Corrective Action Plans

Finding 1170949 (2023-007)

Material Weakness 2023

DARTNet Institute

CO

Procurement, Suspension & Debarment § 200.317 § 200.320

Personnel Responsible for Corrective Action: Eljana Kaziaj, Controller Anticipated Completion Date: ASAP. Goal Date is August 31, 2025 Corrective Action Plan: Management accepts the recommendation. It will modify and strengthen our policy and procedure regarding the procurement process to reflect th...

Personnel Responsible for Corrective Action: Eljana Kaziaj, Controller Anticipated Completion Date: ASAP. Goal Date is August 31, 2025 Corrective Action Plan: Management accepts the recommendation. It will modify and strengthen our policy and procedure regarding the procurement process to reflect the alignment with federal regulations. Will also maintain a suspension and debarment on vendors. The list will be reviewed monthly.

View Audit 384305

Finding 1170948 (2023-006)

Material Weakness 2023

DARTNet Institute

CO

Allowable Costs / Cost Principles § 200.305 § 200.403 § 200.430

Personnel Responsible for Corrective Action: Jim Keeney, CFO Anticipated Completion Date: Completed. Review and Approval continue consistently. Corrective Action Plan: Management has implemented a time and activity method that meets the requirements of federal regulations. It includes the use of JIR...

Personnel Responsible for Corrective Action: Jim Keeney, CFO Anticipated Completion Date: Completed. Review and Approval continue consistently. Corrective Action Plan: Management has implemented a time and activity method that meets the requirements of federal regulations. It includes the use of JIRA Software and an Excel Spreadsheet. Staff are entering time on an ongoing and consistent basis, including both actual and allowable time, for federal and non-federal contracts/agreements. These tools are reviewed and approved by executive management before any billing has transpired. Management is providing ongoing training for existing staff and new staff on an annual basis. This includes review and analysis from the accounting department to ensure proper expense accrual and revenue recognition. Management has also written an improved and detailed policy and procedure on recording actual and allowable time.

View Audit 384305

Finding 1170910 (2023-001)

Material Weakness 2023

Grand Island Regional Medical Center

NE

HUD Housing Programs Reporting Significant Deficiency

Personnel Responsible for Corrective Action: Tracy Schmitt, Chief Financial Officer Anticipated Completion Date: November 30, 2024 Views of Responsible Officials and Planned Corrective Action: The missed reporting was completed in November 2024 and accepted by the granting organization on February 2...

Personnel Responsible for Corrective Action: Tracy Schmitt, Chief Financial Officer Anticipated Completion Date: November 30, 2024 Views of Responsible Officials and Planned Corrective Action: The missed reporting was completed in November 2024 and accepted by the granting organization on February 27, 2025. The Medical Center has implemented a tracking procedure for all grants that includes due dates for required reporting. The Controller maintains a list of compliance requirements for each grant which is reviewed by the Chief Financial Officer. Additionally, the primary contact information for grants is updated upon any changes in personnel to ensure communications are routed to the appropriate individual for follow-up.

View Audit 384219

Finding 1170817 (2023-002)

Material Weakness 2023

Greene County Health Care INC

NC

Special Tests & Provisions

Individuals Responsible for Corrective Action Plan Daphne Betts-Hemby, MBA, CMPE Chief Finance Officer (252) 747-8162 dhemby@contentnea.org Corrective Action Plan: Sliding fee discounts applied to patient charges were inconsistent with the Organization’s sliding fee discount policy. The miscalculati...

Individuals Responsible for Corrective Action Plan Daphne Betts-Hemby, MBA, CMPE Chief Finance Officer (252) 747-8162 dhemby@contentnea.org Corrective Action Plan: Sliding fee discounts applied to patient charges were inconsistent with the Organization’s sliding fee discount policy. The miscalculations seem to be the leading cause of the errors noted by the auditors. Ongoing training/internal audits needs to be more robust to ensure staff understand and accurately calculate which discount the patient qualifies for. Management shall review the slide audits to determine which employees are making errors and provide re-training or corrective action as applicable and document/monitor for improvement. Anticipated Completion Date: June 30, 2026

View Audit 384082

Finding 1170814 (2023-004)

Material Weakness 2023

Pontotoc County Mississippi

MS

Reporting Internal Control / Segregation of Duties § 200.329

Corrective Action Planned: We will ensure the submission of the reports remian timely and general ledgers from the subject fiscal years are used in preparing the reports. The County will ensure that informaiton garnered from the general ledgers coincide and accurately match future reports before sub...

Corrective Action Planned: We will ensure the submission of the reports remian timely and general ledgers from the subject fiscal years are used in preparing the reports. The County will ensure that informaiton garnered from the general ledgers coincide and accurately match future reports before submission. Anticipated Completions Date: April 1, 2024. Name of person responsible for corrective action: Ricky Ferguson, Chancery Clerk.

View Audit 384080

Finding 1170738 (2023-009)

Material Weakness 2023

Hope the Mission

CA

Reporting Internal Control / Segregation of Duties § 200.510

The Schedule of Expenditures of Federal Awards (SEFA) provided to the audit firm was incomplete due to two primary factors: (1) insufficient understanding by staff regarding the requirement to include federally funded capital expenditures, and (2) improper recording of property acquisitions. Managem...

The Schedule of Expenditures of Federal Awards (SEFA) provided to the audit firm was incomplete due to two primary factors: (1) insufficient understanding by staff regarding the requirement to include federally funded capital expenditures, and (2) improper recording of property acquisitions. Management acknowledges this oversight, which occurred during the implementation of a new program and at a time when staff were not fully aware that such expenditures must be reflected on the SEFA. Furthermore, certain capital expenditures paid directly through escrow were not recorded in the organization's accounting records. To remediate these issues, management has taken the following corrective actions: - Delivered targeted training to staff on the proper treatment and reporting of federally funded capital expenditures; - Updated internal closing and reporting procedures to incorporate a formal review of balance sheet activity; and - Updated internal closing and reporting procedures to incorporate a reconciliation to settlement statements when recording new property acquisitions; and - Strengthened internal controls to ensure all federally funded capital items are accurately captured in future SEFA submissions. Management is committed to maintaining compliance with federal reporting requirements and ensuring the completeness and accuracy of future SEFA filings.

View Audit 383905

Finding 1170737 (2023-008)

Material Weakness 2023

Hope the Mission

CA

Procurement, Suspension & Debarment § 200.318 § 200.319 § 200.320

Management acknowledges this finding, which occurred during a period of rapid program expansion when procurement infrastructure had not yet been fully developed. Since the audit period, we have completely overhauled our procurement process to ensure full compliance with the Federal procurement stand...

Management acknowledges this finding, which occurred during a period of rapid program expansion when procurement infrastructure had not yet been fully developed. Since the audit period, we have completely overhauled our procurement process to ensure full compliance with the Federal procurement standards. We have implemented a formal procurement policy, created a dedicated Procurement sub-department within Finance, hired a Procurement Supervisor and support team, and launched a new procurement software platform to ensure proper solicitation, documentation, approval routing, and record retention for all Federally funded programs. These upgrades establish consistent competitive bidding, justification procedures, conflict-of-interest safeguards, and transparent procurement. In addition, we have strengthened oversight, provided staff training on Federal procurement standards, and embedded monitoring practices to ensure ongoing compliance. Management is confident these substantial structural improvements have significantly reduced the risk of noncompliance and positioned the organization for full alignment with federal procurement standards going forward.

View Audit 383905

Finding 1170736 (2023-007)

Material Weakness 2023

Hope the Mission

CA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Management acknowledges this finding and agrees that during the period under audit-while the organization was experiencing rapid growth and increased program activity-our documentation and approval processes did not consistently keep pace with operational demands. Since that time, we have taken sign...

Management acknowledges this finding and agrees that during the period under audit-while the organization was experiencing rapid growth and increased program activity-our documentation and approval processes did not consistently keep pace with operational demands. Since that time, we have taken significant steps to strengthen accounting procedures and internal controls, reinforce our invoice approval policies, and ensure all expenditures charged to Federal awards are properly reviewed and authorized prior to processing. We have enhanced our Accounts Payable workflow by implementing standardized process approval requirements, added additional leadership staffing and oversight within the Finance and Accounting team and provided targeted training to all personnel involved in invoice processing to ensure understanding of Federal cost principles and documentation standards. These corrective actions have improved our control environment since the audit period, and management is committed to continuing to develop and maintain strong financial controls and to prevent recurrence of this issue.

View Audit 383905

Finding 1170735 (2023-006)

Material Weakness 2023

Hope the Mission

CA

Allowable Costs / Cost Principles § 200.430

During this period, Hope the Mission experienced rapid organizational growth in which our internal infrastructure had not yet caught up to support the significant growth in programs and funding. Since then, management changed our 3rd party payroll provider in order to better support our payroll and ...

During this period, Hope the Mission experienced rapid organizational growth in which our internal infrastructure had not yet caught up to support the significant growth in programs and funding. Since then, management changed our 3rd party payroll provider in order to better support our payroll and reporting needs. As part of this transition, we worked closely with our new payroll provider to implement job-costing functionality that will accurately track time across grants funded programs. In addition, we have established a process requiring department leads to review and approve all timesheets prior to submission. We also partnered with our new 3rd party payroll provider to set up time allocation for salaried employees.

View Audit 383905

Finding 1170637 (2023-008)

Material Weakness 2023

City of Adelanto

CA

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303 § 200.334

Recommendation: We recommend the City enhance its internal control by implementing policies and procedures to track wage rate requirements compliance, and ensure that all certified payrolls and supporting wage-rate documentation are retained. Views of Responsible Officials: Management concurs with t...

Recommendation: We recommend the City enhance its internal control by implementing policies and procedures to track wage rate requirements compliance, and ensure that all certified payrolls and supporting wage-rate documentation are retained. Views of Responsible Officials: Management concurs with the finding. The City of Adelanto experienced higher than expected staff turnover in the finance department during the timeframe noted in this audit, which caused a backlog in audit preparation and submission, along with certain financial controls implementation interruption. At the time of this audit publishing, Management believes that implementation of such procedures is in compliance with the noted recommendation. Persons Responsible for Corrective Action: City Finance Staff (various) City Department Heads applying for grant funding (various) City Project Managers (various) Anticipated Completion Date for Corrective Action: Corrective action has been immediately implemented in response to the auditors’ recommendation. As financial reporting is still in the process of becoming current, the City anticipates finding to be removed in future fiscal years.

View Audit 383868

Finding 1170634 (2023-007)

Material Weakness 2023

City of Adelanto

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management § 200.334 § 200.415

Recommendation: We recommended the City establish internal control procedures to ensure that all reimbursement requests are reviewed and approved by an authorized official prior to submission. Views of Responsible Officials: Management concurs with the finding. The City of Adelanto experienced highe...

Recommendation: We recommended the City establish internal control procedures to ensure that all reimbursement requests are reviewed and approved by an authorized official prior to submission. Views of Responsible Officials: Management concurs with the finding. The City of Adelanto experienced higher than expected staff turnover in the finance department during the timeframe noted in this audit, which caused a backlog in audit preparation and submission, along with certain financial controls implementation interruption. At the time of this audit publishing, Management believes that implementation of such procedures is in compliance with the noted recommendation. Persons Responsible for Corrective Action: City Finance Staff (various) City Department Heads applying for grant funding (various) Anticipated Completion Date for Corrective Action: Corrective action has been immediately implemented in response to the auditors’ recommendation. As financial reporting is still in the process of becoming current, the City anticipates finding to be removed in future fiscal years.

View Audit 383868

Finding 1170631 (2023-009)

Material Weakness 2023

City of Adelanto

CA

Subrecipient Monitoring § 200.332 § 200.403 § 200.521

Recommendation: We recommended the City enhance its subrecipient monitoring activities and establish a formal record-keeping policy to ensure complete and timely documentation of expenses. Views of Responsible Officials: Management concurs with the finding. The City of Adelanto experienced higher th...

Recommendation: We recommended the City enhance its subrecipient monitoring activities and establish a formal record-keeping policy to ensure complete and timely documentation of expenses. Views of Responsible Officials: Management concurs with the finding. The City of Adelanto experienced higher than expected staff turnover in the finance department during the timeframe noted in this audit, which caused a backlog in audit preparation and submission, along with certain financial controls implementation interruption. At the time of this audit publishing, Management believes that implementation of such procedures is in compliance with the noted recommendation. Persons Responsible for Corrective Action: City Finance Staff (various) City Department Heads applying for grant funding (various) Anticipated Completion Date for Corrective Action: Corrective action has been immediately implemented in response to the auditors’ recommendation. As financial reporting is still in the process of becoming current, the City anticipates finding to be removed in future fiscal years.

View Audit 383868

Finding 1170544 (2023-005)

Material Weakness 2023

County of Delaware

PA

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

This finding occurred as a result of staff shortages, new employees and increased caseloads. The Domestic Relations Department filled vacant positions through 2023. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time fra...

This finding occurred as a result of staff shortages, new employees and increased caseloads. The Domestic Relations Department filled vacant positions through 2023. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/ petitions to case files and file documentation beginning in November 2023.

View Audit 383805

Finding 1170543 (2023-004)

Material Weakness 2023

County of Delaware

PA

Student Financial Aid Subrecipient Monitoring Eligibility

Turnover and vacancies in positions resulting in applications and petitions not being completed within 20 days of receipt. The Domestic Relations Department filled vacant positions through 2023. In response to the prior year finding, the Domestic Relations Department provided semi-annual training to...

Turnover and vacancies in positions resulting in applications and petitions not being completed within 20 days of receipt. The Domestic Relations Department filled vacant positions through 2023. In response to the prior year finding, the Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/petitions to case files and file documentation beginning in November 2023.

View Audit 383805

Finding 1170542 (2023-003)

Material Weakness 2023

County of Delaware

PA

Special Tests & Provisions Subrecipient Monitoring Reporting

This finding occurred as a result of a data entry error in the file. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/petitions to case files and file documentation beginning in No...

This finding occurred as a result of a data entry error in the file. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/petitions to case files and file documentation beginning in November 2023.

View Audit 383805

Finding 1170541 (2023-008)

Material Weakness 2023

County of Delaware

PA

Special Tests & Provisions Subrecipient Monitoring Allowable Costs / Cost Principles

The County Human Services department noted that the service providers were paid at their negotiated rates agreed upon by contract terms, however no reconciliation was completed for the remainder eligible cost adjustments to the service providers for the fiscal year ended June 30, 2023. The County Hu...

The County Human Services department noted that the service providers were paid at their negotiated rates agreed upon by contract terms, however no reconciliation was completed for the remainder eligible cost adjustments to the service providers for the fiscal year ended June 30, 2023. The County Human Services department will complete the reconciliation of the service providers costs reports for the fiscal year ended June 30, 2024 before March 2025.

View Audit 383805

Finding 1170540 (2023-007)

Material Weakness 2023

County of Delaware

PA

Subrecipient Monitoring Material Weakness Reporting

The County Human Services department will complete the Roster of Personnel (PW 1171) be submitted for the fiscal year ended June 30, 2023 by December 2024 and review the processes and controls to ensure the rosters is completed annually.

View Audit 383805

Finding 1170539 (2023-002)

Material Weakness 2023

County of Delaware

PA

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

The County Human Services department has requested approval from PA DHS of its 2021-2022 fiscal year re-submission in September 2024. Following approval of the 2021-2022 submission and re-investment the County Human Services department will complete the submission of the 2022-2023 fiscal year report...

The County Human Services department has requested approval from PA DHS of its 2021-2022 fiscal year re-submission in September 2024. Following approval of the 2021-2022 submission and re-investment the County Human Services department will complete the submission of the 2022-2023 fiscal year report. The County Human Services department will reconcile the underlying expenditure detail in the accounting system to the expenditures reported. Internal approvals prior to submission and underlying records for reports will be maintained by the County Human Services department.

View Audit 383805

Finding 1170532 (2023-006)

Material Weakness 2023

County of Delaware

PA

Subrecipient Monitoring § 200.332

The County Child and Youth Services department started requiring a corrective action plan for all subrecipients with findings as a result of their on-site monitoring in 2023 that include the entity’s plan to correct the errors noted, individual responsible and timeline for corrections to be implemen...

The County Child and Youth Services department started requiring a corrective action plan for all subrecipients with findings as a result of their on-site monitoring in 2023 that include the entity’s plan to correct the errors noted, individual responsible and timeline for corrections to be implemented. Finding noted are for monitoring completed in January and March 2023, prior to the requirement of written corrective action plans being implemented.

View Audit 383805

Finding 1170506 (2023-006)

Material Weakness 2023

Survivor Advocacy Outreach Program

OH

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.303

SAOP will establish a rocedure to track reporting due dates and implement a process for verifying the accuracy and completeness of required reports before submission.

View Audit 383712

Finding 1170505 (2023-005)

Material Weakness 2023

Survivor Advocacy Outreach Program

OH

Allowable Costs / Cost Principles § 200.403

SAOP will establish more robust internal contols to guarantee that all non-payoll charges are incurred within the tauthoized period of performance. This should involve consistent monitoring of gran periods, providing staff training on the perfoormance period, and conducting periodic reviews of expen...

SAOP will establish more robust internal contols to guarantee that all non-payoll charges are incurred within the tauthoized period of performance. This should involve consistent monitoring of gran periods, providing staff training on the perfoormance period, and conducting periodic reviews of expenditure documentation.

View Audit 383712

Finding 1170504 (2023-004)

Material Weakness 2023

Survivor Advocacy Outreach Program

OH

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

SAOP will enhance the internal controls over the payroll allocation process by conducting regular reviews and reconiliations to ensure the accuracy of payroll allocations.

View Audit 383712

Finding 1170503 (2023-003)

Material Weakness 2023

Survivor Advocacy Outreach Program

OH

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

SAOP shall establish a procedure to securely store payment support, ensuring all transactions are supported by proper documentation.

View Audit 383712

Finding 1170502 (2023-002)

Material Weakness 2023

Survivor Advocacy Outreach Program

OH

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

SAOP shall implement a policy to secure approvals for charges related to the federal program.

View Audit 383712

Finding 1170476 (2023-003)

Material Weakness 2023

Bedford Stuyvesant Restoration Corporation and Affiliates

NY

Reporting Equipment & Real Property Management

Single Audit Reporting for June 30, 2023 Finding: The Restoration did not follow the process in place for ensuring that the Single Audit reporting requirements were satisfied on a timely manner. The audit of the Restoration’s basic financial statements was not completed prior to the Single Audit rep...

Single Audit Reporting for June 30, 2023 Finding: The Restoration did not follow the process in place for ensuring that the Single Audit reporting requirements were satisfied on a timely manner. The audit of the Restoration’s basic financial statements was not completed prior to the Single Audit reporting deadlines. Contact Person: Leah M. Sparrow, WAP Director Marrolin Beauzile, Accountant Corrective Actions Taken or Planned: Restoration has implemented changes in staff that will lead the audit and lead the reporting of the program activities and program management. We are determined to complete the next two audit years (FY24 and FY25) expeditiously. We believe that these changes will lead to positive results within the next year. Anticipated completion date: December 31, 2026

View Audit 383646

Corrective Action Plans

Filters