Corrective Action Plans

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Views of Responsible Officials: In the first quarter of 2023, management deployed a standardized platform across LCMC Health to enhance automated approval workflows. Automated enhancements included: • Automated approval routing based on predefined authorization hierarchies. • System-enforced approva...
Views of Responsible Officials: In the first quarter of 2023, management deployed a standardized platform across LCMC Health to enhance automated approval workflows. Automated enhancements included: • Automated approval routing based on predefined authorization hierarchies. • System-enforced approval checkpoints prior to payment processing. • Audit trail functionality that logs all approval actions and user activities. In addition, management conducts routine staff training and periodic reviews of authorization hierarchies to ensure on-going effectiveness and compliance with financial controls. These enhancements reflect LCMC Health’s proactive commitment to maintaining strong internal control processes
The Organization will be working with staff on retaining and obtaining all applicable, required forms in each client files for the 2024 calendar year end.
The Organization will be working with staff on retaining and obtaining all applicable, required forms in each client files for the 2024 calendar year end.
Action Item Title 2023-002 – Federal Award Findings Status (Open: In-process) Condition Written Policies The Corporation has no written policies for determining whether the activities allowed or unallowed and the allowability of costs as described in subpart E, Cost Principles of 2 CFR Part 200. Ide...
Action Item Title 2023-002 – Federal Award Findings Status (Open: In-process) Condition Written Policies The Corporation has no written policies for determining whether the activities allowed or unallowed and the allowability of costs as described in subpart E, Cost Principles of 2 CFR Part 200. Identified root cause In 2022, the Corporation became subject to Single Audit compliance requirements for the first time. However, it underestimated the complexity of navigating the intricate laws, regulations, and financial management requirements associated with federal funds. The lack of prior experience in implementing adequate internal controls, coupled with the absence of established written policies, contributed to challenges in ensuring compliance with federal cost principles and financial reporting obligations. Grantee resolution plan Written Policies The Corporation received federal funds for the first time in 2022. For the purposes of purchases or acquisitions, the Corporation is governed by Law of the General Service Administration for the Centralization of Government Purchases in Puerto Rico, Law No. 73 of 2019, which establishes the uniform purchasing process for acquisitions by the Commonwealth. The Corporation will adopt regulations for the use and disbursement of federal funds and comply with the federal regulations. Completion date By December 31, 2025. Name and Title of contact: Linnette Dávila Alemán- Financial and Budget Assistant Manager Phone: 787-724-4747 ext. 2105 Email: ldavila@cba.pr.gov Jetppeht Pérez de Corcho Morgado – General Manager Phone: 787-724-4747 ext. 2102 Email: jperez@cba.pr.gov
Finding 2023-005 – Allowable Cost Documentation In response to the finding, GEM addressed allowable cost documentation by instituting the following: A formal policy was established on 9/30/23, and going forward, GEM will implement additional oversight procedures to ensure the policy is followed and ...
Finding 2023-005 – Allowable Cost Documentation In response to the finding, GEM addressed allowable cost documentation by instituting the following: A formal policy was established on 9/30/23, and going forward, GEM will implement additional oversight procedures to ensure the policy is followed and that all requirements are met. GEM has also incorporated the formal credit card policy into the employee handbook, outlining the procedures for submitting receipts on a monthly basis. Anticipated date of completion: This policy has been in effect since September 30, 2023. Responsible party: Jamie Hicks, Senior Accounting Manager
Finding 2023-003 – Indirect Cost Allocations In response to the finding, GEM will improve program costs allocation documentation by instituting the following controls and procedures: GEM allocated indirect costs to the NSF program based on actual expenses incurred and monthly allocations approved by...
Finding 2023-003 – Indirect Cost Allocations In response to the finding, GEM will improve program costs allocation documentation by instituting the following controls and procedures: GEM allocated indirect costs to the NSF program based on actual expenses incurred and monthly allocations approved by the program administrator. These indirect costs are recorded separately in the accounting system. Formal written procedures are now in place, and we will maintain active oversight to ensure full adherence to all established policies. Anticipated date of completion: Monthly journal entry is set up with calculations for determining the dollar amount. The date of completion was October 2022 and have been updated since then. Responsible party: Jamie D. Hicks, Senior Accounting Manager
Finding 2023-002 – Allocation of Program Effort by Employees In response to the finding, GEM will institute controls and processes to document and allocate personnel time and effort to NSF program: A comprehensive manual for grants and federal funding has been developed, establishing clear written p...
Finding 2023-002 – Allocation of Program Effort by Employees In response to the finding, GEM will institute controls and processes to document and allocate personnel time and effort to NSF program: A comprehensive manual for grants and federal funding has been developed, establishing clear written policies and procedures specific to the management of federal awards. With these documented guidelines now in place, our focus is on ensuring strong oversight and consistent adherence to the established policies across all applicable operations. GEM has implemented a new timekeeping system that will allocate time and effort via approved time and expense personnel reports and reconcile these the accounting records and NSF program charges. Anticipated date of completion: Process was implemented on December 31, 2023. Responsible party: Jamie Hicks, Senior Accounting Manager
• Enhance documentation management and quarterly monitoring of performance/reporting requirements through staff coordination. • Note: Re-review of files located nearly 100% of cited documents; underlying support was available. Tagging is not mandatory; future audits to apply professional skepticism ...
• Enhance documentation management and quarterly monitoring of performance/reporting requirements through staff coordination. • Note: Re-review of files located nearly 100% of cited documents; underlying support was available. Tagging is not mandatory; future audits to apply professional skepticism through deeper file reviews. 9/30/2026 Mr. Kemsky Sigrah, Manager, Office of Compact Management Email: Kemskys22@gmail.com & Ms. Senny Phillip, Asst. Secretary Email: senny.phillip@gov.fm
Disagree with adverse compliance opinion and findings, as auditors applied Uniform Guidance (2 CFR Part 200) requirements, which are inapplicable to Compact sector grants (ALN 15.875) governed exclusively by the Compact of Free Association, as amended, and the Fiscal Procedures Agreement (FPA). • Re...
Disagree with adverse compliance opinion and findings, as auditors applied Uniform Guidance (2 CFR Part 200) requirements, which are inapplicable to Compact sector grants (ALN 15.875) governed exclusively by the Compact of Free Association, as amended, and the Fiscal Procedures Agreement (FPA). • Request U.S. Department of the Interior, Office of Insular Affairs, to disregard these findings for grant administration and questioned costs resolution, as they do not reflect noncompliance with Compact/FPA standards. • Maintain commitment to accountability under Compact/FPA standards. 9/30/2026 Ms. Christina Elnei, Asst. Secretary of National Treasury (primary contact) Email: christina.elnei@dofa.gov.fm
• Disagree with adverse compliance opinion and findings, as auditors applied Uniform Guidance (2 CFR Part 200) requirements, which are inapplicable to Compact sector grants (ALN 15.875) governed exclusively by the Compact of Free Association, as amended, and the Fiscal Procedures Agreement (FPA). • ...
• Disagree with adverse compliance opinion and findings, as auditors applied Uniform Guidance (2 CFR Part 200) requirements, which are inapplicable to Compact sector grants (ALN 15.875) governed exclusively by the Compact of Free Association, as amended, and the Fiscal Procedures Agreement (FPA). • Request U.S. Department of the Interior, Office of Insular Affairs, to disregard these findings for grant administration and questioned costs resolution, as they do not reflect noncompliance with Compact/FPA standards. • Maintain commitment to accountability under Compact/FPA standards. 9/30/2026 Ms. Christina Elnei, Asst. Secretary of National Treasury (primary contact) Email: christina.elnei@dofa.gov.fm
Views of responsible officials and planned corrective action: During the transition to the new Executive Director, payroll transaction procedures have been put into effect in order to ensure that pay increases, timesheets, and performance reviews are properly reviewed and approved by management, BOD...
Views of responsible officials and planned corrective action: During the transition to the new Executive Director, payroll transaction procedures have been put into effect in order to ensure that pay increases, timesheets, and performance reviews are properly reviewed and approved by management, BOD, or the executive director. Contact Persons: Carly Burwell, Board Treasurer & Bethany Alhaidri, Executive Director
2023-003 ALLOWABLE ACTIVITIES AND ALLOWABLE COSTS - SIGNIFICANT DEFICIENCY Federal Program Emergency Rental Assistance ALN 21.023; passed through the County of Berks. Condition/Cause For 23 out of 60 cases tested, the amount paid for rent or utilities did not agree to a lease agreement or bills on f...
2023-003 ALLOWABLE ACTIVITIES AND ALLOWABLE COSTS - SIGNIFICANT DEFICIENCY Federal Program Emergency Rental Assistance ALN 21.023; passed through the County of Berks. Condition/Cause For 23 out of 60 cases tested, the amount paid for rent or utilities did not agree to a lease agreement or bills on file for the following reasons: (I) clerical errors, (2) duplicate payments due to multiple staff working on the same file, or (3) failure to request or maintain support before payment was made. Known questioned costs associated with the 23 exceptions noted in our testing were $9,867. Based on the projection of the sampling results to the remaining population, we project additional likely questioned costs of approximately $173,400. The Authority did not have controls in place to detect the noncompliance prior to issuing payments. We recommend the Authority revisit and strengthen internal controls over tracking individual payments for transactions entered as batches, particularly when related to federal awards. We encourage the Authority to continue working to identify the individual transactions making up the remainder of the federal expenditures under this program. We also recommend the Authority revisit and strengthen internal controls over allowable activities and allowable costs related to grant programs. Management Response The Authority launched the Emergency Rental Assistance Program (ERAP) with little administrative guidance from the U.S. Treasury. The Authority contracted with the Berks Coalition to End Homelessness (BCEH) to undertake various aspects of the Emergency Rental Assistance Program and in the late fall of 2021, the Authority began reviewing all case documentation provided by BCEH. This review eliminated the vast majority of the errors noted. The Authority also updated case documentation checklists as well as provided training for staff involved with ERAP. Current Status of Corrective Action Plan The Authority has resolved this finding. An additional review was added at the close of each case.
Going forward, we must be sure to follow the rules in OGAPP Manual 100.3, Personnel Costs, which states that even though cost of overtime/bonuses are chargeable to federal grants, they are only allowable to the extent that the costs comply with certain guidelines. For bonuses, they are limited to 3%...
Going forward, we must be sure to follow the rules in OGAPP Manual 100.3, Personnel Costs, which states that even though cost of overtime/bonuses are chargeable to federal grants, they are only allowable to the extent that the costs comply with certain guidelines. For bonuses, they are limited to 3% of an employee's gross wages (not including fringes) or $1,500, whichever is less. The Ohio Department of Health (ODH) program administrator must approve all bonuses and enter a comment in GMIS in the project comments section.
Finding 1166097 (2023-006)
Material Weakness 2023
Audit Finding Reference: 2023-006 Improve Internal Controls Over Reporting (Significant Deficiency) Planned Corrective Action: The City strives to report accurate expenditures and regretfully an outside consultant was coordinating these tasks and working off site. Regretfully, I can only address thi...
Audit Finding Reference: 2023-006 Improve Internal Controls Over Reporting (Significant Deficiency) Planned Corrective Action: The City strives to report accurate expenditures and regretfully an outside consultant was coordinating these tasks and working off site. Regretfully, I can only address this finding as learning experience. We cannot rely on a vendor to submit expenditure information without proper city sign off. This finding has been addressed moving forward. Our ARP A compliance office has been on board since this finding. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Stephen T .. Spencer, City Comptroller December 31, 2025
Finding 1166078 (2023-003)
Material Weakness 2023
Audit Finding Reference: 2023-003 Maintain Employee's Time and Effort Records (Material Weakness) Planned Corrective Action: The lack of record keeping in Community Development and our Special Education Department is a concern, CD has addressed this finding however still working with the School Depa...
Audit Finding Reference: 2023-003 Maintain Employee's Time and Effort Records (Material Weakness) Planned Corrective Action: The lack of record keeping in Community Development and our Special Education Department is a concern, CD has addressed this finding however still working with the School Department to address this finding. The context below is from CD: Corrective action implemented with City FY24 (07/01/23-06/30/24). Annually, a budget for staff salary and fringe is developed and approved by CD Director Marsh. The annual budget details staff hours and cost centers each will be charged during the year ( e.g. CDBG activity delivery, CDBG admin, Seaport Marina, Auditorium, ESG, etc.). Additionally, employees track time on individual time sheets weekly. This finding was also noted at the last HUD monitoring review, and marked as resolved and closed in June 2024 following HUD's post review. Name of Contact Person and Completion Date James Marsh, Executive Director of The Office of Community Development & Kevin McHugh, School Business Administrator December 31, 2025
Finding 1166069 (2023-002)
Material Weakness 2023
Audit Finding Reference: 2023-002 Improve Controls and Documentation Over Allowability of Costs (Significant Deficiency) Planned Corrective Action: We try our best to have proper paperwork in order prior to processing invoices. In the time of COVID, we had some issues with staff working off site whi...
Audit Finding Reference: 2023-002 Improve Controls and Documentation Over Allowability of Costs (Significant Deficiency) Planned Corrective Action: We try our best to have proper paperwork in order prior to processing invoices. In the time of COVID, we had some issues with staff working off site which could of lead to this finding, I strongly feel that we are improving on this finding as we progress in stressing internal controls. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Stephen T. Spencer, City Comptroller December 31, 2025
Finding 1166049 (2023-001)
Material Weakness 2023
Audit Finding Reference: 2023-001 Improve Controls and Documentation Over Payroll Process (Material Weakness) Planned Corrective Action: The School Payroll Department is working to supply all applicable back up for staff being funded by Federal Funds. This has been an issue and we have been stressin...
Audit Finding Reference: 2023-001 Improve Controls and Documentation Over Payroll Process (Material Weakness) Planned Corrective Action: The School Payroll Department is working to supply all applicable back up for staff being funded by Federal Funds. This has been an issue and we have been stressing that this is a finding and more diligence needs to occur in order to remove this finding. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Kevin McHugh, School Business Administrator December 31, 2025
Corrective Action Planned: In July 2023, the Organization implemented ADP Work Force Now to systematically capture hours worked, the supervisor’s approval and audit trail to reflect the work performed. Budget and Grants in conjunction with the program and Human Resources will implement a hindsight r...
Corrective Action Planned: In July 2023, the Organization implemented ADP Work Force Now to systematically capture hours worked, the supervisor’s approval and audit trail to reflect the work performed. Budget and Grants in conjunction with the program and Human Resources will implement a hindsight review of employee working hours with a certification by the employee and supervisor. Name(s) of Contact Person(s) Responsible for Corrective Action: Betsey Knapp, Director of Budgets and Contracts; Alvin Sinckler, Chief Financial Officer Anticipated Completion Date: November 15, 2025.
Corrective Action Plan: Accounts Payable Specialist will send a series of follow up emails to grant managers for, but not limited to IDEA, Title I, & 21 st Century Grants and will file in designated location for each respective grant. Business Administrator will follow up on a semi-annual basis. Nam...
Corrective Action Plan: Accounts Payable Specialist will send a series of follow up emails to grant managers for, but not limited to IDEA, Title I, & 21 st Century Grants and will file in designated location for each respective grant. Business Administrator will follow up on a semi-annual basis. Name of Responsible Person: Business Administrator - Evan Arsenault Anticipated Implementation Date of Corrective Action: July I, 2024
Description: Management’s schedule of Expenditures of Federal Awards was incomplete, resulting in lack of identification of the need for a Single Audit and the delay in its completion. The State funder indicated that no Federal Single Audit was required. Management had not implemented a formal proce...
Description: Management’s schedule of Expenditures of Federal Awards was incomplete, resulting in lack of identification of the need for a Single Audit and the delay in its completion. The State funder indicated that no Federal Single Audit was required. Management had not implemented a formal process for preparation of the SEFA. Recommendation: Management should prepare a master tracking schedule for government grants which includes the source of funding and audit and reporting requirements. The schedule should be prepared by someone with knowledge of the grant agreements and reviewed by a leader in the accounting department to ensure completeness. Responsible Contact: Laura McQuay, Vice President & Chief Financial Officer Corrective Action Planned: Management has implemented a master tracking schedule for government grants that includes the source of funding and audit and reporting requirements. This tracker is a joint effort between finance and grants management teams. Anticipated Completion Date: December 31, 2025
Since January of 2024, CRA has done the following: Created a Human Resources Department, which did not exist before. Hired a Full Time Human Resources Director to oversee the department. Initiated a comprehensive Human Resources system where staff can review their pay, track their time, and review b...
Since January of 2024, CRA has done the following: Created a Human Resources Department, which did not exist before. Hired a Full Time Human Resources Director to oversee the department. Initiated a comprehensive Human Resources system where staff can review their pay, track their time, and review benefits. Initiated the process of uploading personnel information to our new system, while keeping backups secured in our Google Nonprofit workspace - including hiring documentation and change of status forms for employees.
2023-003 Allowable Costs/Cost Principles: Written Financial Policies The Biddeford-Saco-Old Orchard Beach Transit Committee acknowledges the need to formally adopt certain written financial management policies as outlined in federal regulations. The new finance manager is currently working to draft ...
2023-003 Allowable Costs/Cost Principles: Written Financial Policies The Biddeford-Saco-Old Orchard Beach Transit Committee acknowledges the need to formally adopt certain written financial management policies as outlined in federal regulations. The new finance manager is currently working to draft and formalize these policies and procedures with a targeted completion date of March 31, 2026. We will present them to the Board of Directors for review and official adoption.
2023-002 Activities Allowed and Allowable Costs To address the finding regarding missing backup documentation for cash disbursements, the Biddeford-Saco-Old Orchard Beach Transit Committee has implemented new workflow controls in our new integrated accounting software. Starting July 1, 2025 all empl...
2023-002 Activities Allowed and Allowable Costs To address the finding regarding missing backup documentation for cash disbursements, the Biddeford-Saco-Old Orchard Beach Transit Committee has implemented new workflow controls in our new integrated accounting software. Starting July 1, 2025 all employees are now required to create a purchase order (PO) and obtain approvals before payments can be made. This process controlled by the finance manager creates a complete audit trail for every transaction, ensuring that all disbursements are properly documented.
Finding 2023-007 – Payroll and Cash Management Deficiencies Responsible official: Executive Director and Accountants Corrective action planned: Management acknowledges that the same payroll and cash management deficiencies identified in the 2023 audit also occurred during 2024 and part of 2025. Spec...
Finding 2023-007 – Payroll and Cash Management Deficiencies Responsible official: Executive Director and Accountants Corrective action planned: Management acknowledges that the same payroll and cash management deficiencies identified in the 2023 audit also occurred during 2024 and part of 2025. Specifically, when federal cash balances were insufficient, payroll was paid temporarily from private funds, followed by the issuance of federal checks to employees for reimbursement purposes. During the 2025 audit, management recognized this as a recurring and systemic deficiency. A formal Cash Management and Interfund Transfer Policy is now being drafted and will be approved by the Board by February 2026. This policy will require: 1. Payroll to be processed directly from the federal account when possible. 2. Temporary transfers from private funds to be documented as interfund advances, with full repayment recorded upon reimbursement. 3. Prohibition of issuing duplicate payroll checks to employees. 4. Reconciliation of all interfund transfers within ten (10) business days after reimbursement. The organization will also implement a dual-authorization process for interfund transactions and establish a monthly reconciliation checklist to be completed by accounting staff and reviewed by the Executive Director. Monitoring: Monthly payroll and cash reconciliations will be reviewed by the Executive Director, and External Accountant. Evidence of reconciliations and approvals will be retained for audit purposes. Target completion date: March 31, 2026 Status: New finding – corrective actions in process.
Finding No. 2023-001 Area: Allowable Costs/Cost Principles Views of Auditee and Planned Corrective Action: We agree with this finding and the department will have to seek available funds from our State General Funds to settle this. Unfortunately, this was an expenditure passed two fiscal years, I ca...
Finding No. 2023-001 Area: Allowable Costs/Cost Principles Views of Auditee and Planned Corrective Action: We agree with this finding and the department will have to seek available funds from our State General Funds to settle this. Unfortunately, this was an expenditure passed two fiscal years, I can only admit that the payment process sounded acceptable due to the urgency of the situation at that time; however, now that we have realized that Sector money used to bring the students back was inappropriate and should not have been allowed, we regretfully have to admit our failure and seek solutions to settle this appropriately. In line with the findings, the department of education management is looking into this with the Kosrae State Scholarship Board and agree to formulate a new disbursement policy with Sector student scholarship awards. This new disbursement policy with sector student scholarship will have all student scholarship routed thru Kosrae Department of Education Director’s office for his or his designee for compliance. The department will also strengthen it’s internal control by verifying terms and conditions specified in the Compact grant awards before we proceed with the fund disbursement. Anticipated Completion Date: Ongoing Name of Contact Person: Mr. Tulensru Waguk Director Department of Education Email: twaguk@kosrae.doe.fm
View Audit 373101 Questioned Costs: $1
Finding --- The Organization does not consistently reconcile its quarterly financial reports submitted to governmental agencies to the general ledger by grant program. Corrective action – Management will develop and implement written procedures to improve their reporting process in accordance with U...
Finding --- The Organization does not consistently reconcile its quarterly financial reports submitted to governmental agencies to the general ledger by grant program. Corrective action – Management will develop and implement written procedures to improve their reporting process in accordance with Uniform Guidance and New Jersey 15-08-OMB. Status --- Corrective action in progress. Completion date --- Before December 31, 2025 Contact --- Laura Purdy, COO Contact phone --- (973) 742-5518 Contact address --- 223 Ellison St., Paterson, New Jersey 07505
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