Corrective Action Plans

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Department of Health and Human Services, Passed Through Substance Abuse and Mental Health Services Administration, Section 223 Demonstration Programs to Improve Community Mental Health Services Listing 93.829, H79SM085287, 8/31/2022- 8/30/2023 Allowable Activities or Unallowed, Allowable Costs/Cost ...
Department of Health and Human Services, Passed Through Substance Abuse and Mental Health Services Administration, Section 223 Demonstration Programs to Improve Community Mental Health Services Listing 93.829, H79SM085287, 8/31/2022- 8/30/2023 Allowable Activities or Unallowed, Allowable Costs/Cost Principles, Cash Management, and Matching, Level of Effort, and Earmarking 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
Finding 523383 (2023-033)
Significant Deficiency 2023
Finding No.: 2023-033 Reporting Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency acknowledges this finding and recognizes it as an ongoing issue related to the alignment of our reporting with t...
Finding No.: 2023-033 Reporting Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency acknowledges this finding and recognizes it as an ongoing issue related to the alignment of our reporting with the Department of Administration (DOA) financial system. One of the primary challenges arises from transactions that are not processed within the designated reporting period, which impacts on our initial submissions to CMS. Any adjustments or transactions made after the quarter's close, which were not captured in our previous reports, contribute to this issue. We understand that addressing this finding is a critical part of our corrective action measures. We are currently working on updating the existing Standard Operating Procedure (SOP) 2023-01, which governs interactions between the Department of Public Health and Social Services (DPHSS) and DOA/Division of Accounts. Since November 2024, we have been collaborating with DOA to revise this SOP with the goal of reconciling Medicaid and CHIP expenditures, as well as aligning reports from CMS-64 with the new Guam Financial Management Information System (GFMIS). Currently, PMS staff is in the process in finalizing the DRAFT SOP. We intend to have the DRAFT SOP completed and forwarded to DOA by Friday, January 31, 2025. If there are no changes to the SOP, we will work to have the SOP signed by all parties no later than February 14, 2025.
Finding 523371 (2023-029)
Significant Deficiency 2023
Finding No.: 2023-029 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward.
Finding No.: 2023-029 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward.
View Audit 342645 Questioned Costs: $1
Finding 523340 (2023-002)
Significant Deficiency 2023
This condition existed due to multiple payroll systems used during the last two audit periods and untrained personnel. Current staff is fully trained on a new payroll system and capable of maintaining our newly developed processes and controls. Anicipated completion date is at the completion of the ...
This condition existed due to multiple payroll systems used during the last two audit periods and untrained personnel. Current staff is fully trained on a new payroll system and capable of maintaining our newly developed processes and controls. Anicipated completion date is at the completion of the 2024 audit. Responsible contact person is Caitlin Cole, Human Resources manager.
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
We will work to implement a risk assessment plan. We will implement controls to help make sure we are in compliance with all grant requirements and federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance ...
We will work to implement a risk assessment plan. We will implement controls to help make sure we are in compliance with all grant requirements and federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance supplement to work from.
We agree that we have not been reporting on a timely basis current findings and results. We have established a schedule to ensure that the submission of all required annual reports is strictly adhered to. To this end, we aim to complete the year-end closing within the first 30 days after the end of ...
We agree that we have not been reporting on a timely basis current findings and results. We have established a schedule to ensure that the submission of all required annual reports is strictly adhered to. To this end, we aim to complete the year-end closing within the first 30 days after the end of the calendar year, in order to complete the audit within the first 120 days after the end of the calendar year. This plan was implemented in December 2024. However, because the report for the single audit for December 2023 was already past due by the time of implementation, the positive effects of this plan will be reflected in future reporting periods.
Finding Reference: 2023-003 Views of Responsible Officials and Planned Corrective Actions The Agency agrees with this finding and recommendation as presented. Given this finding, the Agency will review monthly its application of the approved provisional indirect cost rate to all grants, contracts, a...
Finding Reference: 2023-003 Views of Responsible Officials and Planned Corrective Actions The Agency agrees with this finding and recommendation as presented. Given this finding, the Agency will review monthly its application of the approved provisional indirect cost rate to all grants, contracts, and other agreements covered by 2 CFR 200. The agency will proceed in the following scope of work:  Ensure indirect chargers follow the applicable cost principles per 2 CFR 200, Appendix IV, and grant agreement.  Receive permission from funders for indirect charges over the allocation of the indirect costs per the grant agreement. Name of the contact person responsible for corrective action: Michael Young, President, (301) 274-4474. Planned completion date for corrective action plan: December 31, 2025
MFIP and TANF Youth – Assistance Listing No. 93.558 Recommendation: The Organization should implement a comprehensive documentation retention policy that includes specific procedures for maintaining records supporting the allocation of individual employees' time. This policy should ensure that all r...
MFIP and TANF Youth – Assistance Listing No. 93.558 Recommendation: The Organization should implement a comprehensive documentation retention policy that includes specific procedures for maintaining records supporting the allocation of individual employees' time. This policy should ensure that all relevant documentation, such as timesheets and work allocation records, is retained for the required period and is easily accessible for audit purposes. Additionally, staff responsible for timekeeping and financial recordkeeping should receive training on the importance of documentation retention and the specific requirements under the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To establish a standardized cost allocation methodology for staff time, CMJTS implemented in-person monthly allocation meetings with the executive team and program managers responsible for programming, staffing, and budget oversight. These meetings provide a thorough review of program expenditures and staff time, ensuring accurate alignment with funding requirements. Conducting payroll allocation reviews in a group setting allows the executive team to validate cost assignments, address changes in percentage allocations across cost categories, and maintain compliance with administrative regulations and funding guidelines. Name(s) of the contact person(s) responsible for corrective action: Jake Humphrey Planned completion date for corrective action plan: Implemented
MFIP and TANF Youth – Assistance Listing No. 93.558 Recommendation: The Organization should implement a comprehensive documentation retention policy that includes specific procedures for maintaining records supporting the calculation of indirect cost allocations. This policy should ensure that all r...
MFIP and TANF Youth – Assistance Listing No. 93.558 Recommendation: The Organization should implement a comprehensive documentation retention policy that includes specific procedures for maintaining records supporting the calculation of indirect cost allocations. This policy should ensure that all relevant documentation is retained for the required period and is easily accessible for audit purposes. Additionally, the Organization should ensure the formal review process for indirect cost allocations is completed to verify their accuracy and compliance with applicable regulations. Staff responsible for financial record-keeping and review should receive training on the importance of documentation retention, review procedures, and the specific requirements under the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To strengthen our financial recordkeeping, CMJTS will update our Document Retention Policy. This updated policy will introduce detailed guidelines for the management, maintenance, and secure storage of records that support indirect cost allocations, ensuring they are retained for the required period and easily accessible for audits. Additionally, we will establish a structured review process, including quarterly reviews by the accounting team and an annual reconciliation, to verify accuracy and compliance with applicable regulations. Any necessary adjustments will be documented and reviewed by the finance manager. The CMJTS Executive meets monthly to review and calculate indirect cost allocations for all active grants. The established process is to determine total indirect costs (like rent, utilities, administrative salaries) for the agency by location and department and then allocate them across different grants using a calculated "indirect cost rate," which is usually a percentage of the direct costs associated with each program, based on factors like staff time, caseload size, or other relevant allocation bases; this ensures that each program bears a proportional share of the shared overhead expenses. Name(s) of the contact person(s) responsible for corrective action: Jake Humphrey Planned completion date for corrective action plan: Policy updates – 12 months; Indirect Cost Rates process – implemented
Head Start - ALN #93.600 Recommendation: We recommend that the Organization should review and approve the indirect costs that are allocated by the preparer and retain support of this review and approval. Explanation of disagreement with audit finding: There is no disagreement with the audit finding...
Head Start - ALN #93.600 Recommendation: We recommend that the Organization should review and approve the indirect costs that are allocated by the preparer and retain support of this review and approval. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: WCCA will implement a policy to ensure a documented review and approval of indirect cost allocations. Name(s) of the contact person(s) responsible for corrective action: Carrie Tripp, Executive Director Planned completion date for corrective action plan: September 30, 2025
Finding 522900 (2023-003)
Significant Deficiency 2023
Management accepts this finding and notes that payrolls effected were at the very end of the current audit period and that the error was identified and corrected independently in the subsequent fiscal year. To further address this repeat issue, payroll will run monthly payroll queries and conduct an...
Management accepts this finding and notes that payrolls effected were at the very end of the current audit period and that the error was identified and corrected independently in the subsequent fiscal year. To further address this repeat issue, payroll will run monthly payroll queries and conduct an internal audit of payroll. Additionally, the Sponsored Research Office will work with PI’s to encourage them to plan their summer research efforts such that a research project is not included on more than one summer salary request forms. Although management feels this was an isolated incidence, the University will implement a set of controls that require a secondary review of all manuals calculation for payroll authorizations.
This was an oversight and has been corrected.
This was an oversight and has been corrected.
Finding 522819 (2023-005)
Significant Deficiency 2023
All payroll transmittals and payroll reporting forms will be reviewed by the Fiscal Administrator and/or Fiscal Officer to ensure the supervisor’s signature is present on all payroll reporting forms and that the Director’s or their designee’s signature is present on all payroll transmittals submitte...
All payroll transmittals and payroll reporting forms will be reviewed by the Fiscal Administrator and/or Fiscal Officer to ensure the supervisor’s signature is present on all payroll reporting forms and that the Director’s or their designee’s signature is present on all payroll transmittals submitted to the Auditor’s Office. Supervisors were notified of the need to make sure their signature is on their forms before submitting. All forms missing signatures will be returned to the supervisor before reporting hours. Digital and wet signatures are both acceptable signatory forms.
TOFMHS concurs with the finding. The excess drawdowns were the result of accounting entries to record refunds, or other adjustments which reduced previously allowable expenses. Subsequent drawdowns should have been reduced to offset these adjustments. TOFMHS will implement ACF-IM-HS-23-01 (Treatment...
TOFMHS concurs with the finding. The excess drawdowns were the result of accounting entries to record refunds, or other adjustments which reduced previously allowable expenses. Subsequent drawdowns should have been reduced to offset these adjustments. TOFMHS will implement ACF-IM-HS-23-01 (Treatment of Rebates, Refunds, Discounts), and prevent an recurrence of this issue in the future. Corrective Active Taken: TOFMHS returned the $51,664 to the Payment Management System on January 16, 2025 in accordance with the referenced Information Memorandum. Drawdowns will be based upon actual expenses and disbursed within 3 business days. Responsible Person: Finance Director with oversight by the Program Director.
Finding 522783 (2023-009)
Significant Deficiency 2023
2023-009 – Subrecipient Monitoring Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Subrecipient Monitoring). Program. Substance Abuse and Mental Health Services - Projects of Regional and National Significance; U.S. Department of Health and Human ...
2023-009 – Subrecipient Monitoring Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Subrecipient Monitoring). Program. Substance Abuse and Mental Health Services - Projects of Regional and National Significance; U.S. Department of Health and Human Services; Assistance Listing Number 93.243; Award Number 1H79SM084918-01. Auditor Description of Condition and Effect: Subaward contracts review did not contain appropriate information related to the federal program. No assistance listing number or federal program name was noted in the language of the agreements. In addition, no evidence of formal risk assessment was documented. The City is exposed to an increased risk that future noncompliance could occur and not be prevented or detected by the City's internal controls. Auditor Recommendation: We recommend that the City implement necessary internal controls to ensure documentation of its compliance with the requirements of the Uniform Guidance is maintained. Corrective Action: The City will implement the necessary internal controls to ensure the policy for compliance is followed and documented. Part of the solution will be implementing grant management software. Responsible Person: Phillip Moore, Chief Financial Officer Anticipated Completion Date: January 21, 2025
Finding 522781 (2023-010)
Significant Deficiency 2023
2023-010– Special Reporting for Federal Funding Accountability and Transparency Act Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Reporting). Programs. Choice Neighborhoods Implementation Grant; U.S. Department of Housing and Urban Development; ...
2023-010– Special Reporting for Federal Funding Accountability and Transparency Act Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Reporting). Programs. Choice Neighborhoods Implementation Grant; U.S. Department of Housing and Urban Development; Assistance Listing Number 14.889' Award Number MI5F519CNG117. Substance Abuse and Mental Health Services - Projects of Regional and National Significance; U.S. Department of Health and Human Services; Assistance Listing Number 93.243; Award Number 1H79SM084918-01. Auditor Description of Condition and Effect: Despite passing through qualifying amounts, the City could produce no evidence that the subawards had been reported through the FSRS. The City is exposed to an increased risk that future noncompliance could occur and not be prevented or detected by the City's internal controls. Auditor Recommendation: We recommend that the City implement necessary internal controls to ensure that reporting of subawards greater than $30,000 is submitted to the FSRS for all direct grants. Corrective Action: The City will implement the necessary internal controls to ensure the policy for compliance is followed and documented. Responsible Person: Phillip Moore, Chief Financial Officer Anticipated Completion Date: January 21, 2025
2023-012– Support for Payroll Allocations Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control Over Compliance (Allowable Costs/Cost Principles). Program. Community Block Grants/Entitlement Grants; U.S. Department of Housing and Urban Development; Assistance Listing Nu...
2023-012– Support for Payroll Allocations Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control Over Compliance (Allowable Costs/Cost Principles). Program. Community Block Grants/Entitlement Grants; U.S. Department of Housing and Urban Development; Assistance Listing Number 14.218; All awards. Auditor Description of Condition and Effect: During testing it was noted that the actual amounts charged to the grant were initially charged using the allocation rates from the previous pay period, and subsequently adjusted to the proper amount through a manual journal entry. When factoring in the amounts of the journal entries, the amount charged to the grant still differed from the support provided for 3 items of the 29 tested. The City is exposed to an increased risk that future noncompliance could occur and not be prevented or detected by the City's internal controls. Auditor Recommendation: We recommend that the City implement necessary internal controls to ensure that all allocations of personnel cost are allocated according to the support retained. Corrective Action: The City will implement the necessary internal controls to ensure the policy for compliance is followed and documented. Responsible Person: Phillip Moore, Chief Financial Anticipated Completion Date: January 22, 2025
2023-011– Report Filing - 2022 and 2023 CAPER Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Contol Over Compliance (Reporting). Program. Community Block Grants/Entitlement Grants; U.S. Department of Housing and Urban Development; Assistance Listing Number 14.218; All Aw...
2023-011– Report Filing - 2022 and 2023 CAPER Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Contol Over Compliance (Reporting). Program. Community Block Grants/Entitlement Grants; U.S. Department of Housing and Urban Development; Assistance Listing Number 14.218; All Award Numbers. Auditor Description of Condition and Effect: As of the completion of audit fieldwork, the 2022 and 2023 CAPERs have not been filed. The City is exposed to an increased risk that future noncompliance could occur and not be prevented or detected by the City's internal controls. Auditor Recommendation: We recommend that the City implement necessary internal controls to ensure that all required reports are submitted in a timely manner. Corrective Action: The City will implement the necessary internal controls to ensure the policy for compliance is followed and documented. Responsible Person: Phillip Moore, Chief Financial Officer Anticipated Completion Date: January 21, 2025
Management’s response/corrective action plan - We agree the $49,807 was reimbursed twice. We communicated the error to our contact at the USDA and our next grant draw shall be reduced by $49,807.
Management’s response/corrective action plan - We agree the $49,807 was reimbursed twice. We communicated the error to our contact at the USDA and our next grant draw shall be reduced by $49,807.
View Audit 341902 Questioned Costs: $1
Finding #2023-001 Allowable Costs and Cost Principles: Douglas Wilson was unable to determine if the Center complied with the 15% requirement or the $25,000 technical assistance limit for the CCBHC grant. Douglas Wilson was also unable to test a sample of direct costs charged to the program because...
Finding #2023-001 Allowable Costs and Cost Principles: Douglas Wilson was unable to determine if the Center complied with the 15% requirement or the $25,000 technical assistance limit for the CCBHC grant. Douglas Wilson was also unable to test a sample of direct costs charged to the program because transaction details were not provided. Per the recommendation of Douglas Wilson, we have updated the Center’s existing financial policy and procedures to include language specifically related to how the Center will retain documentation to support costs that are charged to the CCBHC grant, and also track and monitor compliance with the 15% and $25,000 maximum requirements for the grant (see Financial Policies and Procedures Policy A-14). Responsible official: Sydney Blair, Chief Executive Officer, 406.791.9603 Expected completion date: June 30, 2025
No payments will be made for purchases until the proper documentation is received and attached to the purchase order
No payments will be made for purchases until the proper documentation is received and attached to the purchase order
View Audit 341776 Questioned Costs: $1
For the coding of expenditures for Federal Awards, State Awards, or Pass-through funding, the appropriate Finance, Program Manager, and Program personnel should review the award packet especially the compliance expenditure section where the agency defines the allowable expenses that can be paid, or ...
For the coding of expenditures for Federal Awards, State Awards, or Pass-through funding, the appropriate Finance, Program Manager, and Program personnel should review the award packet especially the compliance expenditure section where the agency defines the allowable expenses that can be paid, or unallowable expenses cannot be included in the program reporting. There are free webinars provided by the Federal Government that will help personnel understand the criteria under “2 CFR Part 200, Subpart E – Cost Principles “for federal awards. Before expenses are incurred, they should be approved through the Purchase Authorization Process with all appropriate signatures being acquired depending on the amount of the expense planned. We meet on a monthly basis to review allowable expenses and the tracking of funds with departments heads.
View Audit 341763 Questioned Costs: $1
With the changes in the Leadership Team, the staff is currently reviewing and re-allocating personnel costs into direct program costs and indirect allocatable costs to be distributes through an acceptable allocation or De Minimus calculation. These changes are planned for the current contract year ...
With the changes in the Leadership Team, the staff is currently reviewing and re-allocating personnel costs into direct program costs and indirect allocatable costs to be distributes through an acceptable allocation or De Minimus calculation. These changes are planned for the current contract year with the original program budget submissions being amended to reflect these changes and approved by the funding agency. Currently, AUL utilizes two allocation methods when applicable. Those methods are the Federal De Minimus calculation, or the Direct Administrative Cost Recovery Allocation developed in conjunction with Maximus. All direct labor personnel should be recording their time spent on a program in the Paychek’s Payroll System using the appropriate dropdown listing if the program is a Summit County program the personnel should complete a PAR report monthly for the program time and it should be signed and approved by the Program Director or their designee. These forms should be forwarded to the Finance Department to that they are included in any Program Billing that is necessary for reimbursement. We have established a signature coversheet before we send the invoice to the entity for payment. PAR's are part of this reviewing process.
View Audit 341763 Questioned Costs: $1
Corrective Action: Management agrees with the findings. While we have policies and procedures as recommended by the auditors, there is an opportunity to review our policies and procedures related to the review and approval around disbursements. Through the leadership of our Chief Financial Office...
Corrective Action: Management agrees with the findings. While we have policies and procedures as recommended by the auditors, there is an opportunity to review our policies and procedures related to the review and approval around disbursements. Through the leadership of our Chief Financial Officer and our Director of Finance, our internal control policies and procedures will be evaluated and as needed, amended, with an effective date no later than June 30, 2025. Anticipated Completion Date: June 30, 2025 Contact Person: Marco Giordano, Vice President and Chief Financial Officer
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