Corrective Action Plans

Finding 575148 (2023-002)

Material Weakness 2023

PR

Reporting Significant Deficiency

The Municipality Administration is committed to complying with all submissions and has ensured the proper signing of an external auditor's firm to comply with such requirements.

View Audit 365237

Finding 575141 (2023-001)

Significant Deficiency 2023

Regional School Unit No. 18

ME

Internal Control / Segregation of Duties

Management’s response/corrective action plan: Management takes compliance matters seriously and is committed to ensuring that all applicable regulations, including Davis-Bacon Act requirements, are adhered to. We have conducted a review of our processes and procedures related to prevailing wage rate...

Management’s response/corrective action plan: Management takes compliance matters seriously and is committed to ensuring that all applicable regulations, including Davis-Bacon Act requirements, are adhered to. We have conducted a review of our processes and procedures related to prevailing wage rate compliance. This review has helped us identify areas where improvements can be made to ensure full compliance with these requirements. We have taken the following actions to address the identified compliance issue: 1. Management will proactively include prevailing wage language in any qualifying district construction project bids and contracts. 2. To strengthen our compliance efforts, we have improved monitoring to regularly assess our adherence to prevailing wage rate requirements for projects with federal assistance. This includes periodic reviews of construction projects, and proposed projects, to identify any potential non-compliance issues. Additionally, we will conduct prevailing wage compliance reviews of all certified payrolls as they are received. Management will oversee this monitoring to ensure ongoing compliance.

View Audit 365228

Finding 575025 (2023-009)

Significant Deficiency 2023

Leadership Memphis

TN

Allowable Costs / Cost Principles

Corrective Action: This finding is a continuation of a prior year deficiency related to the lack of formal allocation methodologies. Management is currently drafting a cost allocation policy that includes specific guidance on how to allocate shared costs (e.g., rent, insurance, software) across prog...

Corrective Action: This finding is a continuation of a prior year deficiency related to the lack of formal allocation methodologies. Management is currently drafting a cost allocation policy that includes specific guidance on how to allocate shared costs (e.g., rent, insurance, software) across programs, management & general, and fundraising functions. The new policy will include acceptable bases such as square footage, staff headcount, or usage logs and will be reviewed annually. All allocations will be supported by schedules retained with the audit documentation.

View Audit 365202

Finding 575024 (2023-008)

Significant Deficiency 2023

Leadership Memphis

TN

Allowable Costs / Cost Principles

Corrective Action: The Organization lacked adequate timekeeping and pay rate documentation controls during FY23, and no current management or staff were present at the time. As of FY26, the Organization has begun implementing new payroll oversight processes. Going forward, timecards will be required...

Corrective Action: The Organization lacked adequate timekeeping and pay rate documentation controls during FY23, and no current management or staff were present at the time. As of FY26, the Organization has begun implementing new payroll oversight processes. Going forward, timecards will be required for any employee whose time is allocated to multiple functions or funding sources. Management will also require documentation of payroll approvals (e.g., signed letters or memos) for all employees and will store these documents in both hard copy and electronic format. Payroll allocation methodologies will be reassessed at least every three years using a representative time study.

View Audit 365202

Finding 575023 (2023-007)

Significant Deficiency 2023

Leadership Memphis

TN

Corrective Action: Although current management was not involved during the audit period, the Organization recognizes the importance of documented expenditure review under Uniform Guidance. A formal procedure is being developed that will require all grant-related expenditures to be reviewed and initi...

Corrective Action: Although current management was not involved during the audit period, the Organization recognizes the importance of documented expenditure review under Uniform Guidance. A formal procedure is being developed that will require all grant-related expenditures to be reviewed and initialed or electronically approved by authorized personnel. The policy will require documentation that clearly demonstrates both the allowability of the cost and its alignment with approved program activities. These procedures will be implemented and tested beginning with FY26 expenditures.

View Audit 365202

Finding 575015 (2023-005)

Significant Deficiency 2023

New Orleans Career Center

LA

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

Status: In progress. Planned Corrective Action: The New Orleans Career Center will update its financial policies to require verifying all vendors against the SAM.gov suspension and debarment list. Person(s) Responsible: Claire Jecklin, CEO; Darius Munchak, CFO Estimated Completion Date: December 31,...

Status: In progress. Planned Corrective Action: The New Orleans Career Center will update its financial policies to require verifying all vendors against the SAM.gov suspension and debarment list. Person(s) Responsible: Claire Jecklin, CEO; Darius Munchak, CFO Estimated Completion Date: December 31, 2025

View Audit 365197

Finding 575014 (2023-004)

Significant Deficiency 2023

New Orleans Career Center

LA

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Status: In progress. Planned Corrective Action: The New Orleans Career Center will update its financial policies to ensure that employees classified to federal programs receive updated offer letters detailing their compensation. Person(s) Responsible: Claire Jecklin, CEO; Darius Munchak, CFO Estimat...

Status: In progress. Planned Corrective Action: The New Orleans Career Center will update its financial policies to ensure that employees classified to federal programs receive updated offer letters detailing their compensation. Person(s) Responsible: Claire Jecklin, CEO; Darius Munchak, CFO Estimated Completion Date: December 31, 2025

View Audit 365197

Finding 574731 (2023-001)

Significant Deficiency 2023

Pro Viviendas Iv, Inc.

PR

HUD Housing Programs Cash Management

Management will proceed to transfer from the operational to the reserve account $5,684 corresponding to the undeposited deficiency ($812 per month) during the period from June to December 2023. Evidence of the deposit to the reserve account will be sent to HUD office as agreed. Popular bank will be ...

Management will proceed to transfer from the operational to the reserve account $5,684 corresponding to the undeposited deficiency ($812 per month) during the period from June to December 2023. Evidence of the deposit to the reserve account will be sent to HUD office as agreed. Popular bank will be notified about the matter and while the amount is adjusted through the monthly mortgage payment, Management will continue to make monthly deposits of $812.00 through 2023 fiscal year to cover the deficiency. The responsible person for the corrective action plan is Carmen G Rivera, Blanco’s Administrative Director. The estimated completion date for the finding is May 31, 2024. Management will ensure deposits to the replacement reserve account are made on a monthly basis as stated in the use agreement.

View Audit 365039

Finding 574730 (2023-001)

Significant Deficiency 2023

Pro Viviendas Iii, INC

PR

HUD Housing Programs Cash Management

Management will proceed to transfer from the operational to the reserve account $5,684 corresponding to the undeposited deficiency ($812 per month) during the period from June to December 2023. Evidence of the deposit to the reserve account will be sent to HUD office as agreed. Popular bank will be ...

Management will proceed to transfer from the operational to the reserve account $5,684 corresponding to the undeposited deficiency ($812 per month) during the period from June to December 2023. Evidence of the deposit to the reserve account will be sent to HUD office as agreed. Popular bank will be notified about the matter and while the amount is adjusted through the monthly mortgage payment, Management will continue to make monthly deposits of $812.00 through 2023 fiscal year to cover the deficiency. The responsible person for the corrective action plan is Carmen G Rivera, Blanco’s Administrative Director. The estimated completion date for the finding is May 31, 2024. Management will ensure deposits to the replacement reserve account are made on a monthly basis as stated in the use agreement.

View Audit 365038

Finding 574728 (2023-001)

None 2023

Goshen Valley Foundation

GA

Goshen Valley will submit the 2023 report package and ensure that all future audit reports are submitted to the FAC in a timely manner.

View Audit 365035

Finding 574716 (2023-003)

Significant Deficiency 2023

City of Wilkes-Barre, Pennsylvania

PA

Reporting

The City plans to have information ready for auditors to get 2024 done in a reasonable time frame. This finding will likely carry to 2024 but between staffing and priorities, the City hopes to have cleared by the 2025 audit

View Audit 365027

Finding 574708 (2023-001)

Significant Deficiency 2023

National Council of Negro Women, Inc.

DC

Management will implement measures to ensure thst financial statements are completed as expeditiously as possibe to enable the Single Audit to be completed in the required time frame

View Audit 364988

Finding 574610 (2023-003)

Material Weakness 2023

Southwestern Christian University, Inc.

OK

Material Weakness

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Southwestern Christian University acknowledges the importance of the Gramm-Leach-Bliley Act (GBLA) and the responsibilities it places on higher education institutions to protect personal and financial information of students, fami...

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Southwestern Christian University acknowledges the importance of the Gramm-Leach-Bliley Act (GBLA) and the responsibilities it places on higher education institutions to protect personal and financial information of students, families, and employees. We are committed to safeguarding sensitive data as part of our responsibility to operate with integrity and stewardship. To address these findings, SCU is working closely with our IT specialist in taking the following steps: a. Information Security Program: we are formalizing a written information security plan that meets the GLBA requirements, including risk assessment, safeguards, and monitoring. b. Designation of Coordinator: A qualified staff member has been designated to oversee GLBA compliance and ensure accountability in implementing safeguards. c. Employee training: Faculty and staff will be trained on data privacy, cybersecurity practices, and proper handling of sensitive information. d. Technical Safeguards: We will be enhancing systems for data encryption, access controls, and monitoring to reduce risks related to unauthorized access or disclosure. e. Ongoing review: Regular testing, audits, and updates will be conducted to ensure continuous improvement and adherence to GLBA standards. At Southwestern Christian University, we believe in protecting the personal information of our students and families is part of our mission of stewardship. Just as we are called to be faithful with financial resources, we are equally called to be trustworthy in safeguarding data. We are confident that the corrective actions being implemented will ensure that SCU not only meets compliance standards but also reflects our values of integrity, accountability and care. Person Responsible for Corrective Action Plan: Mark Arthur, Chief Financial Officer Anticipated Date of Completion: June 30, 2026

View Audit 364874

Finding 574609 (2023-003)

Material Weakness 2023

Van Bibber Lake Conservancy District

IN

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

FINDING 2023-003 Finding Subject: Water and Waste Disposal Systems for Rural Communities - Reporting Contact Person Responsible for Corrective Action: Tina Sillery, Financial Clerk Contact Phone Number and Email Address: (765) 739-6671 and vblconservancy@airhop.com Views of Responsible Officials: We...

FINDING 2023-003 Finding Subject: Water and Waste Disposal Systems for Rural Communities - Reporting Contact Person Responsible for Corrective Action: Tina Sillery, Financial Clerk Contact Phone Number and Email Address: (765) 739-6671 and vblconservancy@airhop.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Federal funding for the project was fully spent in 2024. In the future, reports required for federal awards will be prepared by the Financial Clerk and reviewed and approved by the District Board or a District Board member. Anticipated Completion Date: August 1, 2025 INDIANA

View Audit 364873

Finding 574594 (2023-004)

Material Weakness 2023

West Hancock Community School District

IA

SEE RESPONSE AND CORRECTIVE ACTION PLAN 2022-001

View Audit 364847

Finding 574592 (2023-005)

Significant Deficiency 2023

Southwest Regional Development Commission

MN

Reporting Internal Control / Segregation of Duties Significant Deficiency

Finding Summary: There was no formal review documented over several reports tested, some reports were not submitted timely as required by the specific award requirements, and one report did not have supporting documentation on hand. Responsible Individuals: Jay Trusty, Executive Director Corrective ...

Finding Summary: There was no formal review documented over several reports tested, some reports were not submitted timely as required by the specific award requirements, and one report did not have supporting documentation on hand. Responsible Individuals: Jay Trusty, Executive Director Corrective Action Plan: Management has reviewed the findings and taken steps in developing an internal control review process. The Commission implemented procedures to ensure all reports have proof of review and submission, as well as working towards submitting all reports timely. Anticipated Completion Date: June 2026

View Audit 364840

Finding 574586 (2023-004)

Material Weakness 2023

Bristol Bay Borough, Alaska

AK

Subrecipient Monitoring Material Weakness Reporting

Finding 2023-004: Reporting – Material Weakness in Internal Control Over Compliance and Material Noncompliance Name of Contact Person: James Wilson, Borough Manager/Acting Finance Director Corrective Action Plan: New controls are being put into place to ensure that all subawards over $30,000 are pro...

Finding 2023-004: Reporting – Material Weakness in Internal Control Over Compliance and Material Noncompliance Name of Contact Person: James Wilson, Borough Manager/Acting Finance Director Corrective Action Plan: New controls are being put into place to ensure that all subawards over $30,000 are properly and timely reported. Completion Date: September 30, 2025

View Audit 364808

Finding 574585 (2023-003)

Significant Deficiency 2023

Bristol Bay Borough, Alaska

AK

Period of Performance Allowable Costs / Cost Principles Reporting § 200.512

Finding 2023-003: Reporting - Timely Submission of Financial Reports – Significant Deficiency in Internal Control over Compliance and Noncompliance Name of Contact Person: James Wilson, Borough Manager/Acting Finance Director Corrective Action Plan: The Borough is in the process of engaging addition...

Finding 2023-003: Reporting - Timely Submission of Financial Reports – Significant Deficiency in Internal Control over Compliance and Noncompliance Name of Contact Person: James Wilson, Borough Manager/Acting Finance Director Corrective Action Plan: The Borough is in the process of engaging additional stakeholders to expedite the completion of future financial reports. Completion Date: September 30, 2025

View Audit 364808

Finding 574582 (2023-006)

Material Weakness 2023

Northshore University Healthsystem

IL

Reporting § 200.303 § 200.502 § 200.510

Finding 2023-006 – Reporting Assistance Listing 21.027, Coronavirus State and Local Fiscal Recovery Fund The management has taken corrective action to ensure accurate SEFA reporting. These actions include clarifying reporting timelines, improving coordination between finance and the grants managemen...

Finding 2023-006 – Reporting Assistance Listing 21.027, Coronavirus State and Local Fiscal Recovery Fund The management has taken corrective action to ensure accurate SEFA reporting. These actions include clarifying reporting timelines, improving coordination between finance and the grants management team, and implementing new policy and procedures for SEFA reporting. Finance and grants management staff will jointly review all grant activity at year-end to ensure proper inclusion in SEFA. Management acknowledges the importance of accurate SEFA reporting and is committed to strengthening internal controls to prevent similar issues in future reporting periods. Responsible Official: Annaliza Villamin, System Director of Accounting, Endeavor Health

View Audit 364802

Finding 574543 (2023-003)

Material Weakness 2023

Northshore University Healthsystem

IL

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

Finding 2023-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple Workday allows costing allocations, which automatically split salaries above and below the cap. This process ensures that only appropriate salaries are charged to the grant. Management...

Finding 2023-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple Workday allows costing allocations, which automatically split salaries above and below the cap. This process ensures that only appropriate salaries are charged to the grant. Management will update the salary cap in the system in a timely manner and validate that the system is calculating correctly. Going forward, management will do a quarterly review of the effort distributions, and make adjustments when needed in a timely manner. Responsible Official: Robert Stanton, Assistant Vice President, Research and Financial Operations, NSH Research Central Office

View Audit 364802 Questioned Costs: $1

Finding 574510 (2023-004)

Material Weakness 2023

Northshore University Healthsystem

IL

Questioned Costs Subrecipient Monitoring

Finding 2023-004 – Subrecipient Monitoring Assistance Listing 93.391, Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis. Management will use the system level policy and procedures related to sub-recipient assessment an...

Finding 2023-004 – Subrecipient Monitoring Assistance Listing 93.391, Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis. Management will use the system level policy and procedures related to sub-recipient assessment and monitoring that are in place from the Research department. We will leverage key resources within the organization to address areas of noncompliance. Responsible Official: Ashlee Jean Roffe, Director of Nutrition and Community Health, Community CARE

View Audit 364802 Questioned Costs: $1

Finding 574488 (2023-005)

Significant Deficiency 2023

Northshore University Healthsystem

IL

Allowable Costs / Cost Principles

Finding 2023-005 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple As soon as the annual rate is calculated and reviewed after the annual audit is complete, Research will provide the approved fringe rate to accounting. Accounting will use the approved...

Finding 2023-005 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple As soon as the annual rate is calculated and reviewed after the annual audit is complete, Research will provide the approved fringe rate to accounting. Accounting will use the approved rate prospectively. Accounting will assess the variance between the new approved rate and the prior rate used. Research will approve the adjustment based on materiality and document the adjustment process. Management will develop a policy around the fringe allocation and adjustment Responsible Official: Robert Stanton, Assistant Vice President, Research and Financial Operations, NSH Research Central Office and Annaliza Villamin, System Director of Accounting, Endeavor Health

View Audit 364802

Finding 574484 (2023-002)

Material Weakness 2023

Northshore University Healthsystem

IL

Allowable Costs / Cost Principles Reporting

Finding 2023-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple The new Workday time and effort certification is now operational. Each individual is able to certify their own time and effort in the system, which eliminates manual tracking and paper...

Finding 2023-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple The new Workday time and effort certification is now operational. Each individual is able to certify their own time and effort in the system, which eliminates manual tracking and paperwork. Management will follow up and validate the effort certification is occurring in a timely manner. Management is currently drafting the policy to align with the new process. There will be continuous staff training and monitoring in this area. Responsible Official: Robert Stanton, Assistant Vice President, Research and Financial Operations, NSH Research Central Office

View Audit 364802

Finding 574483 (2023-001)

Material Weakness 2023

Northshore University Healthsystem

IL

Reporting § 200.303 § 200.502 § 200.510

Finding 2023-001 – Reporting Assistance Listing Multiple In the immediate term, management will work with the grant consultant to modify the existing report to capture all the costs in the general ledger related to grants. Management will start a quarterly review process of the report with reconcil...

Finding 2023-001 – Reporting Assistance Listing Multiple In the immediate term, management will work with the grant consultant to modify the existing report to capture all the costs in the general ledger related to grants. Management will start a quarterly review process of the report with reconciliation to the grant detail. In addition, prior to the UG audit, management will start a year-end review process to ensure accurate and timely reporting. Responsible Official: Annaliza Villamin, System Director of Accounting, Endeavor Health

View Audit 364802

Finding 574457 (2023-003)

Material Weakness 2023

Pinecrest Medical Care Facility

MI

Material Weakness Reporting Matching / Level of Effort / Earmarking

Finding: 2023-003 Condition: The Facility does not have a review process in place related to the lost revenue calculation input into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program. The Facility also did not have a review p...

Finding: 2023-003 Condition: The Facility does not have a review process in place related to the lost revenue calculation input into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program. The Facility also did not have a review process in place for the required submissions. Planned Corrective Action: Management agrees with the finding and will implement a process to ensure an independent review of the reporting submission and its supporting documents is completed prior to finalization. Contact person responsible for corrective action: Brooke Ponchaud, Chief Financial Officer Anticipated Completion Date: 05/01/2024

View Audit 364788

Corrective Action Plans

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