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Corrective Action Plans

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Finding 569021 (2024-004)
Material Weakness 2024
Fairview Health Services
MN
Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303
Finding 2024-004 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Management will improve internal controls to include the documentation and retention of approval on all supply expenditures and the annual fringe benefit analysis. Responsible Offici...
Finding 2024-004 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Management will improve internal controls to include the documentation and retention of approval on all supply expenditures and the annual fringe benefit analysis. Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date –August 2025 Management agrees with the finding. Remediation: The accounting manager reviewed and approved the updated 2025 fringe benefit analysis with 2024 actuals on February 28, 2025. Upon finalization of the 2025 budget, the analysis will be revised and reviewed again. Accounting will collect evidence of review and approval of supply expenditure throughout the year to ensure proper retention of the documentation.
View Audit 360649
Finding 569020 (2024-003)
Material Weakness 2024
Fairview Health Services
MN
Procurement, Suspension & Debarment § 200.303 § 200.320
Finding 2024-003 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Monthly Suspension and Debarment files will be reviewed, and documented approval will be retained within the monthly files. Responsible Official – Dawn Ksepka, VP of Finance and Syst...
Finding 2024-003 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Monthly Suspension and Debarment files will be reviewed, and documented approval will be retained within the monthly files. Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date –June 30, 2025 Management agrees with the finding. Remediation: Starting June 2025, the monthly suspension and debarment file will be reviewed. A signed statement confirming its accuracy will be included post-review. The accounts payable standard work document will be updated accordingly.
View Audit 360649
Finding 569019 (2024-002)
Material Weakness 2024
Fairview Health Services
MN
Procurement, Suspension & Debarment § 200.303 § 200.320
Finding 2024-002 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – July 31, 2025 Management agrees with the finding. Remediation: Fairview update...
Finding 2024-002 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – July 31, 2025 Management agrees with the finding. Remediation: Fairview updated its internal control processes to better retain and document sole source procurement justification before entering vendor agreements. A standard form for sole source justification will be implemented to enhance documentation.
View Audit 360649
Finding 569018 (2024-001)
Material Weakness 2024
Fairview Health Services
MN
Subrecipient Monitoring Reporting § 200.303
Finding 2024-001 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – April 15, 2025 Management agrees with the finding. Remediation: The FFATA repo...
Finding 2024-001 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – April 15, 2025 Management agrees with the finding. Remediation: The FFATA report was filed on April 15, 2025. Fairview has established an internal control to ensure timely filing of FFATA reports in the future.
View Audit 360649
Finding 569017 (2024-001)
Material Weakness 2024
Housing Authority of the City of Lithonia
GA
HUD Housing Programs Special Tests & Provisions
The Authority will obtain SEMAP training for personnel to ensure proper SEMAP reporting and documentation. The Authority will also use the computer system for SEMAP documentation.
The Authority will obtain SEMAP training for personnel to ensure proper SEMAP reporting and documentation. The Authority will also use the computer system for SEMAP documentation.
View Audit 360648
Metropolitan Transit Authority of Harris County, Texas
TX
Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303 § 200.516
The METRO Vanpool Department, in collaboration with the Grant Programs Administration Division, has initiated actions to strengthen internal controls and improve compliance with federal cost principles. These actions include: • Updating existing policies and procedures related to grant-funded expens...
The METRO Vanpool Department, in collaboration with the Grant Programs Administration Division, has initiated actions to strengthen internal controls and improve compliance with federal cost principles. These actions include: • Updating existing policies and procedures related to grant-funded expense transactions; • Developing guidance to ensure transactions are appropriately reviewed for allowability, allocability, and reasonableness; • Enhancing training for relevant personnel to reinforce understanding and application of award-specific terms and conditions; • Ensuring compliance with 2 CFR § 200.403 and § 200.303. These process improvements and control enhancements will be finalized and implemented no later than December 31, 2025, under the direction of the Director, Commuter Services. METRO believes these steps will ensure compliance and mitigate recurrence of similar findings in future audit periods.
View Audit 360643 Questioned Costs: $1
Piazza Apartments
FL
HUD Housing Programs Eligibility Reporting
FINDING No. 2024-003: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to ensure all documentation related to applicants and tenants are properly executed and maintained, and that the manager verifies eligibility by obtaining all requ...
FINDING No. 2024-003: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to ensure all documentation related to applicants and tenants are properly executed and maintained, and that the manager verifies eligibility by obtaining all required documents for potential tenants while verifying and maintaining support for tenant income eligibility through the EIV system in a timely manner. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting and tenant file maintenance and included in monthly reporting procedures. If the Oversight Agency for Audit has questions regarding this plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips, CFO Irene Phillips CFO
View Audit 360638
Piazza Apartments
FL
Reporting HUD Housing Programs
FINDING No. 2024-002: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should comply with state law and HUD regulations for refunding security deposits timely. Action Taken: Staff training has been provided and included in monthly reporting procedures.
FINDING No. 2024-002: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should comply with state law and HUD regulations for refunding security deposits timely. Action Taken: Staff training has been provided and included in monthly reporting procedures.
View Audit 360638
Piazza Apartments
FL
HUD Housing Programs Reporting
Oversight Agency for Audit, Piazza Apartments respectfully submits the following corrective action plan for the year ended September 30, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067 Audit peri...
Oversight Agency for Audit, Piazza Apartments respectfully submits the following corrective action plan for the year ended September 30, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067 Audit period: October 1, 2023, through September 30, 2024 The findings from the September 30, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. SECTION III – FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2024-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: Management should implement procedures to ensure the Project submits PRAC renewal requests in accordance with HUD requirements. Action Taken: New staff has been put in place to monitor and submit all renewals in a timely fashion.
View Audit 360638
Finding 568950 (2024-002)
Significant Deficiency 2024
Universities Space Research Association
MD
Significant Deficiency Internal Control / Segregation of Duties § 200.308
The Company acknowledges the importance of accurately documenting key personnel requirements in support of federal contract compliance. The audit noted one contract with two projects where the individual listed as key personnel did not match the most current contract documentation. However, internal...
The Company acknowledges the importance of accurately documenting key personnel requirements in support of federal contract compliance. The audit noted one contract with two projects where the individual listed as key personnel did not match the most current contract documentation. However, internal “load sheets” and program communications consistently reflected the correct personnel assignments, and there was no impact on contract performance or deliverables. Given the isolated nature of these discrepancies and their lack of effect on program execution or financial reporting, the Company does not consider this matter to be material. Nonetheless, to strengthen internal controls, the Contracts Department now records and maintains all key personnel data directly in Costpoint. Additionally, the Controller performs a quarterly internal review of these records to verify accuracy and completeness. These measures provide added assurance that the Company remains fully compliant with federal award requirements. Director of Contracts/Elena Einstein now oversees this control which was put into place as of April 2025.Notwithstanding these findings, management is confident that the accompanying financial statements present fairly, in all material respects, the Company’s financial position for the fiscal year ended September 30, 2024.
View Audit 360636
Finding 568939 (2024-102)
Significant Deficiency 2024
Health Access Network, Inc.
ME
Matching / Level of Effort / Earmarking
Sliding Fee Application ‑ Background: As sample testing of the program was performed during the 2024 annual financial audit, it was determined that the error rate for retention of applications and accuracy of slide application to charges required additional administrative oversight with attention t...
Sliding Fee Application ‑ Background: As sample testing of the program was performed during the 2024 annual financial audit, it was determined that the error rate for retention of applications and accuracy of slide application to charges required additional administrative oversight with attention to audit standards. Action Plan: Policies and Procedures have been updated and will be presented to the Board of Directors for approval at the April 2025 meeting. The updates include: Inclusion of the application within the policy and procedure document; Review and verification of application by the CFO in addition to the Patient Assistance staff. This will include verification of documentation archival and retention for audit; Daily review of slide applications to charges by AR Staff for accuracy. Responsible Party: Wanda Kimball, Chief Financial Officer.
View Audit 360633
Finding 568938 (2024-101)
Significant Deficiency 2024
Health Access Network, Inc.
ME
Sliding Fee Discount ‑ Background: As sample testing of the program was performed during the 2024 annual financial audit, it was determined that the error rate for retention of applications and accuracy of slide application to charges required additional administrative oversight with attention to a...
Sliding Fee Discount ‑ Background: As sample testing of the program was performed during the 2024 annual financial audit, it was determined that the error rate for retention of applications and accuracy of slide application to charges required additional administrative oversight with attention to audit standards. Action Plan: Policies and Procedures have been updated and will be presented to the Board of Directors for approval at the April 2025 meeting. The updates include: Inclusion of the application within the policy and procedure document; Review and verification of application by the CFO in addition to the Patient Assistance staff. This will include verification of documentation archival and retention for audit; Daily review of slide applications to charges by AR Staff for accuracy. Responsible Party: Wanda Kimball, Chief Financial Officer.
View Audit 360633
Finding 568917 (2024-001)
Material Weakness 2024
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.
We are aware of the condition and will review procedures to make changes when appropriate and cost effective.
View Audit 360623
Finding 568863 (2024-003)
Material Weakness 2024
Palm Beach County Board of County Commissioners
FL
Reporting Cash Management Matching / Level of Effort / Earmarking § 200.502 § 200.510
The Office of Financial Management and Budget (OFMB) has collaborated with County departments and agencies that administer grants to ensure staff are informed of and participate in relevant training opportunities related to State and Federal grants. In addition, OFMB continues to monitor grant activ...
The Office of Financial Management and Budget (OFMB) has collaborated with County departments and agencies that administer grants to ensure staff are informed of and participate in relevant training opportunities related to State and Federal grants. In addition, OFMB continues to monitor grant activity through established agenda review and grant reconciliation processes to identify and address potential errors or omissions and will provide guidance as needed.
View Audit 360603
Finding 568861 (2024-003)
Significant Deficiency 2024
Town of Cleveland
AL
Subrecipient Monitoring Cash Management Significant Deficiency
The Mayor's Office is fully committed to addressing the audit finding and the requirement per the grant agreement to develop and implement a fiscal sustainability plan as of 06/10/2025 on any futhter awarded funds. The corrective actions outlined in this plan reflect the importance of prudent financ...
The Mayor's Office is fully committed to addressing the audit finding and the requirement per the grant agreement to develop and implement a fiscal sustainability plan as of 06/10/2025 on any futhter awarded funds. The corrective actions outlined in this plan reflect the importance of prudent financial management and forward-thinking strategies to safeguard the financial future of our community. Anticipated Completion Date: 6/10/2025 James A. Sullivan, Mayor.
View Audit 360598
Finding 568859 (2024-002)
Significant Deficiency 2024
Town of Cleveland
AL
Cash Management Subrecipient Monitoring Significant Deficiency § 200.303 § 200.305
Town will no longer be holding invoices until ARPA funding is received but will follow the reimbursement guidelines per the grant agreement. April 30th 2025 anticipated completion date. James A. Sullivan Mayor
Town will no longer be holding invoices until ARPA funding is received but will follow the reimbursement guidelines per the grant agreement. April 30th 2025 anticipated completion date. James A. Sullivan Mayor
View Audit 360598
Finding 568858 (2024-009)
Significant Deficiency 2024
Springfield Metropolitan Housing Authority
OH
We will get signed Tenant Participation fund agreement with participating AMPS and establish and approved budgets. Training will be implemented to ensure completed.
We will get signed Tenant Participation fund agreement with participating AMPS and establish and approved budgets. Training will be implemented to ensure completed.
View Audit 360596
Finding 568857 (2024-008)
Significant Deficiency 2024
Springfield Metropolitan Housing Authority
OH
All CFP invoices are to be reviewed and clearly marked as approved and documented to show that the source of funds for payment. Funds will be drawn. After funds are deposited AP will pay within three (3) business days either through check or ACH. Training will be implemented to ensure completed.
All CFP invoices are to be reviewed and clearly marked as approved and documented to show that the source of funds for payment. Funds will be drawn. After funds are deposited AP will pay within three (3) business days either through check or ACH. Training will be implemented to ensure completed.
View Audit 360596
Finding 568856 (2024-007)
Significant Deficiency 2024
Springfield Metropolitan Housing Authority
OH
Account will be reconciled and agreed to detail ledger. At YE balance will be agreed to FDS prior submission Training will be implemented to ensure completed.
Account will be reconciled and agreed to detail ledger. At YE balance will be agreed to FDS prior submission Training will be implemented to ensure completed.
View Audit 360596
Finding 568855 (2024-006)
Material Weakness 2024
Springfield Metropolitan Housing Authority
OH
Accounts will be reconciled and agreed to detail ledger monthly. At YE balance will be agreed to FDS prior submission. Training will be implemented to ensure completed.
Accounts will be reconciled and agreed to detail ledger monthly. At YE balance will be agreed to FDS prior submission. Training will be implemented to ensure completed.
View Audit 360596
Finding 568854 (2024-001)
Significant Deficiency 2024
City of Aurora, Minnesota
MN
Internal Control / Segregation of Duties
Finding Number: 2024-001 Finding Title: SEGREGATION OF DUTIES Name of Contact Person Responsible for Corrective Action Lucas Heikkila, City Administrator Corrective Action Planned Management will attempt to monitor transactions and structure the duties of office personnel to help ensure as much s...
Finding Number: 2024-001 Finding Title: SEGREGATION OF DUTIES Name of Contact Person Responsible for Corrective Action Lucas Heikkila, City Administrator Corrective Action Planned Management will attempt to monitor transactions and structure the duties of office personnel to help ensure as much segregation of duties as possible within the City’s staffing limitations and funding constraints. Anticipated Completion Date Ongoing.
View Audit 360588
Finding 568852 (2024-002)
Material Weakness 2024
King's Daughters Medical Center
MS
Questioned Costs Allowable Costs / Cost Principles Cash Management
Corrective Action Plan Details Finding Number: 2024-002 Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Assistance Listing Number 97.036 Federal Emergency Management Agency Passed through Mississippi Emergency Management Agency Responsible Official: Adam Moor...
Corrective Action Plan Details Finding Number: 2024-002 Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Assistance Listing Number 97.036 Federal Emergency Management Agency Passed through Mississippi Emergency Management Agency Responsible Official: Adam Moore, CFO Finding Detail: Expenses reimbursed from other sources and unsupported expenses were not identified. Appropriate calculations of cost formulas were not utilized for medication reimbursement amounts claimed. Corrective Action Planned: Management concurs with the finding and will implement additional internal controls over the identification of eligible expenditures for the Disaster Grants program. Expenditures identified as potential grant program expenditures will be reviewed by the controller, and final approval of each expense by the chief financial officer to ensure they are eligible expenses and have not been reimbursed by any other sources. We anticipate these additional controls to be in place by September 30. 2025. The Chief Development Officer will oversee the corrective action. Anticipated Completion Date: September 2025
View Audit 360576 Questioned Costs: $1
Finding 568847 (2024-006)
Significant Deficiency 2024
County of Berrien
MI
Allowable Costs / Cost Principles
Finding: 2024-006 - Lack of Independent Review and Approval of Reporting Auditor Description of Condition and Effect: During our audit procedures over the County's reporting process for CSLFRF grants received through pass-through entities, we noted that none of the financial reports selected for te...
Finding: 2024-006 - Lack of Independent Review and Approval of Reporting Auditor Description of Condition and Effect: During our audit procedures over the County's reporting process for CSLFRF grants received through pass-through entities, we noted that none of the financial reports selected for testing included documentation that the reports were subjected to an independent review and approval prior to submission in order to detect and correct potential errors or omissions. As a result of this condition, the County was exposed to an increased risk that the reports filed could contain errors and not be detected and corrected on a timely basis. Auditor Recommendation: We recommend that the County establish procedures to ensure that all reports are subject to review and approval by an independent employee prior to submission, and that the review and approval is adequately documented. Corrective Action: County grant policies and procedures outline requirements of review and approval of grant reporting. Management recognizes the importance of establishing controls as noted, however policies and procedures stop short of requiring the signature and dating of approvals by independent reviewers. Policies and procedures will be modified to include verbiage requiring documentation of review and approval, along with reconciliations to the general ledger prior to submission. Contact Person: Brian Dissette, County Administrator/Controller Estimated Completion Date: December 31, 2025
View Audit 360575
Finding 568846 (2024-007)
Significant Deficiency 2024
County of Berrien
MI
Procurement, Suspension & Debarment Allowable Costs / Cost Principles
Finding: 2024-007 – Suspension and Debarment Auditor Description of Condition and Effect: For three of the four vendors selected for testing, the County was unable to provide evidence that the vendors were not suspended, debarred, or otherwise excluded at the time they were engaged to provide goods...
Finding: 2024-007 – Suspension and Debarment Auditor Description of Condition and Effect: For three of the four vendors selected for testing, the County was unable to provide evidence that the vendors were not suspended, debarred, or otherwise excluded at the time they were engaged to provide goods or services. As a result of this condition, the County was exposed to an increased risk that disbursements of federal awards could be made to vendors or subrecipients suspended or debarred by the federal government. Auditor Recommendation: We recommend that the County review its written policies and procedures over federal awards with employees responsible for grant compliance to ensure that they are being followed consistently. Corrective Action: Vendors are reviewed based on specific criteria upon addition to the accounts payable system for the County. This review process includes review for suspension, debarment, and excluded parties. The County will review grant compliance requirements with employees responsible for federal awards and request retention of documents verifying compliance. Contact Person: Brian Dissette, County Administrator/Controller Estimated Completion Date: December 31, 2025
View Audit 360575
Finding 568845 (2024-005)
Significant Deficiency 2024
County of Berrien
MI
Allowable Costs / Cost Principles Internal Control / Segregation of Duties
Finding: 2024-005 – Reporting Auditor Description of Condition and Effect: The County has not performed all of the required Coronavirus State and Local Fiscal Recovery Funds expenditure reporting. Specifically, the Project and Expenditure report for the second quarter of 2024 was not filed. However...
Finding: 2024-005 – Reporting Auditor Description of Condition and Effect: The County has not performed all of the required Coronavirus State and Local Fiscal Recovery Funds expenditure reporting. Specifically, the Project and Expenditure report for the second quarter of 2024 was not filed. However, these reports were filed for the first, third and fourth quarters of 2024. As a result of this condition, the County did not comply completely with the reporting requirements of the Coronavirus State and Local Fiscal Recovery Funds grant. Auditor Recommendation: We recommend that the County review the reporting requirements for each grant and complete all reporting as required under the terms of the grant agreement. Corrective Action: Management acknowledges the oversight regarding the 2nd quarter reporting and agrees with the condition as noted. The County will provide a reminder to all grant administrators of the policy. An additional confirmation step is under consideration for verification of completion, at the discretion of County Administration, which would require notification to Financial Services personnel that filing activities have occurred. This oversight process change would require additional resources to complete. Contact Person: Brian Dissette, County Administrator/Controller Estimated Completion Date: December 31, 2025
View Audit 360575
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