Corrective Action Plans

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Recommendation – We recommend that management ensure that non-payroll costs charged to the program are allowable costs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – All non-payroll costs are reviewed by a supervisor be...
Recommendation – We recommend that management ensure that non-payroll costs charged to the program are allowable costs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – All non-payroll costs are reviewed by a supervisor before being approved. This supervisor review includes which programs are being charged along with other internal coding. Management has emphasized the requirements for supervisors to review invoices to verify programs are being properly charged along with other internal coding.
View Audit 344486 Questioned Costs: $1
Recommendation – We recommend that management ensure that supporting reports are current and accurate for expenses charged to federal programs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – Reports will be reviewed and ...
Recommendation – We recommend that management ensure that supporting reports are current and accurate for expenses charged to federal programs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – Reports will be reviewed and retained to support expenses in the future.
Recommendation – We recommend that management ensure that non-payroll costs charged to the program are allowable costs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – All non-payroll costs are reviewed by a supervisor be...
Recommendation – We recommend that management ensure that non-payroll costs charged to the program are allowable costs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – All non-payroll costs are reviewed by a supervisor before being approved. This supervisor review includes which programs are being charged along with other internal coding. Management has emphasized the requirements for supervisors to review invoices to verify programs are being properly charged along with other internal coding.
View Audit 344486 Questioned Costs: $1
Recommendation – We recommend that management ensure that supporting documentation for expenses charged to federal programs be maintained to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – Expense documentation will be main...
Recommendation – We recommend that management ensure that supporting documentation for expenses charged to federal programs be maintained to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – Expense documentation will be maintained to support expenses in the future.
View Audit 344486 Questioned Costs: $1
Recommendation — We recommend that management ensure that records are retained to support the validity of expenses charged to federal programs. Views of Responsible Officials and Planned Corrective Actions — Management agrees with the finding and in the future will take steps to retain or insure tha...
Recommendation — We recommend that management ensure that records are retained to support the validity of expenses charged to federal programs. Views of Responsible Officials and Planned Corrective Actions — Management agrees with the finding and in the future will take steps to retain or insure that access to records continues to be available in instances of system migrations.
Management has assessed that all supporting documentation that was unable to be provided for audit support was related to transactions that occurred on the legacy accounting system. The legacy accounting system did not allow for centralized/shared data storage, and as a result, caused personnel to s...
Management has assessed that all supporting documentation that was unable to be provided for audit support was related to transactions that occurred on the legacy accounting system. The legacy accounting system did not allow for centralized/shared data storage, and as a result, caused personnel to store information in different locations. In May 2023, the organization made the transition to the new accounting system where data can easily be centralized/shared. Management has also implemented policies and procedures that require review of documents within the accounting system prior to approval, thus creating internal controls to prevent a lack of supporting documentation for future reporting periods. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller
Management acknowledges that the organization operated with provisional rates in 2023 and did not update to actual indirect rates. Management has calculated actual rates for 2023, will update its NICRA for new provisional rates for 2025 and will institute a policy of updated rates on an annual basis...
Management acknowledges that the organization operated with provisional rates in 2023 and did not update to actual indirect rates. Management has calculated actual rates for 2023, will update its NICRA for new provisional rates for 2025 and will institute a policy of updated rates on an annual basis including computing actual indirect cost rates at the conclusion of each audit. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller
Management has assessed that all supporting documentation that was unable to be provided for audit support was related to transactions that occurred on the legacy accounting system. The legacy accounting system did not allow for centralized/shared data storage, and as a result, it caused personnel t...
Management has assessed that all supporting documentation that was unable to be provided for audit support was related to transactions that occurred on the legacy accounting system. The legacy accounting system did not allow for centralized/shared data storage, and as a result, it caused personnel to store information in different locations. In May 2023, the organization made the transition to the new accounting system where data can easily be centralized/shared. Management has also implemented policies and procedures that require review of documents within the accounting system prior to approval, thus creating internal controls to prevent a lack of supporting documentation for future reporting periods. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller
View Audit 344384 Questioned Costs: $1
Finding 2023-005 Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 5 TIN# 910171250 Activities Allowed or Unallowed, Allowable Cost...
Finding 2023-005 Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 5 TIN# 910171250 Activities Allowed or Unallowed, Allowable Cost/Cost Principles Material Weakness in Internal Control over Compliance and Noncompliance Finding Summary: Confluence Health claimed and reported expenditures that contained errors based upon the underlying documentation. Context: A nonstatistical sample of 60, supplies, services, and payroll transactions out of a population of approximately 5,215 totaling $5,006,903 were selected for testing. The sample contained errors in two transactions in which the amounts claimed on the Period 5 report were not supported by payroll records. The amounts claimed not supported by payroll records totaled $89,582 out of a total sample value of $2,615,445. Corrective Action Plan: Confluence Health will tract with separate payroll codes for employee working on federal grants that involve inpatient facing care for the next pandemic to allow for accurate tracking of costs. Responsible Individual: Eric Caldwell, VP of Finance is responsible for this corrective action plan that was put into place on January 15, 2025.
View Audit 344374 Questioned Costs: $1
We agree with the finding. Management is in the process of assessing the operational controls to prepare adequate financial reporting. The financial staff will be trained to the various steps in monitoring the financial position and operations of the Agency. Additional staff with be hired and traine...
We agree with the finding. Management is in the process of assessing the operational controls to prepare adequate financial reporting. The financial staff will be trained to the various steps in monitoring the financial position and operations of the Agency. Additional staff with be hired and trained to assist with the performance of accurate and timely reporting. We plan to complete these processes by May 31, 2025.
Finding 524563 (2023-001)
Significant Deficiency 2023
Below is Housing Forward’s response to the audit finding for fiscal year 1/1/2023 through 12/31/2023. Federal Award Finding Finding 2023-001: Allowable costs and activities – significant deficiency in internal controls over compliance and compliance finding specific to payroll allocation.  Funding ...
Below is Housing Forward’s response to the audit finding for fiscal year 1/1/2023 through 12/31/2023. Federal Award Finding Finding 2023-001: Allowable costs and activities – significant deficiency in internal controls over compliance and compliance finding specific to payroll allocation.  Funding Source: Coronavirus State and Local Fiscal Recovery Funds ALN 21.027 (CSLFRF).  Condition: During allowable cost and activities testing for the CSLFRF grant, 2 out of 40 timesheets tested did not agree to the number of hours charged to the grant.  Cause: Although the 2 timesheets were filled out completely, signed and reviewed by a supervisor, there was an error in the data entry into the accounting software. Amounts were calculated correctly but inadvertently assigned to the wrong grant. GL detail was provided to the funder as part of the monthly reporting, but neither the funder nor Housing Forward staff noticed this error.  Management’s Response: Management understands the importance of correctly charging time to funders. Housing Forward will continue its timesheet review process and utilize employee timesheets that clearly indicate funding sources and allocate payroll costs based on these records. Housing Forward will implement a second review of the payroll entry at the time it is entered into the accounting system to ensure that errors are corrected before payroll costs are charged to funders. This began in January 2025. The second reviewer will be the VP of Finance/CFO or her designee. In later FY25 the organization also plans to implement a timekeeping software that integrates with the accounting software to prevent future data entry errors. Sincerely, Sarah Kahn Sarah Kahn President & CEO
View Audit 343995 Questioned Costs: $1
Condition: Controls did not identify that expenses submitted to the State were outside of the period of performance. Planned Corrective Action: Background: Sinai began the process of risk assessment in the government grants area at the end of 2022. At that time, Sinai engaged outside counsel to as...
Condition: Controls did not identify that expenses submitted to the State were outside of the period of performance. Planned Corrective Action: Background: Sinai began the process of risk assessment in the government grants area at the end of 2022. At that time, Sinai engaged outside counsel to assist in this process. In December of 2023, Sinai created the Office of Government Grant Administration (OGGA) and developed a comprehensive grant compliance policy and procedure. The Audit and Compliance Committee of the Board was updated on this initiative. In 2024, the OGGA created a Grant Compliance Manual which sets forth processes and procedures in grant management to ensure compliance with government regulations. Unfortunately, these controls were not implemented until after the relevant time period at issue in this audit. In 2025, Sinai is continuing to improve its compliance procedures with respect to government grants, and has developed the following plan: 1. Working Group: Sinai will implement a process of convening a Working Group for each government grant, which will consist of a representative from Finance, the OGGA, and the stakeholder involved (i.e., nursing, medicine, etc.) The Working group will be responsible for, among other things, ensuring that that the reported qualifying expenditures are incurred during the period of performance of the grant. In other words, allowable costs will be discussed early in the process, so that there is fulsome understanding among the key individuals involved. 2. Record-Keeping: The OGGA will also establish shared folders to house all of the pertinent documentation relative to the grant. 3. Invoice/Supporting Documentation Review. The Grant Accounting Manager will review all invoices and other supportive documentation to ensure that allowable costs are submitted for reimbursement. This compliance check will be completed prior to submission of the documentation for reimbursement. Monthly reviews of these activities will be performed by the Grant Accountant, the Compliance Grant Manager, and other OGGA staff as needed. Proactive review to prevent or resolve issues in the upcoming month’s billings should be pursued. 4. Annual Assessment. The Chief Compliance Officer, with the assistance of the General Counsel, will meet with the OGGA team annually to assess procedures and risk controls; a report of this assessment will be made to the Audit and Compliance Committee of the Board of Directors Contact person responsible for corrective action: Dimas Ortega - Vice President of Finance, Deputy Chief Financial Officer Anticipated Completion Date: 06/30/2025
View Audit 343640 Questioned Costs: $1
Finding 524098 (2023-005)
Material Weakness 2023
Action taken in response to finding: Trilogy submitted an application to apply for a new indirect cost rate in January 2024, we also received provisional approval from the federal agency to continue use of our prior approved indirect cost rate. Since then, Trilogy has clearly defined compliance req...
Action taken in response to finding: Trilogy submitted an application to apply for a new indirect cost rate in January 2024, we also received provisional approval from the federal agency to continue use of our prior approved indirect cost rate. Since then, Trilogy has clearly defined compliance requirements for maintaining an up-to-date indirect cost rate. This includes developing a timeline of responsibilities, documents and steps needed for approval. This also includes the development of an annual calendar for Finance to be proactive about expiring NICRA agreements. Name(s) of the contact person(s) responsible for corrective action: Richard Powell, Shunita Rhodes Planned completion date for corrective action plan: August 2023 and January 2024.
Finding 524097 (2023-004)
Material Weakness 2023
Action taken in response to finding: Trilogy will thoroughly review the grant agreements to understand specific start and end dates as well as any allowable cost guidelines. Training will be provided to staff on identifying cut off periods and the reviewing of invoices for expenditures will be moni...
Action taken in response to finding: Trilogy will thoroughly review the grant agreements to understand specific start and end dates as well as any allowable cost guidelines. Training will be provided to staff on identifying cut off periods and the reviewing of invoices for expenditures will be monitored closely when entered into the system to ensure it is entered into the system in the correct period in which the expense is incurred. Documentation will be reviewed by the Controller before posting to the general ledger to ensure expenses are charged to the correct grant period. During the grant invoice preparation there will be an additional review of the expenses in the general ledger to ensure the cut-off for grant expenditures are included in the correct period for the monthly grant vouchers. Trilogy will also implement a quarterly review of expenses charged to grants in preparation of the quarterly reports to ensure proper allocation to grants and cut off grant expenditures during the first and last month of the grant budget period. Name(s) of the contact person(s) responsible for corrective action: Richard Powell, Shunita Rhodes, Hagar Buster, Han Qi Planned completion date for corrective action plan: October 31, 2024, and ongoing as needed.
View Audit 343276 Questioned Costs: $1
Finding 524096 (2023-003)
Material Weakness 2023
Action taken in response to finding: Trilogy implemented a new payroll system in January 2024 that allows staff to change their allocations of time if it varies from the budget when working on grant programs. These changes can be made in blocks of time or by the day. Financial analysts and the FP&...
Action taken in response to finding: Trilogy implemented a new payroll system in January 2024 that allows staff to change their allocations of time if it varies from the budget when working on grant programs. These changes can be made in blocks of time or by the day. Financial analysts and the FP&A manager meet with program directors and program managers monthly to go over allocations and update in the UKG payroll system as well as for the preparation of the monthly grant vouchers. Name(s) of the contact person(s) responsible for corrective action: Richard Powell, Shunita Rhodes, Hagar Buster Planned completion date for corrective action plan: February 2024 and ongoing as needed.
View Audit 343276 Questioned Costs: $1
We agree with the recommendation and moving forward the District will maintain records of all federal expenditures supported by financial reports.
We agree with the recommendation and moving forward the District will maintain records of all federal expenditures supported by financial reports.
View Audit 343203 Questioned Costs: $1
We agree with the recommendation and moving forward the District’s Director of Fiscal Services will implement a review process for indirect costs that will include a review of relevant grant agreements and federal guidance.
We agree with the recommendation and moving forward the District’s Director of Fiscal Services will implement a review process for indirect costs that will include a review of relevant grant agreements and federal guidance.
View Audit 343203 Questioned Costs: $1
We agree with the recommendation and moving forward all expenditure records and financial reports will be maintained for a minimum of three years.
We agree with the recommendation and moving forward all expenditure records and financial reports will be maintained for a minimum of three years.
View Audit 343203 Questioned Costs: $1
COMMUNITY ACTION CENTER AGREES WITH THE FINDINGS REPORTED AND HAS MADE CORRECTIVE ACTION TO RECTIFY THE FINDING.
COMMUNITY ACTION CENTER AGREES WITH THE FINDINGS REPORTED AND HAS MADE CORRECTIVE ACTION TO RECTIFY THE FINDING.
U.S. Department of Housing and Urban Development Home Investment Partnerships Program – Assistance Listing No. 14.239 Recommendation: CLA recommended that PHFA review their procedures surrounding the division sign-off form utilized in the pre-commitment meeting. Explanation of disagreement with a...
U.S. Department of Housing and Urban Development Home Investment Partnerships Program – Assistance Listing No. 14.239 Recommendation: CLA recommended that PHFA review their procedures surrounding the division sign-off form utilized in the pre-commitment meeting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHFA implemented a new process to ensure the required divisional signoffs are received after the completion of the pre-commitment meeting. The Lending Officer prepares an electronic approval listing in Microsoft Teams to capture the approvals after the pre-commitment meeting. The Lending Officer follows up with the requested signors to ensure that all outstanding questions have been answered and the signer can mark the Microsoft Teams’ listing approved. Name of the contact person responsible for corrective action: Jessica Perry, Director of Development The new Microsoft Teams approval system was implemented in August 2023. To date, approximately 20 developments have been approved via the new system.
Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization has made efforts to ensure that proper documentation is maintained and accessible by necessary staff.
Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization has made efforts to ensure that proper documentation is maintained and accessible by necessary staff.
View Audit 342835 Questioned Costs: $1
Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization conducted a review after the completion of the year end to ensure reconcile the total amounts charged to the grant back to accounting records to ensure compliance, howev...
Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization conducted a review after the completion of the year end to ensure reconcile the total amounts charged to the grant back to accounting records to ensure compliance, however, this was not done in a timely enough manner to correct for misstatements. In the future the Organization will review support and reconcile on a more frequent basis.
View Audit 342835 Questioned Costs: $1
We have reviewed the qualifications for allowable expenses classified as supplies versus capital expenditures that of a 600 code with ODE CCIP representatives for project relate cash requests as well as getting pre-approval if varying from the budget details request.
We have reviewed the qualifications for allowable expenses classified as supplies versus capital expenditures that of a 600 code with ODE CCIP representatives for project relate cash requests as well as getting pre-approval if varying from the budget details request.
View Audit 342736 Questioned Costs: $1
Finding #2023-001 – Material Weakness and Material Noncompliance. Major federal programs: U. S. Department of Treasury, Assistance Listing #21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Passed through Harris County, Texas, Contract #220163, Contract year: 12/01/22 – 12/31/24, ...
Finding #2023-001 – Material Weakness and Material Noncompliance. Major federal programs: U. S. Department of Treasury, Assistance Listing #21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Passed through Harris County, Texas, Contract #220163, Contract year: 12/01/22 – 12/31/24, Assistance Listing #93.788, Opioid STR, Passed through the Texas Health and Human Services Commission, Contract #HHS000357900001, Contract years: 09/01/21 – 08/31/22 and 09/01/22 – 08/31/23, Passed through the University of Texas Health Science Center, San Antonio, Contract #HHS000561800001, Contract year: 09/01/21 – 08/31/22. Other federal programs: U. S. Department of Health and Human Services:, Assistance Listing #93.243, Substance Abuse and Mental Health Services Projects of Regional and National Significance, Contract #5H79TI080624-03, Contract year: 09/30/21 – 09/29/22, Contract #5H79TI080624-04, Contract year: 09/30/22 – 09/29/23, Passed through the City of Houston Health Department, Assistance Listing #93.243, Contract #H79SP080300, Contract years: 11/01/21 – 10/31/22, 11/01/22 – 10/31/23 and 06/08/21 – 06/30/23, Assistance Listing #93.959, Block Grants for Prevention and Treatment of Substance Abuse, Passed through the Texas Health and Human Services Commission, Contract #HHS000130500019, Contract years: 09/01/21 – 08/31/22 and 09/01/22 – 08/31/23. Condition and context: Houston Recovery Center has personnel funded by more than one grant award. The responsibilities for each position are examined and an assessment of time needed to perform each assigned task is made. The time allotment is then converted to a percentage of salary, documented on the personnel action form for each employee, and used to create the personnel section of each grant budget. Each grant is charged based on the percentages documented on the personnel action forms. In fiscal 2022, quarterly time studies were utilized to support that the budgeted estimates per the personnel action forms were reasonable and, if needed, adjustments were made in the general ledger. On July 1, 2022, Houston Recovery Center changed third-party payroll processors and the new processor did not provide the capability to charge time to more than one cost center. Therefore, while allocations are still made in the general ledger based on the percentages documented on the employee’s personnel action form, actual time worked by grant/cost center was not tracked. Additionally, a time study was not performed in the year ended June 30, 2023 to evaluate the reasonableness of time charged to the grants. Recommendation: Houston Recovery Center should establish policies and procedures to ensure that grants are charged based on actual time and effort expended. Planned corrective action: Management believes that the grants were reasonably charged in all material respects although the payroll provider was unable to allow us to use actual time and effort. Comparison of fiscal year 2022 actual time and effort with the fiscal year 2022 time studies revealed very small differences. However, Houston Recovery Center is in the process of changing to a payroll software provider where actual time can be tracked to each grant as supported by a timesheet. In addition, Houston Recovery Center is using Time Distribution Sheets (TDSs) where the employee is required to record their hours worked by grants. Training on the TDSs will be completed by November 1, 2023 for all employees on multiple awards as appropriate. TDSs will be turned in weekly and utilized until the payroll conversion is completed and is working as needed. Responsible officer: Leonard Kincaid, Executive Director. Estimated completion date: November 1, 2023.
Department of Health and Human Services, Passed Through Oklahoma Department of Mental Health and Substance Abuse Services, Block Grants for Community Mental Health Services Listing 93.958, 4529063664/4529063519, 711/2022- 6/30/2023 Allowable Activities or Unallowed and Allowable Costs/Cost Principle...
Department of Health and Human Services, Passed Through Oklahoma Department of Mental Health and Substance Abuse Services, Block Grants for Community Mental Health Services Listing 93.958, 4529063664/4529063519, 711/2022- 6/30/2023 Allowable Activities or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: As part of the audit, Eide Bailly LLP identified that the process for allocating payroll or time worked to respective federal programs was insufficient and did not substantiate allowability under the federal award guidelines. Responsible Individuals: Chief Financial Officer and Chief Human Resources Officer Corrective Action Plan: In December 2024, changes were made to the payroll system to improve tracking of time worked and appropriate allocations to respective federal grant programs. Completion Date: December 2024
View Audit 342657 Questioned Costs: $1
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