Corrective Action Plans

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Activities Allowed or Unallowed & Allowable Costs/Cost Principles College of the Marshall Islands acknowledges the finding and agrees that certain payroll and non-payroll expenditures charged to federal programs were not adequately supported with sufficient documentation to clearly demonstrate allow...
Activities Allowed or Unallowed & Allowable Costs/Cost Principles College of the Marshall Islands acknowledges the finding and agrees that certain payroll and non-payroll expenditures charged to federal programs were not adequately supported with sufficient documentation to clearly demonstrate allowability, proper allocation, and alignment with objectives. The deficiencies resulted from weaknesses in internal control procedures, incomplete supporting documentation, and prior filing and record retention practices. To address this, the College has upgraded and institutionalized a cloud-based filing system to ensure complete, accessible, and properly organized documentation for all grant-funded positions and expenditures. Internal controls have been strengthened to require signed employment and overload contracts, proper funding source verification, and supervisory review before any grant-related payroll costs are charged. With the upgraded systems and the support of newly hired skilled staff, the College is now better equipped to maintain compliance and oversight. Staff will continue to be trained twice a year on federal allowability and cost principles to prevent recurrence of similar issues in future audits.
Finding 1216199 (2023-002)
Material Weakness 2023
Life Academy will work to complete the audit for the fiscal year no later than nine months after the end of the audit period.
Life Academy will work to complete the audit for the fiscal year no later than nine months after the end of the audit period.
2023-005 Activities Allowed and Allowable Costs Material Weakness Corrective Action: We now have staff that will complete the TEFAP and CSFP administrative cost reimbursement report and a signoff will be completed on the day of review by management level employees. Person Responsible: Stephano Blake...
2023-005 Activities Allowed and Allowable Costs Material Weakness Corrective Action: We now have staff that will complete the TEFAP and CSFP administrative cost reimbursement report and a signoff will be completed on the day of review by management level employees. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635
2023-002 CDBG Activities Allowed and Allowable Costs Significant Deficiency Corrective Action: We now have staff that can review invoices properly prior to payment. Invoices paid will have a final signoff prior to payment. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-6...
2023-002 CDBG Activities Allowed and Allowable Costs Significant Deficiency Corrective Action: We now have staff that can review invoices properly prior to payment. Invoices paid will have a final signoff prior to payment. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635
Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will maintain written financial and grants management policies to support consistent operations and compliance with Uniform Guidance (2 CFR Part 200). These policies will cover key areas including allowable costs, ...
Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will maintain written financial and grants management policies to support consistent operations and compliance with Uniform Guidance (2 CFR Part 200). These policies will cover key areas including allowable costs, procurement, cash management, subrecipient monitoring, reporting, record retention, and internal controls. The Financial Analyst will be responsible for maintaining and updating these policies, with oversight from the Executive Director, and policies will be reviewed at least annually and updated as needed. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst, by March 31st, 2024
Finding 2023-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster, Public and Indian Housing Program, Public Housing Capital Fund Program, and Coronavirus Relief Fund Assistance Listing Numbers: 14.871, 14.879, 14.850, 14.872, and 21.01...
Finding 2023-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster, Public and Indian Housing Program, Public Housing Capital Fund Program, and Coronavirus Relief Fund Assistance Listing Numbers: 14.871, 14.879, 14.850, 14.872, and 21.019 Material Noncompliance Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance Criteria: The Authority must maintain complete and accurate accounts and other records for the program in accordance with HUD compliance requirements. Condition: The Authority did not maintain complete and accurate accounts and other records in accordance with HUD compliance requirements regarding Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Eligibility, Reporting, and Special Tests and Provisions. Context: The Authority was unable to provide requested documentation at the time of audit to properly test the HUD compliance requirements. Known Questioned Costs: Unknown Cause: There is a material weakness in internal controls over compliance related to the maintenance of tenant files, wait lists, inspection reports and other records. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster is in material non- compliance with the compliance requirements of the program. Recommendation: We recommend that the Authority implement a process whereby Authority documents are stored and safeguarded to ensure compliance with the Uniform Guidance and the compliance supplement. View of Responsible Officials and Corrective Actions: The Authority experienced significant turnover in employees during the year and as a result certain source documents were misplaced or destroyed. Management agrees with the Auditors' finding and has hired a new Executive Director who will implement the required safeguards and ensure that the Authority follows its internal control over compliance processes and procedures related to the Housing Voucher Cluster, Public and Indian Housing Program and Public Housing Capital fund Program to remedy the aforementioned deficiencies. Byran McClellan, CFO, will be responsible to implement this corrective action by December 31, 2023.
Develop and implement a comprehensive capital asset and inventory management system. Ensure all federally funded equipment includes required documentation: Funding source (FAIN); Acquisition date and cost; Location, use, and condition. Conduct a full inventory of all federally funded equipment. Esta...
Develop and implement a comprehensive capital asset and inventory management system. Ensure all federally funded equipment includes required documentation: Funding source (FAIN); Acquisition date and cost; Location, use, and condition. Conduct a full inventory of all federally funded equipment. Establish procedures to ensure proper classificaiton of expenditures as capital outlay. Provide training on Unidorm Guidance (2 CFR 200) requirements to all relevant staff. Inventory and system implementation: Within 90 days. Full compliance: By end of fiscal year.
For 11 of 22 tenant files selected for testing, the Organization was unable to provide both the signed sublease agreement and the master lease agreement. One file lacked both documents. Although the Compliance Supplement does not require these documents for determining rent reasonableness under the ...
For 11 of 22 tenant files selected for testing, the Organization was unable to provide both the signed sublease agreement and the master lease agreement. One file lacked both documents. Although the Compliance Supplement does not require these documents for determining rent reasonableness under the Continuum of Care Program, the Organization’s internal policies require them. Management acknowledges the condition noted. While the Compliance Supplement does not require examination of lease agreements for this program and no instances of noncompliance were identified, we agree that maintaining complete tenant files—including signed sublease agreements and master lease agreements—is an important internal control to support documentation of rent reasonableness and compliance with our own policies. The missing documents resulted from inconsistent file maintenance during the audit period. The Organization has taken steps to strengthen its documentation and retention procedures to ensure all required lease documents are properly maintained and readily accessible going forward.
Finding No: 2023 002 Federal Agency: U.S. Department of Homeland Security Federal Emergency Management Agency Assistance Listing Number: 97.036 Program: COVID 19 – Disaster Grants Public Assistance (Presidentially Declared Disasters) Award Year: July 1, 2022 to June 30, 2023 Compliance Requirements:...
Finding No: 2023 002 Federal Agency: U.S. Department of Homeland Security Federal Emergency Management Agency Assistance Listing Number: 97.036 Program: COVID 19 – Disaster Grants Public Assistance (Presidentially Declared Disasters) Award Year: July 1, 2022 to June 30, 2023 Compliance Requirements: Activities allowed or unallowed and Allowable costs/cost principles Criteria In accordance with the Federal Emergency Management Agency (FEMA) Public Assistance Program and Policy Guide, Version 2.1, Chapter 2, costs are not eligible for reimbursement if the applicant received funding from another source (e.g., patient revenue or insurance) for the same work funded by FEMA. FEMA refers to this as a duplication of benefits. On February 15, 2023, FEMA issued a memorandum titled Hypothetical Reasonable Applicant Methods, which outlines the basic elements for estimating duplication of benefits within net patient service revenue. Subsequent to FEMA both obligating and paying project worksheet #548183A, the Department of Homeland Security (DHS) engaged the RAND Corporation’s Homeland Security Research Division (RAND), through the Homeland Security Operational Analysis Center (HSOAC), to assist with the administration of disaster grants to health care providers related to COVID 19. Additionally, 2 CFR 200.303 requires non federal entities receiving federal awards to establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. Conditions Found On March 3, 2023, FEMA obligated and paid project worksheet #548183A for $2,719,181 related to Remdesivir drug costs and reimbursements which were included in the total expenditures for this program of $16,310,090 for the year ended June 30, 2023. Most insurance providers, including the federal government, pay hospitals a single flat fee for an entire patient stay (known as a ‘bundled payment’) rather than paying for every individual item used. As a result, when the System receives a payment for an inpatient stay, it isn’t possible to determine exactly how much of that payment was for a specific drug like Remdesivir. However, FEMA program requirements require the hospital to offset claimed costs by payments from other sources. Since there is not a payer level breakdown of the payment for Remdesivir, management applied a cost based allocation methodology to estimate the portion of bundled inpatient reimbursement attributable to Remdesivir. In June 2023, HSOAC issued an Applicant Review Memo indicating that they had evaluated project #548183A and determined the methodology utilized by management to calculate the estimated payments received from other sources related to Remdesivir drug costs and reimbursements to be unreasonable. The System could not provide the additional information requested by RAND to support actual payments received from other sources related to Remdesivir costs within project #548183A since that information does not exist under prevailing inpatient reimbursement structures. Therefore, at the request of the System, FEMA de obligated $2,719,181. Cause The System used a methodology to calculate the estimated payments received from other sources that was not in accordance with FEMA’s regulations. Further, the System was unable to provide requested documentation related to actual payments received from other sources to RAND because that information specific to the Remdesivir drug costs does not exist under prevailing inpatient reimbursement structures. Effect The funds obligated for project worksheet #548183A were subsequently de obligated at the request of the System and the System returned these funds to FEMA. Questioned Cost $2,719,181 Statistical Sample The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year Not a repeat finding. Recommendation We recommend that the System strengthen controls over the management review process to prevent unallowable costs and inaccurate amounts from being charged to Federal programs as well as ensure all relevant documentation is maintained in accordance with Federal requirements. View of Responsible Official For project worksheet 548183A, Wellstar Health System, Inc was not provided with methodology or approach to FEMAs request for patient level financials, including all costs incurred directly with each patient. Wellstar Health System, Inc. believed the request for information from FEMA was in conflict with FEMA’s "COVID-19 Patient Care Revenue Duplication of Benefits Recipient and Subrecipient Guide", published in October 2022, as well as overly burdensome and unreasonable. Wellstar Health System, Inc. subsequently requested FEMA to de obligate project worksheet 548183A and repaid all funds. Corrective Action Plan Wellstar Health System has trained responsible internal team members on approach and methodology of FEMA published guidelines. Wellstar Health System, Inc. will also engage external, experienced consultants as needed for future FEMA claims. Anticipated Completion Date: Wellstar Health System, Inc has already implemented the corrective action. Name of Contact Person for Corrective Action: Beth Loudermilk, VP Financial Planning & Analysis
Upon receiving results of the FY21 audit (completed in FY24), TAS’ Director of Finance was informed that the inclusion of the Biological Expertise line item on federal billing records (approximately 7.5% additional uplift) was not allowable as it was being calculated. TAS is allowed a 10% de minimis...
Upon receiving results of the FY21 audit (completed in FY24), TAS’ Director of Finance was informed that the inclusion of the Biological Expertise line item on federal billing records (approximately 7.5% additional uplift) was not allowable as it was being calculated. TAS is allowed a 10% de minimis rate on noted FY22 Federal awards, some of which also included a Biological Expertise line item that is budgeted as an hourly rate. TAS had been calculating uplift amounts owed by simply adding the Biological Expertise (7.5%) to the de minimis rate (10%) for a total uplift of 17.5%. This was done at the direction and approval of our federal partners. However, due to Biological Expertise being entered in the federal and approved budgets as an hourly line item and not a percentage TAS was considered out of compliance by using this method of calculation. After the presentation of this finding in mid-2024, TAS adjusted federal billing for administrative expenses to the de minimis rate (10%) as a percentage, unless otherwise noted in the agreement. Anticipated completion date: In effect.
Recommendation: We recommend that management implement a requirement for employees to complete level of effort forms attesting to actual time spent working on the federal program on a regular basis, but no less than annually, during the fiscal period. These forms should be reviewed by a supervisor k...
Recommendation: We recommend that management implement a requirement for employees to complete level of effort forms attesting to actual time spent working on the federal program on a regular basis, but no less than annually, during the fiscal period. These forms should be reviewed by a supervisor knowledgeable of the employee’s activities and grant requirements and retained thereafter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management established a standardized quarterly process for updating Level of Effort (LOE) forms. All completed forms are retained and archived within the organization’s SharePoint environment to support proper documentation and audit readiness. Name(s) of the contact person(s) responsible for corrective action: Deidre Calcoate, Executive Director Planned completion date for corrective action plan: 01/09/2025
Recommendation: We recommend that management implement a requirement for employees to complete level of effort forms attesting to actual time spent working on the federal program on a regular basis, but no less than annually, during the fiscal period. These forms should be reviewed by a supervisor k...
Recommendation: We recommend that management implement a requirement for employees to complete level of effort forms attesting to actual time spent working on the federal program on a regular basis, but no less than annually, during the fiscal period. These forms should be reviewed by a supervisor knowledgeable of the employee’s activities and grant requirements and retained thereafter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management established a standardized quarterly process for updating Level of Effort (LOE) forms. All completed forms are retained and archived within the organization’s SharePoint environment to support proper documentation and audit readiness. Name(s) of the contact person(s) responsible for corrective action: Deidre Calcoate, Executive Director Planned completion date for corrective action plan: 01/09/2026
U.S. Department of Health & Human Services Allowable Costs/Cost Principles Recommendation: We recommend that CAC Discontinue the use of unrestricted gift cards for CSBG funded participant assistance. Implement policies requiring that any gift cards or vouchers be restricted at the vendor level to al...
U.S. Department of Health & Human Services Allowable Costs/Cost Principles Recommendation: We recommend that CAC Discontinue the use of unrestricted gift cards for CSBG funded participant assistance. Implement policies requiring that any gift cards or vouchers be restricted at the vendor level to allowable CSBG purposes or replaced with alternative assistance mechanisms that provide adequate safeguards. Consult state CSBG administering agency guidance prior to implementing participant assistance methods to ensure costs are allowable and properly controlled. Explanation of disagreement with audit finding: CAC does not disagree with the audit finding. Action taken in response to finding: Management acknowledges the finding regarding the provision of direct assistance using Relief Assistance (RAP) gift cards under the CSBG program. In its role as a designated essential service provider, CAC used CSBG funds to provide direct assistance to eligible individuals and families in need. RAP cards were used for allowable purchases such as food, household items, clothing, and personal necessities. Management explored options to implement vendor-based restrictions on card usage; however, no vendors were identified with the capability to apply such restrictions. As an alternative, CAC implemented participant acknowledgment forms outlining allowable uses and restrictions. Due to COVID-related conditions at the time, post-distribution verification procedures were not feasible. Upon further evaluation of Uniform Guidance requirements and program-specific restrictions, management determined that this approach did not provide sufficient control to ensure allowability. Based on this determination, CAC has discontinued the use of unrestricted gift cards for CSBG-funded participant assistance and will not utilize federal funds for direct assistance cards unless they can be appropriately restricted and controlled in accordance with program requirements. Planned completion date for corrective action plan: The prohibition against using CSBG funds for unrestricted gift cards is currently in effect.
Corrective Action: Utilize project management detail record keeping for any public assistance grants to assure that the expenditures qualify for cost principles as outlined in 2 CFR part 200 subpart E.
Corrective Action: Utilize project management detail record keeping for any public assistance grants to assure that the expenditures qualify for cost principles as outlined in 2 CFR part 200 subpart E.
Recommendation We recommend that management: ▪ Implement procedures requiring complete supporting documentation for all costs charged to federal awards ▪ Ensure costs are reviewed for allowability, reasonableness, and allocability prior to recording ▪ Establish and document formal cost allocation me...
Recommendation We recommend that management: ▪ Implement procedures requiring complete supporting documentation for all costs charged to federal awards ▪ Ensure costs are reviewed for allowability, reasonableness, and allocability prior to recording ▪ Establish and document formal cost allocation methodologies ▪ Require approval and documentation of all journal entries affecting federal programs ▪ Provide training to staff on Uniform Guidance cost principles (2 CFR 200 Subpart E) ▪ Conduct periodic internal reviews to ensure compliance
"Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Pe...
"Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Perform ongoing monitoring and review of program activities ▪ Train staff on federal compliance requirements and documentation expectations"
Corrective action: Management understands the due date for single audit reporting package submission to the Federal Audit Clearinghouse and filed as soon as possible
Corrective action: Management understands the due date for single audit reporting package submission to the Federal Audit Clearinghouse and filed as soon as possible
Finding 2023-002: Allocation of Payroll Costs - Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance – Allowable Costs/Cost Principles Program: U.S. Department of Health and Human Services – Medicaid Cluster Response and Corrective Action Plan: Management agrees w...
Finding 2023-002: Allocation of Payroll Costs - Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance – Allowable Costs/Cost Principles Program: U.S. Department of Health and Human Services – Medicaid Cluster Response and Corrective Action Plan: Management agrees with finding and will develop a written policy and procedure for managing the payroll related expenditures by implementing the use of time studies on all personnel working on Federal awards to ensure that reasonable assurance of activity performed is charged to the Federal award. Anticipated Completion Date: by June 30, 2026 Responsible Person: Virginia Lui VP, Controller
Audit Finding Reference: 2023-003 Improve Controls Over Cash Management & Application of Indirect Cost Rate (Significant Deficiency) Planned Corrective Action: Federal reimbursement requests will include two or more individuals. Review of the reimbursement request, including the application of the i...
Audit Finding Reference: 2023-003 Improve Controls Over Cash Management & Application of Indirect Cost Rate (Significant Deficiency) Planned Corrective Action: Federal reimbursement requests will include two or more individuals. Review of the reimbursement request, including the application of the indirect rate, will be formally documented and a copy of the documentation will be maintained in our records. Note, the audit finding was originally included in the 2022 single audit report completed in early 2025. Planned Implementation Date of Corrective Action: March 14, 2025. Persons Responsible for Corrective Action: Kirk Geadelmann, Finance Director Tyler Piebes, Bookkeeper Nick Fisichelli, President & CEO
The City of Cascade Locks has an allowable cost procedure that was approved by Council on March 26, 2026. The City Administrator is responsible for adhering to this policy.
The City of Cascade Locks has an allowable cost procedure that was approved by Council on March 26, 2026. The City Administrator is responsible for adhering to this policy.
The Crenulated will request a quarterly in-kind contribution report from DOE and will ensure the in-kind contributions are recorded in the financial statements. The Crenulated plans to hire an in-house Controller with expertise in accounting for grants and review its existing contract with current t...
The Crenulated will request a quarterly in-kind contribution report from DOE and will ensure the in-kind contributions are recorded in the financial statements. The Crenulated plans to hire an in-house Controller with expertise in accounting for grants and review its existing contract with current third-party accounting provider. Anticipated completion date This corrective action plan will begin immediately.
Given the volume and increase of grants and documentation, we acknowledge that these two errors slipped through. Two mitigation steps are to require a wet signature or a confirmation box that requires gouging through the document prior to administrator approval, and to reduce the amount of grant mon...
Given the volume and increase of grants and documentation, we acknowledge that these two errors slipped through. Two mitigation steps are to require a wet signature or a confirmation box that requires gouging through the document prior to administrator approval, and to reduce the amount of grant monitoring work on a single employee by reducing the responsibilities from nine districts to one single district as we move to RSU #48
Responsible Individual: Michael Vocu, Executive Director. Corrective Action Plan: The Organization has transitioned to new payroll software that facilitates online timecard submission and third-party processing. Furthermore, forms for payroll rate approvals and changes are being implemented. Anticip...
Responsible Individual: Michael Vocu, Executive Director. Corrective Action Plan: The Organization has transitioned to new payroll software that facilitates online timecard submission and third-party processing. Furthermore, forms for payroll rate approvals and changes are being implemented. Anticipated Completion Date: September 30, 2025
The County will engage in competent consulting services to advise prior to audit findings of any deficiencies in the County's policies, procedures or recording keeping required of the federal funds.
The County will engage in competent consulting services to advise prior to audit findings of any deficiencies in the County's policies, procedures or recording keeping required of the federal funds.
The County Board does not believe the finding is appropriate. The Recipient "partner" was not an elected official at the time of application or award. The funds were utilized to restore a building located in the County and owned by a County resident. The County Board believes that this award falls w...
The County Board does not believe the finding is appropriate. The Recipient "partner" was not an elected official at the time of application or award. The funds were utilized to restore a building located in the County and owned by a County resident. The County Board believes that this award falls within the parameters of economic development, one of the allowable uses of the funds. Again, the Auditor has failed to provide any legal basis for the belief of the Auditing Firm or what legal opinion they relied upon in forming their beliefs.
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