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Corrective Action Plans

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Healthfirst Bluegrass INC
KY
Special Tests & Provisions Eligibility Matching / Level of Effort / Earmarking
Views of responsible officials and planned corrective actions – Management has begun staff training and will meet with the billing team regarding the sliding fee policy and process, including scanning of application into the patient's file. Management will ensure HFBG continues to apply and audit t...
Views of responsible officials and planned corrective actions – Management has begun staff training and will meet with the billing team regarding the sliding fee policy and process, including scanning of application into the patient's file. Management will ensure HFBG continues to apply and audit the application of sliding fee discounts on the patient accounts consistent with policy.
View Audit 362384
Finding 571466 (2024-001)
Significant Deficiency 2024
Healthfirst Bluegrass INC
KY
Reporting Program Income
Views of responsible officials and planned corrective actions – Management will continue their review process of the submitted reports.
Views of responsible officials and planned corrective actions – Management will continue their review process of the submitted reports.
View Audit 362384
Finding 571464 (2024-006)
Significant Deficiency 2024
City and County of Denver
CO
Reporting Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303
Federal Program Name: Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recom...
Federal Program Name: Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: We recommend the City establish and implement a formal process to consistently retain documentation of FFATA report submission dates, as well as evidence of the review and approval of each report submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: Denver’s Department of Economic Development and Opportunity (DEDO) will establish a formal approval process to establish and document submission dates of all FFATA filings going forward. While the Federal Government does not provide any timestamps of initial submission for FFATA filings, nor require approval for FFATA submissions, DEDO will begin providing written and dated approvals of when FFATA reporting is taking place. We will put together a formal process that will provide dates to show review/approval of FFATA filings to meet our external auditor’s request, despite the Federal Government not requiring it. DEDO is able to provide a documented historical consistency of maintaining effective internal controls over this Federal award, and will begin including FFATA filings in the documentation that is already maintained showing timely submission of reporting to the Federal Government. Name(s) of the contact person(s) responsible for corrective action: Fanta Harkiso & Derek Cary Planned completion date for corrective action plan: August 31, 2025
View Audit 362374
Finding 571462 (2024-005)
Significant Deficiency 2024
City and County of Denver
CO
Matching / Level of Effort / Earmarking § 200.303
Federal Program Name: Child Care and Development Fund Cluster – Assistance Listing No. 93.575, 93.596 Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend the City implement a control to ensure the CBMS user acce...
Federal Program Name: Child Care and Development Fund Cluster – Assistance Listing No. 93.575, 93.596 Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend the City implement a control to ensure the CBMS user access rights are offboarded timely when employees separate employment or move departments that do not require them to keep CBMS access. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Add Second Level verification: DHS Help Desk supervisor will be copied on Departure notices from Human Resources. The DHS Help Desk Supervisor will match IAM offboard notices from State OIT to Internal Human Resources Departure notices on a weekly basis and follow-up on any unmatched items. Name(s) of the contact person(s) responsible for corrective action: Carl Ellis, TS IT Supervisor Planned completion date for corrective action plan: April 1, 2025
View Audit 362374
Finding 571454 (2024-004)
Significant Deficiency 2024
City and County of Denver
CO
Procurement, Suspension & Debarment § 200.303
Federal Program Name: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds (CSLFRF Program)– Assistance Listing No. 21.027 Compliance Requirement: Suspension and Debarment Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: We recommend ...
Federal Program Name: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds (CSLFRF Program)– Assistance Listing No. 21.027 Compliance Requirement: Suspension and Debarment Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: We recommend that the City incorporate specific language into its existing procurement process—particularly regarding suspension and debarment requirements—by clearly assigning responsibility for conducting these checks to the agency receiving and overseeing the federal award, both prior to any federal spending and on a recurring basis thereafter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:  Procedure Enhancement: The Department of Finance’s Grant Operations team will develop and publish a more detailed procedure and FAQ outlining the process for conducting suspension and debarment checks in compliance with federal requirements. This will include clear guidance on: o The timing (prior to execution and upon renewal or amendment) o The verification method (e.g., SAM.gov), o Required documentation standards for these checks (attaching with the contract or purchase order in Workday, the City’s financial system of record)  Clarification of Roles and Responsibilities: The updated procedure will explicitly address multi-agency procurements. It will specify that the agency receiving and managing the federal funding is responsible for completing and documenting the suspension and debarment check, regardless of which agency initiates or supports the procurement process.  Training and Communication: The Department of Finance and will communicate these updates through: o Direct outreach to agencies where the finding was made o Regular Grant Policy Advisory Committee (GPAC) meetings o Updated training materials for agency grant leads/liaisons Name(s) of the contact person(s) responsible for corrective action: Justin Sykes, Budget and Management Director; Toni Bellucci, Citywide Grants Manager Planned completion date for corrective action plan: August 30, 2025
View Audit 362374
Finding 571439 (2024-001)
Material Weakness 2024
Hancock County, Illinois
IL
Subrecipient Monitoring Internal Control / Segregation of Duties
Corrective Action Plan: The County Board will continue to review all claims provided to them. Anticipated Completion Date: The County is not in a financial position to hire additional employees. The increased monitoring has already begun. Responsible Parties: Mark Menn, County Board Chairman. 500 M...
Corrective Action Plan: The County Board will continue to review all claims provided to them. Anticipated Completion Date: The County is not in a financial position to hire additional employees. The increased monitoring has already begun. Responsible Parties: Mark Menn, County Board Chairman. 500 Main Street, P.O. Box 248 Carthage, Illinois 62321. (217) 357-3986; Kris Pilkington, County Treasurer. 500 Main Street, P.O. Box 248 Carthage, Illinois 62321. (217) 357-3986; Holly Wilde-Tillman, County Clerk. 500 Main Street, P.O. Box 248 Carthage, Illinois 62321. (217) 357-3911
View Audit 362373
Finding 571438 (2024-004)
Material Weakness 2024
Town of Paoli
IN
Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking Material Weakness § 200.302 § 200.303 § 200.328 § 200.329
FINDING 2024-004 Finding Subject: Water and Wast Disposal System for Rural Communities - Reporting Contact Person Responsible for Corrective Action: Beth Jones Contact Phone Number and Email Address: 812 723-2739, clerk@paoli.in.gov Views of Responsible Officials: We concur with the findings Descrip...
FINDING 2024-004 Finding Subject: Water and Wast Disposal System for Rural Communities - Reporting Contact Person Responsible for Corrective Action: Beth Jones Contact Phone Number and Email Address: 812 723-2739, clerk@paoli.in.gov Views of Responsible Officials: We concur with the findings Description of Corrective Action Plan: The town is contracted with Baker Tilly Financial Advisors and the Clerk Treasurer will provide all pertinent information to Baker Tilly in order for them to prepare the Statement of Budget, Income, and Equity- Form 442-2; and the Balance Sheet - Form 442-3) that is required by the USDA for the Sewer Bonds. Once the reports are completed by Baker Tilly, the Clerk Treasurer will review the reports and then submit them to the USDA. This will be done annually. Anticipated Completion Date: Effective immediately
View Audit 362372
Finding 571437 (2024-003)
Material Weakness 2024
Town of Paoli
IN
Procurement, Suspension & Debarment § 200.303 § 200.317 § 200.318 § 200.319 § 200.320
FINDING 2024-03 Finding Subject: Water and Waste Disposal System for Rural Communities - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Beth Jones Contact Phone Number and Email Address: 812 723-2739, clerk@paoli.in.gov Views of Responsible Officials: We c...
FINDING 2024-03 Finding Subject: Water and Waste Disposal System for Rural Communities - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Beth Jones Contact Phone Number and Email Address: 812 723-2739, clerk@paoli.in.gov Views of Responsible Officials: We concur with the findings Description of Corrective Action Plan: The Clerk Treasurer will work with the council and town attorney to make sure we are following the procurement policy and that we are compliant with the Federal and State guidelines. If a new project or a current project is being extended to a significant amount; during a council meeting, we will state that we are retaining a certain vendor for the project and explain why we are using that vendor. Anticipated Completion Date: August 1, 2025
View Audit 362372
Finding 571436 (2024-003)
Significant Deficiency 2024
Hope Shines Bright Holding Company, Inc.
NV
Procurement, Suspension & Debarment § 200.62
2024-003: Controls over Procurement, etc. The CFO, Finance Director, and/or outsourced accountant will review all contracts involving federal funds prior to execution to verify adherence to 2 CFR Part 200, Subpart D. Given the unique nature of the contract in question being executed prior to the aw...
2024-003: Controls over Procurement, etc. The CFO, Finance Director, and/or outsourced accountant will review all contracts involving federal funds prior to execution to verify adherence to 2 CFR Part 200, Subpart D. Given the unique nature of the contract in question being executed prior to the awarding of federal funds but subsequently using the federal funds to cover expenditures related to the contract, St. Jude’s Ranch for Children (the parent entity of HSB Holding Company) does not anticipate a similar scenario in the future. However, SJRC will meet with legal counsel to review existing boilerplate contracts and incorporate a 2 CFR Part 200, Subpart D compliance clause for use in any contracts with the potential to be funded by federal awards. Training will be provided to SJRC finance and program staff, led by legal counsel, covering: (i) contract negotiation basics; (ii) federal clauses that are non-negotiable (e.g., 2 CFR 200 provisions); and (iii) when legal review is required.
View Audit 362369
Finding 571435 (2024-002)
Material Weakness 2024
Hope Shines Bright Holding Company, Inc.
NV
Allowable Costs / Cost Principles Internal Control / Segregation of Duties Cash Management § 200.62
2004-002: Controls over Allowable Costs, etc. St. Jude’s Ranch for Children (the parent entity of HSB Holding Company) acknowledges that weaknesses in the financial oversight process contributed to this finding. Specifically, limited knowledge of Generally Accepted Accounting Principles (GAAP) and ...
2004-002: Controls over Allowable Costs, etc. St. Jude’s Ranch for Children (the parent entity of HSB Holding Company) acknowledges that weaknesses in the financial oversight process contributed to this finding. Specifically, limited knowledge of Generally Accepted Accounting Principles (GAAP) and federal cost principles by key financial personnel led to misclassification of costs and errors in reimbursement requests in a new type of grant unfamiliar to the accounting team. In response, the organization is restructuring its finance department to ensure that individuals with appropriate qualifications and experience in nonprofit GAAP and federal grant compliance are responsible for reviewing accounting records and reimbursement requests. This includes a new Chief Financial Officer with demonstrated experience in federal grant accounting and compliance and a dedicated grants manager to prepare all reimbursement submissions under the oversight of the CFO.
View Audit 362369
Finding 571432 (2024-001)
Material Weakness 2024
City of Cleveland
OH
Subrecipient Monitoring Reporting Internal Control / Segregation of Duties
The Department of Community Development is actively developing a formalized process to ensure FFATA compliance for all first-tier subawards exceeding $30,000. The following actions are currently underway and are anticipated to be fully implementation on July 1, 2025: Assignment of Responsibility – ...
The Department of Community Development is actively developing a formalized process to ensure FFATA compliance for all first-tier subawards exceeding $30,000. The following actions are currently underway and are anticipated to be fully implementation on July 1, 2025: Assignment of Responsibility – A designated staff member within the Fiscal Operations unit is being identified to assume primary responsibility for FFATA reporting and compliance trackingPolicy and Procedure Development – Comprehensive written procedures are being drafted to support consistent FFATA complianceTraining – Plans are in place to provide appropriate staff with the targeted training on FFATA requirements and FSRS system functionality to ensure readiness and compliance.Monitoring and Internal Controls – The Department is designing a compliance calendar and supervisory review process to track reporting deadlines and ensure adequate oversight prior to FRSR submissionSubrecipient Notification – Beginning in July 2025 program cycle, all subrecipients receiving federal awards exceeding $30,000 will be notified in their funding award letters of these additional FFATA related reporting and monitoring requirements.Review of Prior-Year Activity – The Department is reviewing subawards made during the previous reporting to assess the feasibility of retroactive reporting in consultation with the United States Department of Housing and Urban Development guidance.
View Audit 362367
Finding 571428 (2024-002)
Material Weakness 2024
Albia Community School District
IA
Internal Control / Segregation of Duties Reporting
The District will continue to review duties and procedures throughout all fiscal services to improve segregation of duty procedures. We have made changes internally that shift responsibilities between the Business Manage and Office Manager which provides an additional person having responsibilities...
The District will continue to review duties and procedures throughout all fiscal services to improve segregation of duty procedures. We have made changes internally that shift responsibilities between the Business Manage and Office Manager which provides an additional person having responsibilities with investments, cash, and the overall financial reporting.
View Audit 362355
Cook County (midlothian) School District No. 143
IL
Reporting
The District will implement a process to track the submission time of the data collection form and audit package.
The District will implement a process to track the submission time of the data collection form and audit package.
View Audit 362350
Finding 571398 (2024-002)
Significant Deficiency 2024
Jefferson County Iowa
IA
Allowable Costs / Cost Principles
Data Collection Form Name of the contact person: Christy Conner, County Auditor Corrective Action: Future data collection forms will be filed by the due date. Proposed Completion Date: Future audits.
Data Collection Form Name of the contact person: Christy Conner, County Auditor Corrective Action: Future data collection forms will be filed by the due date. Proposed Completion Date: Future audits.
View Audit 362348
Finding 571397 (2024-001)
Material Weakness 2024
Jefferson County Iowa
IA
Internal Control / Segregation of Duties
Segregation of Duties Name of contact person: Christy Conner, County Auditor Corrective Action: The duties will be separated as much as possible and alternative controls will be considered to compensate for lack of separation. Proposed Completion Date: Ongoing.
Segregation of Duties Name of contact person: Christy Conner, County Auditor Corrective Action: The duties will be separated as much as possible and alternative controls will be considered to compensate for lack of separation. Proposed Completion Date: Ongoing.
View Audit 362348
Adams County, Colorado
CO
Questioned Costs Eligibility Cash Management
Condition: During our testing of 40 Foster Care IV-E benefit transactions, we noted one sample out of forty total samples where the individual receiving payment under Foster Care IV-E was not eligible as the individual did not meet the eligibility requirement of living with a parent or specified rel...
Condition: During our testing of 40 Foster Care IV-E benefit transactions, we noted one sample out of forty total samples where the individual receiving payment under Foster Care IV-E was not eligible as the individual did not meet the eligibility requirement of living with a parent or specified relative during the required timeframe. Recommendation: We recommend the County collaborate with the Colorado Department of Human Services to ensure that reimbursements under Foster Care IV-E only occur for individuals that are eligible under the Foster Care IV-E Program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: The Adams County Human Services (ADHS) finance staff will implement a monthly review comparing the IV-E status report in the ADHS Mango application to the monthly Discoverer payments report from the State of Colorado system. This monthly process should show IV-E payments made for clients who were flagged non-IV eligible. If errors are found, ADHS will send a list of the clients and payments in question to the state for their review and correction. ADHS finance staff will also verify that we have correctly entered the client eligibility determination in the state system. Name of the contact person responsible for corrective action: Maurice Stenberg Planned completion date for corrective action plan: December 31, 2025
View Audit 362347 Questioned Costs: $1
Finding 571395 (2024-002)
Material Weakness 2024
Windham Exempted Village School District
OH
Equipment & Real Property Management Internal Control / Segregation of Duties § 200.313
The District will maintain property records in accordance with District Policy & Uniform Guidance and ensure that equipment and/or property acquired with federal funds will be inventoried and reconciled within two preceding years of acquisition.
The District will maintain property records in accordance with District Policy & Uniform Guidance and ensure that equipment and/or property acquired with federal funds will be inventoried and reconciled within two preceding years of acquisition.
View Audit 362333
Finding 571392 (2024-002)
Significant Deficiency 2024
St. Vincent General Hospital District
CO
Reporting
The hospital asked the audit team for support in filing this year. An action plan has been developed so that this is done internally in 2025.
The hospital asked the audit team for support in filing this year. An action plan has been developed so that this is done internally in 2025.
View Audit 362330
Finding 571391 (2024-001)
Material Weakness 2024
St. Vincent General Hospital District
CO
Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303
Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, ...
Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, over the past 12 months we have started to reap the reward of the hard work through operationally increasing revenue, reducing costs, and being more strategic on service lines. This will allow for us to hit the reserve amounts in 2025, while maintaining the cash flow needed for operations.
View Audit 362330
Finding 571386 (2024-001)
Material Weakness 2024
City of Laporte
IN
Internal Control / Segregation of Duties Special Tests & Provisions HUD Housing Programs § 200.303
FINDING Section III – Internal Controls - CDBG Contact Person Responsible for Corrective Action: Mary Ann Richards, CDBG Program Manager Contact Phone Number: (219) 362-8260 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Reporting-Financial Summary ...
FINDING Section III – Internal Controls - CDBG Contact Person Responsible for Corrective Action: Mary Ann Richards, CDBG Program Manager Contact Phone Number: (219) 362-8260 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Reporting-Financial Summary Report (PR26) The City of La Porte Community Development Block Grant will submit the following report to the Clerk/Treasurer and Director of Community Development and Planning for review and approval prior to submitting to HUD: PR26 Annual Financial Summary. Special Tests and Provisions - Environmental Reviews The City of La Porte Community Development Block Grant will develop a checklist listing forms and correspondence required when completing an environmental review. The Director of Community Development and Planning will review the environmental review file and sign the checklist thereby indicating the environmental review is complete and properly maintained. Special Tests and Provisions – Rehabilitation The City of La Porte Community Development Block Grant will develop a evaluation form for the Director of Community Development and Planning to review to compare the initial site visit, work scope, and certificate of completion is properly maintained. The Community Development Block Grant program manager will initiate the form for review by the Director of Community Development and Planning at the end of the rehab activity per address. Anticipated Completion Date: July 1, 2025
View Audit 362316
Finding 571358 (2024-001)
Significant Deficiency 2024
Franklin County Public Utility District No. 1
WA
Subrecipient Monitoring Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.318
The District will modify the federal procurement language existing in its current policy in accordance with 2 CFR 200.
The District will modify the federal procurement language existing in its current policy in accordance with 2 CFR 200.
View Audit 362298
Finding 571349 (2024-001)
Significant Deficiency 2024
Powell Boulevard Apartments, Inc.
OR
HUD Housing Programs Eligibility
Powell Boulevard Apartments, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024 Name and address of independent accounting firm: CohnReznick LLP 350 Granite Street Suite 1200 Braintree MA 02184 Audit period: January 1 – December 31, 2024 The fi...
Powell Boulevard Apartments, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024 Name and address of independent accounting firm: CohnReznick LLP 350 Granite Street Suite 1200 Braintree MA 02184 Audit period: January 1 – December 31, 2024 The findings from the December 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Federal Award Findings and Questioned Costs Item 2024-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.181 Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that recertifications are performed timely and signed, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: Management reviewed the AR in question and confirmed that all documentation, including EIV, was performed and obtained in January 2024. The 50059 was not signed until 3/13/24 for a 3/1/24 effective date because the tenant was unavailable due to sickness. Property staff were reminded it is REACH policy to receive all documentation and signatures by the effective date to be considered complete. Completion Date: May 23, 2025. If the Department of the Housing and Urban Development has questions regarding this plan, please contact Margaret Salazar at (503) 231-0682 or by email at msalazar@reachcdc.org Sincerely, Margaret Salazar Chief Executive Officer May 23, 2025
View Audit 362296
Finding 571348 (2024-002)
Material Weakness 2024
Collaborative for Children
TX
Procurement, Suspension & Debarment
Finding #2024-002 – Material Weakness and Other Noncompliance. Applicable federal program: U. S. Department of Treasury, Passed through Harris County, COVID-19 – Coronavirus State and Local Fiscal Recovery Funds, Assistance Listing #: 21.027, Contract Number: SLFRFP1966, Contract Year: 05/16/23 ...
Finding #2024-002 – Material Weakness and Other Noncompliance. Applicable federal program: U. S. Department of Treasury, Passed through Harris County, COVID-19 – Coronavirus State and Local Fiscal Recovery Funds, Assistance Listing #: 21.027, Contract Number: SLFRFP1966, Contract Year: 05/16/23 – 05/15/25. Recommendation: Provide additional training to program and finance personnel on the required procurement processes using updated written procurement policies and procedures and emphasize adherence to these policies and procedures. Planned corrective action: CFC will review and revise current procurement policies to reflect best practices and regulatory requirements, create comprehensive training materials, including presentations, handouts, and real-world procurement scenarios, and schedule and deliver mandatory annual training sessions for all program and finance personnel. We will also conduct periodic reviews to ensure adherence to procurement policies and provide feedback and corrective guidance as needed. Responsible officer: Leslie Gruver, Chief Financial Officer. Estimated completion date: September 30, 2025.
View Audit 362290
Finding 571347 (2024-001)
Significant Deficiency 2024
Trellis Co.
MN
Questioned Costs HUD Housing Programs
FINDING 2024-001: Unauthorized fees paid by the Corporation Corrective action - Management has contacted HUD and is awaiting response on how to address the situation.
FINDING 2024-001: Unauthorized fees paid by the Corporation Corrective action - Management has contacted HUD and is awaiting response on how to address the situation.
View Audit 362286 Questioned Costs: $1
Finding 571344 (2024-009)
Material Weakness 2024
Morris Colllege
SC
Equipment & Real Property Management
Management has taken the necessary steps to perform a capital asset inventory. The College has implemented the fixed asset modules in the Enterprise Resource Planning (ERP) system, Jenzabar. The College is in the process completing of completing and annual inventory.
Management has taken the necessary steps to perform a capital asset inventory. The College has implemented the fixed asset modules in the Enterprise Resource Planning (ERP) system, Jenzabar. The College is in the process completing of completing and annual inventory.
View Audit 362285
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