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Corrective Action Plans

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Finding 1156720 (2024-001)
Material Weakness 2024
Norton Healthcare, Inc. and Affiliates
KY
Allowable Costs / Cost Principles
Finding 2024-001 – A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, H. Period of Performance Identification of the federal program: Federal Agency: U.S. Department of Homeland Security Assistance Listing No: 97.036 COVID-19 Disaster Grants – Public Assistance (Presidentially D...
Finding 2024-001 – A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, H. Period of Performance Identification of the federal program: Federal Agency: U.S. Department of Homeland Security Assistance Listing No: 97.036 COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Award Period: January 1, 2024 through December 31, 2024 Summary of finding: A material weakness in internal control over compliance was issued related to activities allowed or unallowed for the COVID-19 Disaster Grants – Public Assistance of Norton Healthcare, Inc. and Affiliates (the Corporation). While Management designed internal controls that required expenditures to be reviewed by members of the respective departments in which they originated (e.g. payroll and accounts payable) as expenditures were incurred, internal controls were not designed or implemented around the accumulation of expenditures and review of such expenditures for allowability under the projects for which Norton was approved under the COVID-19 Disaster Grants. Furthermore, the Company does not have formalized policies or documentation around internal contract agency travel allowances, and the payroll department did not retain documentation to evidence the function’s review of unapproved timesheets. Planned corrective action: Norton Healthcare is currently upgrading its timekeeping and attendance system. As part of this initiative, enhanced training and expanded functionality for timekeepers will help ensure that timecards are reviewed and approved prior to payment, in compliance with internal requirements. Relevant policies and procedures will be updated to support this process, including the retention of appropriate documentation. Additionally, the Norton Clinical Agency will establish a formal written policy outlining the stipend review and approval process, ensuring that all documentation is properly maintained. All other expenses submitted to FEMA will be reviewed and approved in writing, outside of the Grants Portal, with appropriate documentation. At this time, there are no pending or anticipated projects related to FEMA claims. Anticipated completion date: December 31, 2026 Responsible contact person: Adam Kempf
View Audit 369066
Finding 1156719 (2024-005)
Material Weakness 2024
Advocate Aurora Health, Inc.
IL
Equipment & Real Property Management
Finding 2024-005 National Bioterrorism Hospital Preparedness Program (ALN 93.889) The Organization did not have sufficiently designed internal controls to ensure that property records are retained in accordance with Section 200.313(d)(1) and (2), and to ensure that physical inventory procedures are ...
Finding 2024-005 National Bioterrorism Hospital Preparedness Program (ALN 93.889) The Organization did not have sufficiently designed internal controls to ensure that property records are retained in accordance with Section 200.313(d)(1) and (2), and to ensure that physical inventory procedures are conducted over property at least once every two years as it pertains to the Program. Management Response: To address this deficiency, the Program and Fixed Asset Accounting teams will collaborate to ensure adherence to the established asset tracking and inventory management procedures. This joint effort will ensure that the subsidiary ledger is accurately maintained, equipment acquired through federal grants is properly recorded, and physical inventories are conducted within the prescribed biennial timelines in compliance with 2 CFR section 200.313(d). Contact Person (s) Responsible for Corrective Action: Steve Baron, Program Manager and Tony Hamric, Fixed Assets Manager. Anticipated Completion Date: December 31, 2025
View Audit 369065
Finding 1156714 (2024-003)
Material Weakness 2024
Advocate Aurora Health, Inc.
IL
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking
Finding 2024-003 Coronavirus State and Local Fiscal Recovery Funds/ National Bioterrorism Hospital Preparedness Program/ Block Grants for Community Mental Health Services (21.027/93.889/93.958) Management did not have sufficiently designed internal controls to ensure that effort certifications were ...
Finding 2024-003 Coronavirus State and Local Fiscal Recovery Funds/ National Bioterrorism Hospital Preparedness Program/ Block Grants for Community Mental Health Services (21.027/93.889/93.958) Management did not have sufficiently designed internal controls to ensure that effort certifications were completed for all individuals working on multiple federal programs. Management Response: To address the identified deficiency, management is introducing standardized procedures to ensure that effort certifications are completed accurately and on time for all program staff. Program staff will receive targeted training, and a monitoring process will be implemented to support ongoing reviews. In addition, improvements to the effort tracking methodology are being considered to enhance the accuracy of employee time reporting across multiple federal grants, thereby strengthening compliance and minimizing the risk of reporting errors. Contact Person (s) Responsible for Corrective Action: David McDermott, Grants Director, Venice Northe, Grants Accounting Manager and Program teams. Anticipated Completion Date: December 31, 2025.
View Audit 369065
Finding 1156705 (2024-004)
Material Weakness 2024
Advocate Aurora Health, Inc.
IL
Eligibility Matching / Level of Effort / Earmarking
Finding 2024-004 Opiod STR (ALN 93.788) Management did not have sufficiently designed and documented - internal controls to ensure that all participants in the program were eligible to receive services through the program. Management Response: A more complete procedure to verify participant eligibil...
Finding 2024-004 Opiod STR (ALN 93.788) Management did not have sufficiently designed and documented - internal controls to ensure that all participants in the program were eligible to receive services through the program. Management Response: A more complete procedure to verify participant eligibility will be developed. This procedure will include detailed steps and required documentation, supported by a standardized eligibility checklist to guide staff in confirming and accurately recording participant eligibility. Additionally, all program staff involved in intake and eligibility determination will be trained on the new procedure. Contact Person - Responsible for Corrective Action: Elizabeth LaRoy, Program Manager Anticipated Completion Date: December 31, 2025.
View Audit 369065
Finding 1156697 (2024-002)
Material Weakness 2024
Advocate Aurora Health, Inc.
IL
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking
Finding 2024-002 Crime Victim Assistance (ALN 16.575) The Organization has internal controls in place to ensure employees’ effort certifications are approved. However, the Organization did not have internal controls to ensure that allchanges in employees’ certified effort were communicated, recorded...
Finding 2024-002 Crime Victim Assistance (ALN 16.575) The Organization has internal controls in place to ensure employees’ effort certifications are approved. However, the Organization did not have internal controls to ensure that allchanges in employees’ certified effort were communicated, recorded and charged to the grant. Management Response: Management will develop and implement written procedures to ensure the timely communication of discrepancies identified during the effort certification process to the Grant Accounting team for appropriate review and adjustment. Program staff will be trained in the new process, and reviews will be conducted to monitor compliance and ensure the continued effectiveness of the process. Contact Person (s) Responsible for Corrective Action: David McDermott, Grants Director and Venice Northe, Grants Accounting Manager. Anticipated Completion Date: December 31, 2025.
View Audit 369065
Finding 1156691 (2024-001)
Material Weakness 2024
Advocate Aurora Health, Inc.
IL
Eligibility Reporting Matching / Level of Effort / Earmarking
Finding 2024-001 WIC Special Supplemental Nutrition Program for Women, Infants, and Children (ALN 10.557) Advocate Aurora Health, Inc., follows a paperless system as supported by the State of Wisconsin and the U.S. Department of Agriculture. The state does not require third-party supporting document...
Finding 2024-001 WIC Special Supplemental Nutrition Program for Women, Infants, and Children (ALN 10.557) Advocate Aurora Health, Inc., follows a paperless system as supported by the State of Wisconsin and the U.S. Department of Agriculture. The state does not require third-party supporting documentation of eligibility determinations to be retained. As a result, no corrective action will be taken. Contact Person - Responsible for Corrective Action: Jen Agnello, Program Manager Anticipated Completion Date: N/A
View Audit 369065
Finding 1156689 (2024-002)
Material Weakness 2024
Town of Kewanna
IN
Procurement, Suspension & Debarment § 200.1 § 200.303 § 200.317 § 200.318 § 200.319
Finding 2024-002 Drinking Water State Revolving Fund - Procurement Contact Person Responsible for Corrective Action: JoAnn Collins/Clerk Treasurer Contact Phone Number and Email Address: 574-653-2112 kewanna@fourway.net Views of Responsible Officials: We concur with the finding Description of Correc...
Finding 2024-002 Drinking Water State Revolving Fund - Procurement Contact Person Responsible for Corrective Action: JoAnn Collins/Clerk Treasurer Contact Phone Number and Email Address: 574-653-2112 kewanna@fourway.net Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: We will update our procurement policy and implement a system of internal controls to ensure a purchasing policy is in place and quotes are obtained for small purchases. Anticipated Completion Date: A policy and internal controls will be in place by January 1, 2026
View Audit 369056
Finding 1156688 (2024-002)
Material Weakness 2024
Chief Seattle Club
WA
Procurement, Suspension & Debarment § 200.318 § 200.320
Reporting - Reportable Findings and Questioned Costs for Federal Awards Contact Person Marc Taylor, CFO E-Mail: Marc@chiefseattleclub.org Corrective Action Planned This finding occurred because of a lack of both procurement knowledge and staff oversight over a contractor handling the procurement for...
Reporting - Reportable Findings and Questioned Costs for Federal Awards Contact Person Marc Taylor, CFO E-Mail: Marc@chiefseattleclub.org Corrective Action Planned This finding occurred because of a lack of both procurement knowledge and staff oversight over a contractor handling the procurement for Eagle Village. Thanks to this finding, our real estate team has gained a better understanding of federal procurement requirements. Our auditor provided us with a procurement checklist, which we began using and will ensure that we comply with our procurement policy and better document future procurements. Anticipated Completion Date September 30, 2025
View Audit 369055
Finding 1156687 (2024-004)
Material Weakness 2024
Madonna Center, Inc.
TX
Questioned Costs Allowable Costs / Cost Principles
Management agrees and will develop review procedures to respond to the findings.
Management agrees and will develop review procedures to respond to the findings.
View Audit 369054 Questioned Costs: $1
Finding 1156686 (2024-003)
Material Weakness 2024
Madonna Center, Inc.
TX
Questioned Costs Internal Control / Segregation of Duties
Management agrees and will reimburse the employee for the amounts due for hours worked more than 40 hours in a work week during the fiscal year. Management will develop review procedures to respond to this finding.
Management agrees and will reimburse the employee for the amounts due for hours worked more than 40 hours in a work week during the fiscal year. Management will develop review procedures to respond to this finding.
View Audit 369054 Questioned Costs: $1
Finding 1156685 (2024-002)
Material Weakness 2024
Madonna Center, Inc.
TX
Questioned Costs Allowable Costs / Cost Principles Cash Management
Management agrees and will develop review procedures to respond to the findings.
Management agrees and will develop review procedures to respond to the findings.
View Audit 369054 Questioned Costs: $1
Finding 1156684 (2024-001)
Material Weakness 2024
Madonna Center, Inc.
TX
Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.430
Management agrees with the finding and will work with the City of San Antonio to correct the issue, and develop review procedures to respond to the finding.
Management agrees with the finding and will work with the City of San Antonio to correct the issue, and develop review procedures to respond to the finding.
View Audit 369054 Questioned Costs: $1
Finding 1156683 (2024-002)
Material Weakness 2024
Housing Authority of the City of Ellijay
GA
HUD Housing Programs Internal Control / Segregation of Duties
2024-002 Condition: Deficiencies Noted in Cash Disbursements Steps to resolve: Management agrees with the audit finding and the auditor’s recommendation. We will review the cash disbursement documentation process in order to ensure that each disbursement is fully documented prior to check issuance. ...
2024-002 Condition: Deficiencies Noted in Cash Disbursements Steps to resolve: Management agrees with the audit finding and the auditor’s recommendation. We will review the cash disbursement documentation process in order to ensure that each disbursement is fully documented prior to check issuance. We will further review our internal control procedures and policies over cash disbursements and conduct regular quality control reviews to ensure compliance with HUD regulations. We will implement any needed procedures and changes to ensure that this finding will be cleared by the subsequent fiscal year audit. Individual responsible for correction: Ms. Linda Dillard, Executive Director Timeframe: As of December 31, 2025
View Audit 369051
Finding 1156682 (2024-001)
Material Weakness 2024
Housing Authority of the City of Ellijay
GA
Procurement, Suspension & Debarment
2024-001 Condition: Deficiencies Noted in Procurement Steps to resolve: Management agrees with the audit finding and the auditor’s recommendation. Going forward we will review and follow our procurement policies and HUD guidelines in obtaining and signing contracts so that all contracts are in accor...
2024-001 Condition: Deficiencies Noted in Procurement Steps to resolve: Management agrees with the audit finding and the auditor’s recommendation. Going forward we will review and follow our procurement policies and HUD guidelines in obtaining and signing contracts so that all contracts are in accordance with applicable HUD regulations. We will implement any needed procedures and changes to ensure that this finding will be cleared by the subsequent fiscal year audit. Individual responsible for correction: Ms. Linda Dillard, Executive Director Timeframe: As of December 31, 2025
View Audit 369051
Finding 1156681 (2024-001)
Material Weakness 2024
Town of Upland
IN
Equipment & Real Property Management § 200.303 § 200.313
Finding 2024-001 Finding Subject: Community Development Block Grant Program- Equipment and Real Property Management. Contact Person Responsible for Corrective Action: Mary Fletcher, Clerk-Treasurer Contact Phone Number and Email Address: (765) 998-7439 ext. 1, mfletcher@uplandindiana.com Views of Re...
Finding 2024-001 Finding Subject: Community Development Block Grant Program- Equipment and Real Property Management. Contact Person Responsible for Corrective Action: Mary Fletcher, Clerk-Treasurer Contact Phone Number and Email Address: (765) 998-7439 ext. 1, mfletcher@uplandindiana.com Views of Responsible Officials: We concur with the finding. Correction Action Plan: The Town of Upland will concur with our asset management consultant and have the missing information added to our asset ledger. Anticipated Completion Date: September 30, 2025
View Audit 369047
Finding 1156680 (2024-001)
Material Weakness 2024
Thf San Gabriel Holdings, LLC
TX
Procurement, Suspension & Debarment Subrecipient Monitoring HUD Housing Programs § 200.512
Name of auditee: THF San Gabriel Holdings, LLC HUD auditee identification number: 115-11319 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2024 CAP prepared by Name: Allison Milliorn Position: Chief Executive Officer Telephone number: 830-693-8...
Name of auditee: THF San Gabriel Holdings, LLC HUD auditee identification number: 115-11319 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2024 CAP prepared by Name: Allison Milliorn Position: Chief Executive Officer Telephone number: 830-693-8100 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2024-001: Comments on the Finding and Each Recommendation: For the year ended December 31, 2023, the Company did not submit the Data Collection Form (SF-SAC) to the Federal Audit Clearinghouse in the time period required by Uniform Guidance Section 2 CFR 200.512. Action(s) taken or planned on the finding: The Data Collection Form was submitted to the Federal Audit Clearinghouse on May 10, 2024 and management will submit the Data Collection Form timely going forward.
View Audit 369043
Finding 1156679 (2024-002)
Material Weakness 2024
Employment Connection
MO
Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.430
Corrective Action Plan: Strengthen detailed process for review over payroll charges billed to federal programs. To address the significant deficiency over allowable costs identified in the Single Audit, the Organization will enhance its existing review procedures by implementing a more detailed mont...
Corrective Action Plan: Strengthen detailed process for review over payroll charges billed to federal programs. To address the significant deficiency over allowable costs identified in the Single Audit, the Organization will enhance its existing review procedures by implementing a more detailed monthly review process. This will include verifying payroll charges against supporting documentation such as payroll registers, time records, and allocation spreadsheets. Management will also explore the development of a standardized reconciliation checklist and introduce a secondary review step to ensure accuracy and completeness. These measures, combined with continued monthly oversight by the CFO, are intended to reduce the risk of billing errors due to human oversight and reinforce the reliability of payroll cost allocations. Name of Responsible Person: Nora Davis, Chief Financial Officer Anticipated Completion Date: April 30, 2026
View Audit 369034
Finding 1156668 (2024-003)
Material Weakness 2024
Belmont County
OH
Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.405
Belmont County Department of Job and Family Services reviews employee’s job duties routinely to determine the most appropriate and accurate cost pool they should be assigned. The essential job duties and how they align with the program area determine cost pool assignment based on the agency’s interp...
Belmont County Department of Job and Family Services reviews employee’s job duties routinely to determine the most appropriate and accurate cost pool they should be assigned. The essential job duties and how they align with the program area determine cost pool assignment based on the agency’s interpretation. As a result of this finding, BCDJFS will reassign the FCFC Coordinator to the shared cost pool and reimburse the shared cost pool from the applicable FCFC allocations through a MOU signed between the council and BCDJFS
View Audit 369030 Questioned Costs: $1
Finding 1156667 (2024-006)
Material Weakness 2024
Adams County
OH
Student Financial Aid Allowable Costs / Cost Principles § 200.302
The Children Service Department will seek legal advice on the implementation of a policy that meets the requirements set for in 2 CFR 200.302(b)(7) for determining the allowability of costs in accordance with Subpart E-Cost Principles.
The Children Service Department will seek legal advice on the implementation of a policy that meets the requirements set for in 2 CFR 200.302(b)(7) for determining the allowability of costs in accordance with Subpart E-Cost Principles.
View Audit 369025
Finding 1156666 (2024-005)
Material Weakness 2024
Adams County
OH
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Special Tests & Provisions
Training will occur with staff on the correct entry of rates into the SACWIS system and the importance of rates matching what was agreed to with the provider. Staff will review the invoices with the SACWIS entry prior to them being paid by the fiscal officer.
Training will occur with staff on the correct entry of rates into the SACWIS system and the importance of rates matching what was agreed to with the provider. Staff will review the invoices with the SACWIS entry prior to them being paid by the fiscal officer.
View Audit 369025
Finding 1156665 (2024-004)
Material Weakness 2024
Adams County
OH
Allowable Costs / Cost Principles § 200.302 § 200.430 § 200.464
The Commissioner’s office will consult with legal counsel to update polices to meet requirements of 2 CFR 200.
The Commissioner’s office will consult with legal counsel to update polices to meet requirements of 2 CFR 200.
View Audit 369025
Finding 1156663 (2024-003)
Material Weakness 2024
Adams County
OH
Procurement, Suspension & Debarment Subrecipient Monitoring
The Commissioner’s office will implement additional policies to ensure verification is performed to ensure a vendor is not suspended, debarred, or otherwise excluded from a project and to ensure documentation is maintained.
The Commissioner’s office will implement additional policies to ensure verification is performed to ensure a vendor is not suspended, debarred, or otherwise excluded from a project and to ensure documentation is maintained.
View Audit 369025
Finding 1156661 (2024-004)
Material Weakness 2024
Marquette County
WI
Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking
Finding 2024-004 Repeat of Finding 2023-004 Program Federal Assistance Listing and Title: 93.778 Medicaid Cluster, Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Wisconsin Department of Health Services State Program ID Number and Title: 437.3561/3681 CW Children an...
Finding 2024-004 Repeat of Finding 2023-004 Program Federal Assistance Listing and Title: 93.778 Medicaid Cluster, Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Wisconsin Department of Health Services State Program ID Number and Title: 437.3561/3681 CW Children and Families State Agency: Wisconsin Department of Children and Families State Program ID Number and Title: 435.560100 ADRC 435.000561/000681 Basic County Allocation State Agency: Wisconsin Department of Health Services State Program ID Number and Title: 395.168 Specialized Transit County Operating Aids (Elderly & Disabled) State Agency: Wisconsin Department of Transportation State Program ID Number and Title: 435.000283 IMAA State Share State Agency: Wisconsin Department of Health Services Award Numbers: Unknown Criteria: 2 CRF 200.303 Internal Controls requires that non-federal entities receiving federal awards establish and maintain internal control designed to reasonably ensure compliance with federal laws, regulations and program compliance requirements. The State Single Audit Guidelines (SSAG) require that local entities receiving State awards establish and maintain internal control designed to reasonably ensure compliance with laws, regulations and program compliance requirements. To minimize the risk of errors, internal controls should be in place for all program compliance requirements, including appropriate review and approval of expenditures. Condition/Context: During our testing, we were unable to view approval for the following number of payroll expenditures in each program: • 93.778: 13 out of 20 expenditures tested. • 435.000561/000681, 437.3561/3681: 7 out of 40 expenditures tested. • 435.560100: 14 out of 20 expenditures tested. For programs 395.168 and 435.000283, these are carried over from the prior year as controls have not changed within the system. These samples were not statistically valid. Corrective Action Plan Corrective Action Planned: In response to Finding 2024-004 regarding Internal Control Over Financial Reporting, note that the County is aware that there is lack of controls over its year-end financial reporting process. The County will endeavor to evaluate the need to increase additional staff to meet the deficiencies noted in the finding. However, due to its size, the County does not feel it is cost-effective to hire the number of employees needed to complete these task in house at this point in time and will rely on an outside audit firm. Administration is aware the current payroll and financial system allows to only go back to view payroll approvals within one year. Name(s) of Contact Person(s) Responsible for Corrective Action: Ron Barger, Marquette County Administrator Anticipated Completion Date: Administration will examine the lack of internal financial reporting on a yearly ongoing basis.
View Audit 369021
Finding 1156659 (2024-002)
Material Weakness 2024
Marquette County
WI
Internal Control / Segregation of Duties Allowable Costs / Cost Principles
Finding 2024-002 Repeat of Finding 2023-002 Program Federal Assistance Listing and Title: 93.778 Medicaid Cluster, Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Wisconsin Department of Health Services Program Federal Assistance Listing and Title: 21.027 COVID-19 C...
Finding 2024-002 Repeat of Finding 2023-002 Program Federal Assistance Listing and Title: 93.778 Medicaid Cluster, Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Wisconsin Department of Health Services Program Federal Assistance Listing and Title: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Wisconsin Department of Health Services State Program ID Number and Title: 437.3561/3681 CW Children and Families State Agency: Wisconsin Department of Children and Families State Program ID Number and Title: 435.560100 ADRC 435.000561/000681 Basic County Allocation State Agency: Wisconsin Department of Health Services Award Numbers: Unknown Criteria: The State Single Audit Guidelines (SSAG) require that local entities receiving State awards establish and maintain internal control designed to reasonably ensure compliance with laws, regulations and program compliance requirements. The Uniform Guidance and State Single Audit Guidelines further require auditors to obtain an understanding of the local entity's internal control over federal and state programs. To minimize the risk of errors, internal controls should be in place for all program compliance requirements, including the preparation and submission of reports, which should be reviewed and approved by a responsible party other than the original preparer. Condition/Context: The County does not have controls in place to ensure there is documentation of the approval and review of reports prior to submission. Of the reports tested for the current year single audit, 12 of the 13 reports did not have documentation of the review process prior to submittal as follows: 10 of 10 monthly GEARS reports and 1 of 1 WIMCR annual reports did not have documentation of approval, and 1 of 2 monthly SPARC reports did not have documentation of approval. The sample was not statistically valid. Corrective Action Plan Corrective Action Planned: {The county is reviewing and updating its internal controls to put processes in place to ensure documentation of the review process prior to submittal of reports.} Name(s) of Contact Person(s) Responsible for Corrective Action: {Mandy Stanley and Jennifer Vote.} Anticipated Completion Date: {Beginning with reports dated 1/1/2026 and later.}
View Audit 369021
Finding 1156656 (2024-001)
Material Weakness 2024
Cultivate Kansas City, Inc.
MO
Allowable Costs / Cost Principles
Significant Deficiency
Significant Deficiency
View Audit 369013
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