although this is difficult with a limited number of employees
The District reviews this audit finding internally on an annual basis, identifying control procedures and processes that would leverage movement toward the maximum internal control possible with available staffing although this is difficult with a limited number of employees
View Audit 6862
Finding 4398 (2022-001)
Significant Deficiency 2022
Jeff Davis County Board of Education
GA
Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.403
FA 2022-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Federal Communications Commission Ass...
FA 2022-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Federal Communications Commission Assistance Listing Number and Title: COVID-19-32.009-Emergency Connectivity Fund Federal Award Number: ECF202105452 (Year: 2022) Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund Federal Award Number: S425D210012 (Year: 2021) Questioner Costs: $63,399 Description: A review of expenditures charged to the Emergency Connectivity Fund and Elementary and Secondary School Emergency Relief Fund programs revealed that the School District's internal control procedures were not operating appropriately to ensure that expenditures were allowable. Corrective Action Plans: The district will contact each Federal Program to determine the appropriate action to take to ensure the funds are appropriately allocated. Moving forward, Finance will review all reimbursements as well as work with other Departments to ensure that expenses are being allocated to the correct program. Estimated Completion Date: June 30, 2023 Contact Person: Betty Corbitt, Finance Director Telephone: 912-699-6009 Email: betty.corbitt@jeff-davis.k12.ga.us
View Audit 6845 Questioned Costs: $1
Finding 4385 (2022-002)
Material Weakness 2022
Schc Companies, Inc. and Affiliates
NY
Internal Control / Segregation of Duties Eligibility Reporting
2022-002 Reporting Recommendation: Our auditors recommend that we review and strengthen current procedures regarding review of reporting by an appropriate level of management prior to submission. As well as that we work with HRSA to take corrective action to rectify this reporting matter. Action Tak...
2022-002 Reporting Recommendation: Our auditors recommend that we review and strengthen current procedures regarding review of reporting by an appropriate level of management prior to submission. As well as that we work with HRSA to take corrective action to rectify this reporting matter. Action Taken: The accounting department had a significant turnover during 2022 which cause reporting errors go unreviewed. Since 2023, the appropriate accounting team has been assembled and proper policies, procedures, authorization, segregation of duties and reviews have been put in place so that going forward this will not be an issue. All reporting is now being reviewed prior to submission so that reporting requirements including proper period and proper information is reported correctly. We have proactively reached out to the PRF Reporting Help Desk to correct the reporting and communicated the noted reporting corrections needed. Name(s) of Contact Person(s) Responsible for Corrective Action: John Milligan, CFO, (315) 430-1708. Anticipated Completion Date: October 2023
View Audit 6819
Finding 4382 (2022-001)
Material Weakness 2022
Schc Companies, Inc. and Affiliates
NY
Internal Control / Segregation of Duties Subrecipient Monitoring HUD Housing Programs
2022-001 Sliding Fee Discounts Recommendation: Our auditors recommend we review and strengthen the current procedures in place for determining a patient’s financial responsibility for their visit using the sliding fee scale. This should include requiring a knowledgeable representative of the Organiz...
2022-001 Sliding Fee Discounts Recommendation: Our auditors recommend we review and strengthen the current procedures in place for determining a patient’s financial responsibility for their visit using the sliding fee scale. This should include requiring a knowledgeable representative of the Organizations’ signature approval on the documentation received and the fee calculated and provided to the applicant. All applications should contain support for the individual’s income level or documentation of no income, and the determination of the resulting fee. Action Taken: This finding was repeated in 2022. Since this was a repeat finding, an internal audit was performed on all 2023 approved sliding fee applications to ensure compliance with our policy. Any corrective actions to the 2023 application were address and the facility’s sliding fee scale was modified to reflect proper authorization and proper segregation of duties going forward. Going forward, all sliding fee scale applications are now reviewed and authorized by the Manager of Revenue Cycle. Future auditing procedures have been put in place to review applications and adjusted, if needed, in a timely manner between now and the end of the year. Name(s) of Contact Person(s) Responsible for Corrective Action: John Milligan, CFO, (315) 430-1708. Anticipated Completion Date: October 2023
View Audit 6819
Cabarrus College of Health Sciences
NC
Reporting § 200.328 § 200.329
The College has implemented procedures in which the Manager, Business Operations will work with the Director of Financial Aid to ensure that all HEERF quarterly reports depict accurate data. The Dean, Student Affairs and Enrollment will verify the accuracy of these reports prior to submission.
The College has implemented procedures in which the Manager, Business Operations will work with the Director of Financial Aid to ensure that all HEERF quarterly reports depict accurate data. The Dean, Student Affairs and Enrollment will verify the accuracy of these reports prior to submission.
View Audit 6679
Finding 4262 (2022-004)
Significant Deficiency 2022
Asian and Pacific Islander Wellness Center, Inc. D/b/a San Francisco Community Health Center
CA
Cash Management Matching / Level of Effort / Earmarking
2022-003 Compliance Over Reporting Name of Contact Person: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with this finding which is directly related to the transitions in financial leadership and the need for a more robust finance team. The Center’s full-time pe...
2022-003 Compliance Over Reporting Name of Contact Person: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with this finding which is directly related to the transitions in financial leadership and the need for a more robust finance team. The Center’s full-time permanent CFO was hired in January 2022 who then immediately increased the team by two new members (1.0 FTE Controller hired in July 2022 and 1.0 FTE Staff Accountant hired in January 2023) and overhauled the Center’s financial policies and procedures manual. With the five-member finance team currently in place, we are on track to complete our FY2022-23 audit process by December 31, 2023. It is also relevant to note that San Francisco community health clinics migrated en masse to OCHIN Epic in 2022 with the overarching goal of our safety net hospitals and all community clinics being on the same EHR system to strengthen patient health outcomes for our city. The Center’s go-live date for this was June 2022 and required extensive time from all executive management, with our newly hired CFO being a key leader in this migration. This one-time, significant event had a direct impact on our ability to complete our audit in a timely manner. Proposed Completion Date: June 30, 2023
View Audit 6569
Finding 4261 (2022-003)
Significant Deficiency 2022
Asian and Pacific Islander Wellness Center, Inc. D/b/a San Francisco Community Health Center
CA
Cash Management Reporting
2022-002 Sliding Fee Discount Determination Name of Contact Persons: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with the recommendation and is taking steps to correct the errors of ensuring all sliding fee patient applications are maintained within the patient f...
2022-002 Sliding Fee Discount Determination Name of Contact Persons: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with the recommendation and is taking steps to correct the errors of ensuring all sliding fee patient applications are maintained within the patient files; and, ensuring all patients who apply for the sliding fee scale program receive the correct discount based upon income and family size. During the Center’s HRSA three-day operational site visit in July 2022, the Center made revisions to its Sliding Fee Application form to make space for our eligibility team members to clearly present their mathematical calculations to determine our patients’ annual incomes. This revision contributed to our 100% score that we received after the HRSA operational site visit. In order to further ensure we are in full compliance, the Center has contracted with an external consultant who is aware of HRSA standards and requirements and will thoroughly review current processes, procedures, and systems, and then will provide recommendations to the Center to implement and adopt. The Center will seek additional training and technical assistance to provide specific sliding fee scale training for all employees involved in our Sliding Fee program. Additionally, the Center will continue to implement quarterly audits of all sliding fee scale patients to ensure all sliding fee scale applications are complete and patients receive the correct discount. Proposed Completion Date: October 31, 2023
View Audit 6569
Finding 4260 (2022-002)
Significant Deficiency 2022
Asian and Pacific Islander Wellness Center, Inc. D/b/a San Francisco Community Health Center
CA
Special Tests & Provisions Eligibility
2022-001 Internal Control Over Financial Close Process Name of Contact Person: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with this finding and recommendations. The Center went through a change in CFO leadership throughout this fiscal year and our full-time p...
2022-001 Internal Control Over Financial Close Process Name of Contact Person: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with this finding and recommendations. The Center went through a change in CFO leadership throughout this fiscal year and our full-time permanent CFO started in January 2022, who then immediately expanded the Center’s finance department and implemented corrective procedures and greatly improved accounting processes and accounting operations, including all balance sheet accounts being reviewed and reconciled in a timely manner. In order to ensure we are fully compliant, two new positions were created and filled – a 1.0 FTE Controller hired in July 2022 and a 1.0 FTE Staff Accountant hired in January 2023. Additionally, our CFO overhauled our financial policies and procedures manual which was approved by the Center’s Board of Directors in July 2022. These policies and procedures were also reviewed by our HRSA consultants during our three-day operational site visit which took place in July 2022. Specific process improvements were made and included more specific segregation of duties, enhanced communication across all departments to address program items around budgetary and resource planning, transactional accuracy, and transparency. Moreover, the five-member finance department is working collaboratively with program management to advise and support the finance department on continued process improvements and maintaining open communication with program staff for effective feedback on program monitoring systems essential to strengthening internal control over financial close and reporting process. Proposed Completion Date: June 30, 2023
View Audit 6569
The Durham Trinity Corporation
CT
Federal Audit Clearinghouse 1201 East 10th Street Jefferson, Indiana 47132 The Durham Trinity Corporation d/b/a Mauro Meadow (the Project) respectfully submits the following Corrective Action Plan for the year ended December 31, 2022. Hoyt, Filippetti & Malaghan, LLC 1041 Poquonnock Road Groton, C...
Federal Audit Clearinghouse 1201 East 10th Street Jefferson, Indiana 47132 The Durham Trinity Corporation d/b/a Mauro Meadow (the Project) respectfully submits the following Corrective Action Plan for the year ended December 31, 2022. Hoyt, Filippetti & Malaghan, LLC 1041 Poquonnock Road Groton, Connecticut 06340 Audit Period: Year ended December 31, 2022 The finding from the December 31, 2022 Schedule of Federal Findings and Questioned Costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. 2022-001 RESERVE ACCOUNT FUNDING Criteria: The Project’s reserve account must be fully funded in accordance with the budget as approved by USDA-RD and maintained in a separate bank account. Condition: During our audit testing, we noted that while the Project maintained a separate bank account for reserve funds, it was not funded in accordance with the budget. Cause: Budgeted transfers were not made before yearend to ensure the account is fully funded. Effect: Reserve bank account is underfunded. Questioned Costs: None noted. Recommendation: The Project should implement controls to ensure that the reserve bank account is fully funded. Management’s Views and Corrective Action Plan: Management will correct this when sufficient funds are able to be transferred into the reserve account. If you have any questions regarding this plan, please contact Matthew Scibek at 860-398-5425, or matt@westfordmgt.com.
View Audit 6512
Finding 4162 (2022-004)
Significant Deficiency 2022
Township of Bloomfield
NJ
Reporting Internal Control / Segregation of Duties
Description: The Township’s IDISC04PR29 Cash on Hand quarterly reports did not agree to the reconciled cash balance in the Community Development Trust bank account. Analysis: Policies and procedures be implemented to ensure the CDBG IDISC04PR29 cash on hand quarterly reports are prepared correctly ...
Description: The Township’s IDISC04PR29 Cash on Hand quarterly reports did not agree to the reconciled cash balance in the Community Development Trust bank account. Analysis: Policies and procedures be implemented to ensure the CDBG IDISC04PR29 cash on hand quarterly reports are prepared correctly and in agreement with the reconciled cash balances on hand. Corrective Action: Policies and procedures will be implemented to ensure the CDBG IDISC04PR29 cash on hand quarterly reports are prepared correctly and in agreement with the reconciled cash balances on hand. Implementation Date: Ongoing
View Audit 6483
Finding 4161 (2022-003)
Significant Deficiency 2022
Township of Bloomfield
NJ
Reporting Internal Control / Segregation of Duties
Description: The Township did not file the Community Development Block Grant program Annual Performance and Evaluation Report within 90 days after the end of the program year. Analysis: The Township implement policies and procedures to ensure all required reporting under the Community Development ...
Description: The Township did not file the Community Development Block Grant program Annual Performance and Evaluation Report within 90 days after the end of the program year. Analysis: The Township implement policies and procedures to ensure all required reporting under the Community Development Block Grant program is completed. Corrective Action: Township is working towards implementing reporting process to meet the 90 day filing deadline for CDGB Annual Performance and Evaluation Report. Implementation Date: Ongoing
View Audit 6483
Finding 4160 (2022-002)
Significant Deficiency 2022
Township of Bloomfield
NJ
Allowable Costs / Cost Principles Cash Management Equipment & Real Property Management
Description: Administrative charges to Community Development Block Grant program, are in some instances, not supported by detailed documentation nor are they charged to the correct program year in budgetary records Analysis: All administrative salary and wage and other administrative expenses be ch...
Description: Administrative charges to Community Development Block Grant program, are in some instances, not supported by detailed documentation nor are they charged to the correct program year in budgetary records Analysis: All administrative salary and wage and other administrative expenses be charged to the proper program year and be supported by detail documentation Corrective Action: Finance and Planning departments will coordinate to ensure administrative costs are charged to proper program year, and proper supporting documentation is maintained. Implementation Date: Ongoing
View Audit 6483
Finding 4159 (2022-001)
Significant Deficiency 2022
Township of Bloomfield
NJ
Cash Management
Description: The Township has excess cash proceeds in its Community Development Block Grant Program as a result of drawing down funds in excess of expenditures incurred. Analysis: The Township’s drawdown policies be enhanced; that only actual supported expenditures be drawn down against Community ...
Description: The Township has excess cash proceeds in its Community Development Block Grant Program as a result of drawing down funds in excess of expenditures incurred. Analysis: The Township’s drawdown policies be enhanced; that only actual supported expenditures be drawn down against Community Development Block Grant award allocations in IDIS. Corrective Action: IDIS drawdowns will be made based on the actual expenditures on the Township’s semi-monthly Bill list. Implementation Date: Ongoing
View Audit 6483
International Service Center
PA
Cash Management
The Program Manager, alongside the Executive Director, will work on updating the ISC's Government Contracts Management Procedures. It will include detailed written procedures that encompass key areas of federal grants. We will develop a reimbursement policy consistent with federal guidelines for our...
The Program Manager, alongside the Executive Director, will work on updating the ISC's Government Contracts Management Procedures. It will include detailed written procedures that encompass key areas of federal grants. We will develop a reimbursement policy consistent with federal guidelines for our staff and volunteers. We aim to finalize this by 12/31/23. Starting the new year, we will also train all staff and volunteers involved with federal grants to ensure compliance.
View Audit 6460
Finding 4154 (2022-003)
Material Weakness 2022
International Service Center
PA
Questioned Costs Cash Management
We are exploring software alternatives to QuickBooks to improve our record-keeping for research expenditures. We target to complete this analysis by 12/31/23 and will share the results with you thereafter. We are exploring software alternatives to QuickBooks to improve our record-keeping for resear...
We are exploring software alternatives to QuickBooks to improve our record-keeping for research expenditures. We target to complete this analysis by 12/31/23 and will share the results with you thereafter. We are exploring software alternatives to QuickBooks to improve our record-keeping for research expenditures. We target to complete this analysis by 12/31/23 and will share the results with you thereafter. The Program Manager will train the Administrative Assistant and Fiscal Assistant on proper accounting procedures adhering to accounting standards.
View Audit 6460 Questioned Costs: $1
Finding 4153 (2022-002)
Material Weakness 2022
International Service Center
PA
Questioned Costs
The following measures will be implemented: 1. Enhanced Documentation Process: Starting immediately, every grant expenditure will be accompanied by detailed documentation that clearly identifies its relation to a particular program. This will ensure transparency and ease of traceability. 2. Trainin...
The following measures will be implemented: 1. Enhanced Documentation Process: Starting immediately, every grant expenditure will be accompanied by detailed documentation that clearly identifies its relation to a particular program. This will ensure transparency and ease of traceability. 2. Training & Awareness: We will provide additional training to our accounting and program teams to ensure that they are fully aware of the new documentation requirements and understand their importance. 3. Regular Review: We will conduct periodic internal reviews of our grant expenditure records to ensure that the new procedures are being consistently followed and that there are no gaps in documentation.
View Audit 6460 Questioned Costs: $1
The Bridge Over Troubled Waters, Inc.
TX
Reporting § 200.302 § 200.328 § 200.329 § 200.502 § 200.510
Finding 2022-004: Internal Control over Compliance and Compliance with Reporting (Preparation of Schedule of Expenditures of Federal Awards) Finding: The SEFA as prepared by management did not originally include one federal grant with federal expenditures during the year and one grant for which the ...
Finding 2022-004: Internal Control over Compliance and Compliance with Reporting (Preparation of Schedule of Expenditures of Federal Awards) Finding: The SEFA as prepared by management did not originally include one federal grant with federal expenditures during the year and one grant for which the Assistance Listing Number (ALN) did not match the grant documents. Corrective Action: Compare all contract or award letters for accurate information reported on the SEFA prior to submission. Contact: Carmen Stevens, Finance Director Expected Completion Date: 11/30/2023 If you have any questions, please contact Carmen Stevens at 713-472-0753 or by email at cstevens@tbotw.org.
View Audit 6440
The Bridge Over Troubled Waters, Inc.
TX
Internal Control / Segregation of Duties Reporting § 200.512
Finding 2022-003: Data Collection Form and Single Audit Reporting Package Finding: The Organization did not comply with the required submission date of the data collection form and reporting package to the FAC for the fiscal year ended December 31, 2022. Corrective Action: Prepare reports prior to d...
Finding 2022-003: Data Collection Form and Single Audit Reporting Package Finding: The Organization did not comply with the required submission date of the data collection form and reporting package to the FAC for the fiscal year ended December 31, 2022. Corrective Action: Prepare reports prior to due dates in case there is a computer issue. If a report is late, request an exception/extension in writing to file with report. Contact: Evelyn Vargas, Grants Compliance Manager Expected Completion Date: 11/30/2023 If you have any questions, please contact Evelyn Vargas at 713-472-0753 or by email at evargas@tbotw.org.
View Audit 6440
Finding 4041 (2022-001)
Significant Deficiency 2022
L.b.s.h. Housing Corporation
NY
Reporting
Management will work with their independent auditor to ensure that a proper data collection form will be submitted on a timely basis for the 2022 audit.
Management will work with their independent auditor to ensure that a proper data collection form will be submitted on a timely basis for the 2022 audit.
View Audit 6360
Finding 4038 (2022-002)
Significant Deficiency 2022
Granville Health System
NC
Questioned Costs Significant Deficiency Internal Control / Segregation of Duties
Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System ensure that remaining statement balance for uninsured testing is not balance billed to the patient. Explanation of disagreement with audit finding: There is no di...
Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System ensure that remaining statement balance for uninsured testing is not balance billed to the patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We understand the finding. All balances remaining after HRSA payments will be reviewed and adjusted to zero. Name(s) of the contact person(s) responsible for corrective action: Adam McConnell, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2023
View Audit 6359 Questioned Costs: $1
Finding 4037 (2022-001)
Significant Deficiency 2022
Granville Health System
NC
Questioned Costs Cash Management Significant Deficiency
Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System review the submissions to HRSA to ensure that the patients they requested reimbursement for were in fact uninsured. Explanation of disagreement with audit finding...
Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System review the submissions to HRSA to ensure that the patients they requested reimbursement for were in fact uninsured. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We understand the finding. In future submissions, the System will review all patients to ensure that are uninsured. Name(s) of the contact person(s) responsible for corrective action: Adam McConnell, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2023
View Audit 6359 Questioned Costs: $1
Finding 4015 (2022-003)
Significant Deficiency 2022
Young Women's Christian Association of Metropoliatan St. Louis
MO
Procurement, Suspension & Debarment Reporting § 200.512
Management has historically submitted their financial statements to the federal audit clearinghouse in a timely fashion. Unfortunately, due to new reporting requirements such as the lease accounting standards we were not successful in achieving timely submission for the annual audit report. Manageme...
Management has historically submitted their financial statements to the federal audit clearinghouse in a timely fashion. Unfortunately, due to new reporting requirements such as the lease accounting standards we were not successful in achieving timely submission for the annual audit report. Management and their audit firm are currently adjusting planning procedures and strategy to ensure timely submission of the annual audit report in the future.
View Audit 6330
Finding 4011 (2022-002)
Material Weakness 2022
Young Women's Christian Association of Metropoliatan St. Louis
MO
Reporting Subrecipient Monitoring Material Weakness
Management is committed to ensuring we are in compliance with all Head Start Reporting required by the Department of Health and Human Services and other regulatory bodies. Management will thoroughly review all the terms and conditions of its grant awards with internal management and externally with ...
Management is committed to ensuring we are in compliance with all Head Start Reporting required by the Department of Health and Human Services and other regulatory bodies. Management will thoroughly review all the terms and conditions of its grant awards with internal management and externally with the Department of Health and Human Services and other regulatory bodies to ensure the proper completion of subaward reports in FSRS, the SF429 and other required reporting.
View Audit 6330
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