Corrective Action Plans

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Finding Number: 2023‐002 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: James Serbin, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The District will monitor and track federal grant...
Finding Number: 2023‐002 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: James Serbin, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The District will monitor and track federal grants expenditures and revenues in a fiscally responsible manner to reduce the number of inaccurate information.
Finding Number: 2023‐001 Program Names/Assistance Listing Titles: Assistance Listing Numbers: Title I Grants to Local Educational Agencies 84.010 Supporting Effective Instruction State Grants 84.367 Student Support and Academic Enrichment Program 84.424 Education Stabilization Fund 84.425C Education...
Finding Number: 2023‐001 Program Names/Assistance Listing Titles: Assistance Listing Numbers: Title I Grants to Local Educational Agencies 84.010 Supporting Effective Instruction State Grants 84.367 Student Support and Academic Enrichment Program 84.424 Education Stabilization Fund 84.425C Education Stabilization Fund 84.425D Education Stabilization Fund 84.425U Contact Person: James Serbin, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The District will provide trainings on a regular basis for personnel responsible for grants management. The District will adhere to internal controls to ensure expenditures align to grant budgets.
View Audit 366183 Questioned Costs: $1
Finding 576296 (2023-009)
Material Weakness 2023
U.S. Department of Health and Human Services Medical Assistance Program Assistance Listing Number: 93.778 Passed Through Minnesota Department of Human Services Pass Through Number: H55215048 Award Period: 2023 Recommendation: We recommend that the County review its procedures and control to ensu...
U.S. Department of Health and Human Services Medical Assistance Program Assistance Listing Number: 93.778 Passed Through Minnesota Department of Human Services Pass Through Number: H55215048 Award Period: 2023 Recommendation: We recommend that the County review its procedures and control to ensure all RMS listings sent to the State properly exclude those necessary individuals no longer working in the programs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will ensure that the reports are reviewed prior to submission going forward. Name of the contact person responsible for corrective action: Nataliya Schull, Social Services Program Analyst Planned completion date for corrective action plan: December 31, 2024
Finding 576279 (2023-014)
Significant Deficiency 2023
U.S. Department of Agriculture & U.S. Department of Health and Human Services Supplemental Nutrition Assistance Program Cluster, Temporary Assistance for Needy Families & Medical Assistance Program Assistance Listing Number: 10.561, 93.558, & 93.778 Passed Through Minnesota Department of Human Serv...
U.S. Department of Agriculture & U.S. Department of Health and Human Services Supplemental Nutrition Assistance Program Cluster, Temporary Assistance for Needy Families & Medical Assistance Program Assistance Listing Number: 10.561, 93.558, & 93.778 Passed Through Minnesota Department of Human Services Pass Through Number: H55230010, H55214077, & H55215048 Award Period: 2023 Recommendation: We recommend that the County retain documentation of review and approval of all expenditures included in the County’s Cost Allocation Plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will ensure the cost allocation plan is reconciled to the supporting documents and expenditures prior to the final review and signing of the cost allocation plan. Name of the contact person responsible for corrective action: Will Wallo, Finance Director Planned completion date for corrective action plan: December 31, 2024
Finding 576278 (2023-012)
Material Weakness 2023
U.S. Department of Agriculture & U.S. Department of Health and Human Services Supplemental Nutrition Assistance Program Cluster, Temporary Assistance for Needy Families & Medical Assistance Program Assistance Listing Number: 10.561, 93.558, & 93.778 Passed Through Minnesota Department of Human Serv...
U.S. Department of Agriculture & U.S. Department of Health and Human Services Supplemental Nutrition Assistance Program Cluster, Temporary Assistance for Needy Families & Medical Assistance Program Assistance Listing Number: 10.561, 93.558, & 93.778 Passed Through Minnesota Department of Human Services Pass Through Number: H55230010, H55214077, & H55215048 Award Period: 2023 Recommendation: We recommend that the County retain documentation of review and approval of all expenditures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will ensure documentation for all disbursements and the related review and approvals are retained going forward. Name of the contact person responsible for corrective action: Tiffinie Miller, Deputy Director of Employment & Economic Assistance Planned completion date for corrective action plan: December 31, 2024
Corrective Actions Taken or Planned Management concurs with the finding and has already initiated enhancements to its review process to ensure that expense reports are consistently reviewed and approved by both supervisors and finance personnel prior to being charged to federal awards. These steps a...
Corrective Actions Taken or Planned Management concurs with the finding and has already initiated enhancements to its review process to ensure that expense reports are consistently reviewed and approved by both supervisors and finance personnel prior to being charged to federal awards. These steps are designed to further strengthen internal controls and support compliance with federal requirements. In addition, Finance staff are formalizing procedures to reconcile payroll charges on a regular basis to ensure compliance with federal requirements and to confirm that all charges to federal programs are supported by actual time and effort records. Responsible person: Jackie Ramirez, Operations & Finance Associate Director Expected Implementation date: October 31, 2025
View Audit 366115 Questioned Costs: $1
The Organization is in the process of updating its procurement and expenditure approval procedures and will implement training for staff involved in managing federally funded programs.
The Organization is in the process of updating its procurement and expenditure approval procedures and will implement training for staff involved in managing federally funded programs.
2023-006 – Payroll (Material Weakness in Internal Controls over Compliance/Material Noncompliance) Recommendation: We recommend the College develop and implement adequate policies and procedures to ensure charging of expenses for allowability are based off approved amounts. Action Taken: The 2022-...
2023-006 – Payroll (Material Weakness in Internal Controls over Compliance/Material Noncompliance) Recommendation: We recommend the College develop and implement adequate policies and procedures to ensure charging of expenses for allowability are based off approved amounts. Action Taken: The 2022-2023 fiscal year was entirely encompassed by the separation Memorandum of Understanding (MOU) of March 2022 and then the final release settlement in December 2023. It is important to note that Southeast New Mexico College was a newly established independent community college, having formally separated from New Mexico State University (NMSU) as of April 2022. During this transition period, many administrative processes, including federal grant compliance procedures, were in the process of being developed, transitioned, and implemented independently from NMSU systems. As a result, certain policies, procedures, and documentation processes were not yet fully established or operational at the time of the audit. Unfortunately, due to the untimely receipt of the completed audit report, the College did not have the opportunity to review and begin addressing several of the findings until well after the end of the audit period. While the College is committed to corrective action, the delayed delivery of the audit limited the ability to implement corrective measures earlier. The College is working proactively to ensure that these issues are resolved going forward. Corrective Action Taken / Planned: • Policy and Procedure Development o The institution will revise or develop written policies and procedures to ensure compliance with 2 CFR §200.430. The revised procedures will include:  Detailed requirements for supporting documentation for payroll costs.  Clear guidance on time and effort reporting  Procedures for periodic payroll reconciliation between payroll records and grant charges. • Staff Training o Training will be provided for payroll, grants accounting, and department personnel involved in charging payroll costs to federal awards to ensure understanding and compliance with the new procedures. • Payroll Reconciliation o A process will be established to reconcile payroll charges to the grant with actual payroll records at least quarterly, with reviews and approvals documented. • Effort Certification o Employees whose salaries are charged to federal grants will be required to complete effort certifications, which will be reviewed and retained per federal guidelines. • Monitoring and Review o Grant accounting and payroll offices will implement an annual review to ensure continued compliance and address any gaps or errors identified. Due Date of Completion: August 31, 2025 Responsible Official: Carolyn Kasdorf, Vice President for Business and Finance (or appropriate official), Karla Volpi, Dean of Business and Finance, Lisa Ryan, Restricted Funds Manager, Steven Gonzales, Payroll Manager
View Audit 365884 Questioned Costs: $1
2023-005 – Inadequate Policies and Procedures (Significant Deficiency in Internal Controls over Compliance) Recommendation: We recommend the College establish the required written procedures for federal monies and have them available to all personnel who work with federal programs. Action Taken: T...
2023-005 – Inadequate Policies and Procedures (Significant Deficiency in Internal Controls over Compliance) Recommendation: We recommend the College establish the required written procedures for federal monies and have them available to all personnel who work with federal programs. Action Taken: The 2022-2023 fiscal year was entirely encompassed by the separation Memorandum of Understanding (MOU) of March 2022 and then the final release settlement in December 2023. It is important to note that Southeast New Mexico College was a newly established independent community college, having formally separated from New Mexico State University (NMSU) as of April 2022. During this transition period, many administrative processes, including federal grant compliance procedures, were in the process of being developed, transitioned, and implemented independently from NMSU systems. As a result, certain policies, procedures, and documentation processes were not yet fully established or operational at the time of the audit. Unfortunately, due to the untimely receipt of the completed audit report, the College did not have the opportunity to review and begin addressing several of the findings until well after the end of the audit period. While the College is committed to corrective action, the delayed delivery of the audit limited the ability to implement corrective measures earlier. The College is working proactively to ensure that these issues are resolved going forward. Corrective Action Taken / Planned: • Policy Development o The institution will develop comprehensive written policies and procedures to address compliance requirements related to 2 CFR 200, Subparts D and E of the Uniform Guidance and approved by institutional leadership by July 31, 2025. • Policy Review and Approval o Draft policies will be reviewed by VP of Business and Finance and approved by institutional leadership by August 31, 2025. • Training o Relevant personnel will be trained on the new policies and procedures to ensure consistent understanding and compliance. • Implementation o The institution will fully implement the new procedures by August 31, 2025, and will ensure all departments involved with federal awards are following them. • Ongoing Review: o Policies and procedures will be reviewed annually, and updates will be made as necessary to ensure continued compliance with federal regulations. Due Date of Completion: August 31, 2025 Responsible Official: Carolyn Kasdorf, Vice President for Business and Finance (or appropriate official), Karla Volpi, Dean of Business and Finance, Rebecca Silva, Director of Finance, Lisa Ryan, Restricted Funds Manager
The District received the findings. We have implemented the requirement for all staff working under federal programs to complete Time & Effort and/or Semi-Annual Certification Documents.
The District received the findings. We have implemented the requirement for all staff working under federal programs to complete Time & Effort and/or Semi-Annual Certification Documents.
View Audit 365860 Questioned Costs: $1
2023-003 Internal Controls and Compliance over Allowable Costs (Significant Deficiency) Recommendation: Review process should be reevaluated and employees retrained to ensure that only actual hours worked from timesheets are charged to grant. Corrective Action: The Finance Department was restruct...
2023-003 Internal Controls and Compliance over Allowable Costs (Significant Deficiency) Recommendation: Review process should be reevaluated and employees retrained to ensure that only actual hours worked from timesheets are charged to grant. Corrective Action: The Finance Department was restructured in August 2024 and the finance staff involved in payroll preparation and review were trained in Allies in Hope’s processes on recording payroll costs to the grants and other funding sources. Responsible Parties: Robert Marchbanks, Chief Financial Officer Date Corrected: August 2024
View Audit 365590 Questioned Costs: $1
The Municipality Administration is committed to identify the control of deficiency that allowed for the deficiency to happen. Additionally, the administration is committed to implementing the correct control sturcture to prevent the situation from happening in the future. The Municipality Managem...
The Municipality Administration is committed to identify the control of deficiency that allowed for the deficiency to happen. Additionally, the administration is committed to implementing the correct control sturcture to prevent the situation from happening in the future. The Municipality Management will continue the search of supporting documentation of the highlighted transactions. New proposed contrl strucure to be evaluated by Municipality for adequacy. The Municipality ensures the compliance with the Disaster Grants disbursement policies.
The Municipality Administration is committed to identify the control of deficiency that allowed for the deficiency to happen. Additionally, the administration is committed to implementing the correct control structure to prevent the situation from happening in the future. The Municipality Manageme...
The Municipality Administration is committed to identify the control of deficiency that allowed for the deficiency to happen. Additionally, the administration is committed to implementing the correct control structure to prevent the situation from happening in the future. The Municipality Management will continue the search of supporting documentation of the highlighted transactions. New proposed control structure to be evaluated by Municipality for adequacy. The Municipality ensures the compliance with the Coronavirus State and Local Fiscal Recovery Funds Assistance disbursement policies.
View Audit 365237 Questioned Costs: $1
Finding 575025 (2023-009)
Significant Deficiency 2023
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.
Finding 575024 (2023-008)
Significant Deficiency 2023
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.
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
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 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
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
Criteria: Recipients of federal awards must follow the costs principles set out at 2 CFR section 200.430 to substantiate compensation and other purchases charged to a federal program. “Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performe...
Criteria: Recipients of federal awards must follow the costs principles set out at 2 CFR section 200.430 to substantiate compensation and other purchases charged to a federal program. “Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: …(iii) reasonable reflect the total activity for which the employee is compensated by the non‐Federal entity” 2 CFR section 200.430(i). The Organization’s processes did not maintain sufficient documentation of the approval of the activity of each employee or the purchase of goods/services. Audit Recommendation: We recommend the Organization ensure it 1) maintains records of each employee’s activity and 2) monitors compliance with the job‐costing system implemented. Auditee Response: The Organization believes that leadership/personnel turnover, along with outsourced financial management, allowed paychecks to be approved without the proper approval flow. We have ensured documenation is downloaded/kept each pay period to ensure such documentation is not lost when a change in service provider is made. Corrective Action Plan: UICSL has moved away from its prior payroll processor to better account for these labor allocations and grant classifications. In our FY23 audit, we requested data from our prior processor multiple times. They were unable to provide some of the reports and data which was purged from their system. Our new payroll processor ensures employees' time is allocated to each grant program and there is a designated reporting funcation allowing us to reviews what is assigned. UICSL also has better defined leadership and directors for each division so there are clearly defined approvers and supervisors for each purchase and transaction. Person Responsible: Matt Poss, Executive Director and Eva Leyer, Human Resources Manager Timeline: UICSL transitioned to a new payroll processor at the end of 2023 and Leadership was designated and assigned for 2024.
Management’s Response and Corrective Action Plan: The City has implemented a procedure requiring the project manager to prepare required finance-based grant reports in conjunction with the finance director. The finance director must approve the required grant report before the project manager is au...
Management’s Response and Corrective Action Plan: The City has implemented a procedure requiring the project manager to prepare required finance-based grant reports in conjunction with the finance director. The finance director must approve the required grant report before the project manager is authorized to submit. The procedure includes timelines and authorizations requiring all grants to be entered into the City’s financial management software suite to ensure complete and timely project monitoring. All users have access to the financial software and have real-time access to all data.
While BREC currently does not have any federal expenses identified as unallowable costs applicable to this finding, a written SOP was recently developed for determining allowable costs and procurement requirements in accordance with the applicable CFR to guide key finance staff with responsibility f...
While BREC currently does not have any federal expenses identified as unallowable costs applicable to this finding, a written SOP was recently developed for determining allowable costs and procurement requirements in accordance with the applicable CFR to guide key finance staff with responsibility for federally eligible expenditures. Anticipated completion date: November 1, 2024 Responsible contact person: Don Johnson, Cheif Finance Officer
Type of Finding: Significant Deficiency in Internal Control over Compliance 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with reporting requirements. During our testing, we noted the Town did not have submit the Pr...
Type of Finding: Significant Deficiency in Internal Control over Compliance 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with reporting requirements. During our testing, we noted the Town did not have submit the Project and Expenditure report, that was due by April 30, 2023. Recommendation: CLA recommends the Town implement procedures to ensure compliance with all requirements under which the Town if obligated to comply as part of their grant agreements. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Taken in Response to Finding: Management will implement procedures to ensure compliance with all requirements under which the Town if obligated to comply as part of our grant agreements. Name(s) of Contact Person(s) responsible for Corrective Active Plan: Kevin Gervais Jr. Planned completion date for corrective action plan: July 2025
Finding ref number: 2023-002 Finding caption: The City did not have adequate internal controls with federal wage rate requirements. Name, address, and telephone of City contact person: Nancy Reddick, Clerk-Treasurer, 149 Hodgden St S, Tenino, WA 98589, (360) 264-2368. Corrective action the auditee p...
Finding ref number: 2023-002 Finding caption: The City did not have adequate internal controls with federal wage rate requirements. Name, address, and telephone of City contact person: Nancy Reddick, Clerk-Treasurer, 149 Hodgden St S, Tenino, WA 98589, (360) 264-2368. Corrective action the auditee plans to take in response to the finding: The City will include the required wage rate provisions in future contracts and will require weekly certified payroll reports prior to paying the contractor for the appropriate periods. Anticipated date to complete the corrective action: Immediately
Corrective Action Plan Financial Statement Finding: 2023-007 Noncompliance with Uniform Guidance Late Filing of Single Audit Reporting Package Criteria: Under the Single Audit Act of 1996 and Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, ...
Corrective Action Plan Financial Statement Finding: 2023-007 Noncompliance with Uniform Guidance Late Filing of Single Audit Reporting Package Criteria: Under the Single Audit Act of 1996 and Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), §200.512, Report Submission, the Single audit reporting package is required to be filed within the earlier of 30 calendar days after receipt of the auditors' report, or 9 months after the end of the audit period. Cause/Condition: Staffing shortages caused the delays in financial reporting. This deadline was not met on a timely basis for the year ended December 31, 2023. Effect: As a result, the entity is not incompliance with §200.512 of the Uniform Guidance. Recommendation: We recommend the requirements of §200.512 of the Uniform guidance be adhered to by striving to have all information required for the audit available on a timely basis. This will help to ensure timely audit report issuance and compliance with the filing deadline. Response: The City is still facing staffing shortages and is working to get the subsequent financial statements completed. It is expected the 2024 reporting package will be filed on time. Corrective Action Plan: The City has hired a full complement of staff in the Finance department, and anticipates timely filings going forward. Anticipated Completed Date: September 30, 2025. Responsible Contact Person: Elizabeth Greenwood, Director of Administration & Finance
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