Corrective Action Plans

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Cause: We were not able to meet reporting responsibilities in a timely manner during a period high personnel turnover which resulted in missed reconciliations and incomplete documentation. Corrective Action Taken: Monthly reconciliations and timely filing of required reports have been reinstated. Su...
Cause: We were not able to meet reporting responsibilities in a timely manner during a period high personnel turnover which resulted in missed reconciliations and incomplete documentation. Corrective Action Taken: Monthly reconciliations and timely filing of required reports have been reinstated. Supporting documentation is now reviewed and filed as part of the monthly process. Multiple staff members are involved in the reporting and reconciliation process to provide oversight and ensure continuity. Preventive Measures: Cross-training has been implemented so that multiple staff members can complete required tasks. Internal controls have been enhanced with supervisory review to ensure ongoing compliance with federal requirements. Responsible Parties: Lori Schmidt, Business Administrator and Scott LaFortune, Grant Manager are responsible for monitoring and ensuring continued compliance. Anticipated Completion Date: June 30, 2025
The Project will contact HUD to discuss favorable remedies to resolve the issues. Procedures related to authorization have been enhanced to ensure that transactions entered into by the Project are allowable. The Project will ensure that all parties that authorize and process transactions have a work...
The Project will contact HUD to discuss favorable remedies to resolve the issues. Procedures related to authorization have been enhanced to ensure that transactions entered into by the Project are allowable. The Project will ensure that all parties that authorize and process transactions have a working knowledge of allowable vs unallowable costs.
We plan to start the next fiscal year's audit right after issuance of September 30, 2023 financial statements to catch up on the filing of the reporting package.
We plan to start the next fiscal year's audit right after issuance of September 30, 2023 financial statements to catch up on the filing of the reporting package.
Corrective Action Plan Action Item Responsible Party Monitoring Implement a formal reconciliation process to ensure federal grant expenditures recorded in the general ledger reconcile to the SEFA prior to year-end reporting. CFO / Finance Department Documented reconciliation Establish a standardized...
Corrective Action Plan Action Item Responsible Party Monitoring Implement a formal reconciliation process to ensure federal grant expenditures recorded in the general ledger reconcile to the SEFA prior to year-end reporting. CFO / Finance Department Documented reconciliation Establish a standardized grant expenditure tracking schedule for each federal award to ensure costs charged to the program are properly supported and traceable to accounting records. CFO / Grants Accounting Periodic internal review Maintain supporting documentation (invoices, payroll allocations, grant records) in a centralized electronic filing system for accessibility and audit readiness. CFO / Accounting Staff Ongoing monitoring In FY 2026, management developed and implemented a formal Records Retention Policy to ensure that accounting records, supporting documentation, and organizational records are properly maintained and retained in accordance with applicable regulatory and audit requirements. CFO Reviewed by management Conduct periodic internal reviews of grant expenditures to verify compliance with federal cost principles and ensure adequate supporting documentation. CFO / Finance Management Quarterly review ________________________________________ Management Response Management would like to clarify that the HRSA Health Center Program (No. 93.224) was inadvertently affected by this finding. The organization maintained a SEFA schedule for the HRSA Section 330 program grant; however, because the overall SEFA schedule did not fully reconcile to the general ledger, the auditors were unable to rely on the population of expenditures for testing. As a result, detailed testing samples could not be provided during the audit. Management is strengthening reconciliation procedures to ensure that the SEFA fully reconciles to the general ledger and supporting grant expense schedules prior to audit to support accurate reporting and facilitate audit testing. ________________________________________ Responsible Official: Chief Financial Officer Expected Completion Date: FY 2026
We have implemented internal controls to ensure disbursements are properly reviewed and approved and all documentation and are retained on file based on the Center’s documentation retention policy. Implementation date: June 16, 2025
We have implemented internal controls to ensure disbursements are properly reviewed and approved and all documentation and are retained on file based on the Center’s documentation retention policy. Implementation date: June 16, 2025
ROE 40 will use time and effort documentation to distribute salary and benefit costs for employees paid from multiple funding sources. Procedures will be put into place to ensure that employee withholdings are correct and to ensure that Medicare tax is properly calculated.
ROE 40 will use time and effort documentation to distribute salary and benefit costs for employees paid from multiple funding sources. Procedures will be put into place to ensure that employee withholdings are correct and to ensure that Medicare tax is properly calculated.
Views of Responsible Officials and Planned Corrective Action The Organization understands the criteria cited re: Title 2, Subtitle A Chapter II, Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), §200.334, requiring “Fina...
Views of Responsible Officials and Planned Corrective Action The Organization understands the criteria cited re: Title 2, Subtitle A Chapter II, Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), §200.334, requiring “Financial records, supporting documents, statistical records, and all other non-Federal records must be retained for a period of three years from the date of submission of the final expenditure report…”, and recommendation made. However, because two programs are listed U.S. Department of Education and the U.S. Department of Health and Human Services, the Organization will work with the auditors to: A. Better understand the findings (i.e., inconsistent document retention substantiating contractor performance of services) identified by the field work and expenditure and contractor testing, as it relates to which program, and which subrecipient contractor the findings relate to; B. Clarify the specific source and subcontractor awarding and payment criteria as noted in the Organization’s award and sub-award criteria, and subsequently reflected in the subcontractor contract(s); C. Analyze the findings to identify root causes and/or conditions in related contract monitoring processes that resulted in inconsistent document retention practices; and D. Address and implement corrective actions through identified needs (e.g., policy development and implementation, contract monitoring processes and procedures). The Organization will prioritize the above with the auditors as soon as possible, so the appropriate corrective actions can be addressed.
Contact Person Responsible for Corrective Action Plan: G. Janina Trzmiel, Chief School Financial Officer Corrective Action Plan: We agree with the auditors’ comments and have taken the following actions: The Board will implement policies to ensure that all employees who begin to work under a federal...
Contact Person Responsible for Corrective Action Plan: G. Janina Trzmiel, Chief School Financial Officer Corrective Action Plan: We agree with the auditors’ comments and have taken the following actions: The Board will implement policies to ensure that all employees who begin to work under a federal or state fund sign certifications of all time working on a single award. Anticipated Completion Date: September 30, 2024
CONDITION: During the calendar year 2023, the City did not record the necessary adjustments to the various ‘Fund’ general ledgers of the City to properly reconcile certain balance sheet accounts, such as interfund receivables and payables, and payroll-related liabilities to the underlying supporting...
CONDITION: During the calendar year 2023, the City did not record the necessary adjustments to the various ‘Fund’ general ledgers of the City to properly reconcile certain balance sheet accounts, such as interfund receivables and payables, and payroll-related liabilities to the underlying supporting documentation available at the City. This included the City’s Community Development Block Grant (CDBG) Program. As a result, the financial position and results of operations as shown throughout the calendar year were inaccurately stated. CRITERIA: Prudent internal control procedures in the areas of general ledger management and financial reporting include the reconciliation of all general ledger account balances to underlying supporting documentation monthly with independent oversight and approval as part of the process. In specific as it relates to federal programs, Section 2 CFR 200.403(g) of the Uniform Guidance requires that federal costs must be adequately documented which would include the City’s Federal Programs general ledger which accounts for the financial activity of the City’s Community Development Block Grant Program.MANAGEMENT’S CORRECTIVE ACTION PLAN: Management of the City is reviewing the options as presented by the Audit Firm’s recommendation for feasibility considering current manpower, expertise, and budgetary constraints. In addition, the City plans to ensure that written procedures for all accounting functions are implemented, reviewed and updated as necessary with the objective of ensuring that all applicable balance sheet account balances are accurate and supported by the underlying documentation available at the City. The City is currently in continuous communication with the Audit Firm for specific recommendations regarding the handling of interfund receivables and payables, and payroll-related liabilities, so as to ensure the accuracy of the City’s financial reporting. The timeframe for completion of this review will occur during the first six months of calendar year 2026 with the intention of having the City be in full compliance with Section 2 CFR 200.403(g) of the Uniform Guidance which requires federal costs to be adequately documented which would include the applicable general ledgers of the City.
Item 2023-006 Activities Allowed or Unallowed/Allowable Costs/Cost Principles Head Start ALN# 93.600 US Department of Health & Human Services (Repeat 2022- 008) Federal Grant/Contract Number: 10CH011215-03-03; 10CH011215-03 C3; 10CH011215-04; 10HE000901-01-C6 Grant period – 2022 & 2023 The HS progra...
Item 2023-006 Activities Allowed or Unallowed/Allowable Costs/Cost Principles Head Start ALN# 93.600 US Department of Health & Human Services (Repeat 2022- 008) Federal Grant/Contract Number: 10CH011215-03-03; 10CH011215-03 C3; 10CH011215-04; 10HE000901-01-C6 Grant period – 2022 & 2023 The HS program has established an internal process of requester/approver in place to review transaction requested. Documents then get reviewed again by HR or Finance staff based on the transaction type before getting processed.
Reference Number: 2023-012 Finding: Recordkeeping and Documentation for the HOME Investment Partnerships Program Name of Contact Person: Lara Auclair Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued ...
Reference Number: 2023-012 Finding: Recordkeeping and Documentation for the HOME Investment Partnerships Program Name of Contact Person: Lara Auclair Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued all program files creating separate documents for files that are discharged or still active. The documents can be reviewed to add monitoring information. The document contains the period of affordability and the amount due at payoff. Proposed Completion Date: 3/31/26
Reference Number: 2023-011 Finding: Improve Controls and Compliance with Approval of Allowable Costs Name of Contact Person: Lorina Esposito Corrective Active Plan: The City will implement a policy mandating documented approval for all invoices before they are paid or charged to federal programs. In...
Reference Number: 2023-011 Finding: Improve Controls and Compliance with Approval of Allowable Costs Name of Contact Person: Lorina Esposito Corrective Active Plan: The City will implement a policy mandating documented approval for all invoices before they are paid or charged to federal programs. In addition, the City will conduct regular, scheduled reviews of invoice processing to verify compliance with allowable cost procedures and address any deviations promptly. Training will be provided to staff involved in invoice approval and payment processes to ensure understanding and adherence to these internal control requirements. Proposed Completion Date: 6/30/26
Reference Number: 2023-007 Finding: Improve Controls and Compliance with Procurement Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement standardized procurement procedures specifically for federally funded purchases, ensuring that all transactio...
Reference Number: 2023-007 Finding: Improve Controls and Compliance with Procurement Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement standardized procurement procedures specifically for federally funded purchases, ensuring that all transactions are fully documented in accordance with applicable procurement policies. Staff will be trained on these procedures, and a central repository will be established to maintain executed contracts and all supporting documentation. Regular audits will be conducted to verify compliance and that all required records are retained and readily accessible. Proposed Completion Date: 6/30/26
Reference Number: 2023-006 Finding: Improve Segregation of Duties over Expenditure Approvals Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will establish formal procedures to ensure that the responsibilities for approving purchase orders and invoices are assigned to ...
Reference Number: 2023-006 Finding: Improve Segregation of Duties over Expenditure Approvals Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will establish formal procedures to ensure that the responsibilities for approving purchase orders and invoices are assigned to different individuals, thereby maintaining effective segregation of duties. In instances where staffing limitations make segregation impractical, management will implement compensating controls, including independent review and approval of these transactions. Documentation of all reviews and approvals will be maintained for audit purposes. Training will be provided to relevant staff to ensure understanding and compliance with these procedures. Proposed Completion Date: 6/30/26
Reference Number: 2023-005 Finding: Update Documented Policies amt Procedures Over Federal Awards Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement comprehensive policies and procedures specifically addressing the management and oversight of fe...
Reference Number: 2023-005 Finding: Update Documented Policies amt Procedures Over Federal Awards Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement comprehensive policies and procedures specifically addressing the management and oversight of federal awards to ensure compliance with the Uniform Guidance. Designated staff will be tasked with drafting these documents, which will be reviewed and approved by senior management. Training sessions will be conducted for all relevant personnel to ensure consistent application of the new policies and procedures. Proposed Completion Date: 3/31/26
In response to the noted deficiencies regarding cost allocation, the Organization developed a Written Cost Allocation plan using allocation rates approved by the funding agency as well as implementing required Lookback-on-Budget-to-Actual analysis as part of month-end close out procedures. This will...
In response to the noted deficiencies regarding cost allocation, the Organization developed a Written Cost Allocation plan using allocation rates approved by the funding agency as well as implementing required Lookback-on-Budget-to-Actual analysis as part of month-end close out procedures. This will ensure internal controls are in complaince with allowable cost principles.
In response to the noted deficiencies in salary rates and allocated costs, Management introduced Personnel Action Forms (PAFs) to document any changes in an employee’s salary or supervisory status. These forms ensure that salary adjustments are properly recorded and authorized in alignment with stan...
In response to the noted deficiencies in salary rates and allocated costs, Management introduced Personnel Action Forms (PAFs) to document any changes in an employee’s salary or supervisory status. These forms ensure that salary adjustments are properly recorded and authorized in alignment with standard operating procecures and with the necessary supervisory approval. If a salary or supervisory status changes is due to a promotion or interim role, a formal letter accompanies the PAF, clearly outlining the terms of the change. These letters require signatures from the employee, their supervisor, and the CEO and are securely stored in the employee’s e-file with Human Resources. To further improve the documentation process, Management is transitioning to a new Applicant Tracking System (ATS) that integrates with Management’s PEO system, Paychex. This system allows for electronic distribution and automatic storage of offer letters, ensuring they are consistently filed and easily retrievable. These procedures reinforce the existing Payroll policy, ensures staff receive targeted training on relevant requirements such as timesheet approvals, and incorporates additional review measures into the payroll process. Furthermore, the Grants Director must review timesheets and payroll rates for allocations before payroll costs are requested for reimbursement. The payroll platform has been upgraded to manage employee pay rate changes, and the Human Resources manager is required to maintain approved documentation of pay rate changes in a centralized location, thereby ensuring full compliance with federal requirements relating to allowable salary costs and time and effort documentation. In addition, employees whose compensation is charged to federal awards complete biweekly time and effort certifications identifying the program or cost objective worked. Certifications are approved by the employee’s supervisor and retained in payroll records. Payroll charges to federal awards are based solely on certified time.
Finding Number: 2023-003 Planned Corrective Action: City Auditor will stay in contact with Municipal Court Administrator and the Police Captain to ensure they submit Quarterly Reports on a timely basis. Anticipated Completion Date: July 3, 2025 Responsible Contact Person: City Auditor Sherri Hess
Finding Number: 2023-003 Planned Corrective Action: City Auditor will stay in contact with Municipal Court Administrator and the Police Captain to ensure they submit Quarterly Reports on a timely basis. Anticipated Completion Date: July 3, 2025 Responsible Contact Person: City Auditor Sherri Hess
Finding Number: 2023-002 Planned Corrective Action: City Auditor has confirmed the ARPA 3/31/24 and 3/31/25 Project and Expenditure Reports submitted agree to City Accounting records. Anticipated Completion Date: July 3, 2025 Responsible Contact Person: City Auditor Sherri Hess
Finding Number: 2023-002 Planned Corrective Action: City Auditor has confirmed the ARPA 3/31/24 and 3/31/25 Project and Expenditure Reports submitted agree to City Accounting records. Anticipated Completion Date: July 3, 2025 Responsible Contact Person: City Auditor Sherri Hess
We agree with the finding as stated and the corrective action plan follows. 1. Person responsible for the corrective action: Terry Terry, Chief Financial Officer 2. Corrective Action: a. Policies and procedures have been modified to ensure that reports are complete and accurate. b. Additional proced...
We agree with the finding as stated and the corrective action plan follows. 1. Person responsible for the corrective action: Terry Terry, Chief Financial Officer 2. Corrective Action: a. Policies and procedures have been modified to ensure that reports are complete and accurate. b. Additional procedures have been implemented to reconcile and verify all details prior to submission of reports 3. The Corrective Action has been implemented and will be reviewed no less than annually to ensure that no additional procedures are needed for compliance.
The new VIP processing system and accompanying spreadsheet is now used to complete a more thorough list for the Board for approval.
The new VIP processing system and accompanying spreadsheet is now used to complete a more thorough list for the Board for approval.
Timesheets will be signed off on by the Health Commissioner or by the department director (Nursing, Environmental Health, Community Health, Administration). Staff will be required to present the timesheets to their supervisor before turning them in for processing. All unsigned timesheets will be ret...
Timesheets will be signed off on by the Health Commissioner or by the department director (Nursing, Environmental Health, Community Health, Administration). Staff will be required to present the timesheets to their supervisor before turning them in for processing. All unsigned timesheets will be returned to the department director and will not be processed until signed.
The department will adopt written policies with the Uniform Guidance for Federally Funded Grant Programs accepted by the department.
The department will adopt written policies with the Uniform Guidance for Federally Funded Grant Programs accepted by the department.
2023 – 003: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2021-003 and 2022-003) Material Weakness – 93.U01 Title V Condition: The Organization’s general ledger did not allow for sufficient identification of ...
2023 – 003: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2021-003 and 2022-003) Material Weakness – 93.U01 Title V Condition: The Organization’s general ledger did not allow for sufficient identification of transactions related to the major program, Title V. Title V expenditures were recorded through journal entries without supporting transaction-level detail. Because of this, the population of expenditures could not be tied to individual transactions, and pulling samples from this population would not provide a reasonable basis for drawing conclusions about the population tested. As a result, we were unable to select transactions for testing or perform the necessary audit procedures to assess compliance with federal requirements. Corrective Action Plan: As of October 1, 2024, the start of FY25, QuickBooks has been the only software used, and Revenue and Disbursements are being classed by Fund. General ledgers are reconciled monthly. Management is strengthening documentation and recordkeeping procedures to ensure compliance with federal record retention requirements, including improved tracking of Title V expenditures and retention of transaction-level support.
Contact Person – Benjamin Schafer, Executive Director Corrective Action Plan – Training will be provided for all employees involved with the grant if the Cooperative receives a similar grant in the future. Completion Date – As needed
Contact Person – Benjamin Schafer, Executive Director Corrective Action Plan – Training will be provided for all employees involved with the grant if the Cooperative receives a similar grant in the future. Completion Date – As needed
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