Corrective Action Plans

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Major Federal Award Programs Audit Material Weakness #2023-006 Condition and criteria: The City is required to file an annual report for the Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) program. As part of the reporting process, the City designates the portion allocable to revenue rep...
Major Federal Award Programs Audit Material Weakness #2023-006 Condition and criteria: The City is required to file an annual report for the Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) program. As part of the reporting process, the City designates the portion allocable to revenue replacement to allow for the amount of expenditures that can be claimed as the broad general government services category. In addition, the City reports the amount of funds that were obligated and the amount that was actually expended. All the funds were obligated, but a significant amount had not been expended at the time of the report and the City reported the funds as fully expended. The reporting discussed tranche two funds received in some of the narratives but not in the obligations or revenue loss sections, which should be included in the reports. Cause: There were several changes in staff during the year and the staff that filed the March 2023 report was new to the process. Staff relied on the prior year’s reporting, which also did not meet regulatory requirements. The grant has a wide latitude on allowable costs and management changed their decision on costs charged to the grant causing further difficulties in reporting. Auditor’s recommendation: We recommend that the City only report funds actually incurred as expenditures in future reports, and we recommend additional training for staff reporting under this grant. We also recommend that the City review the intended spending of the remaining funds and to have an updated spending plan approved by Council. Management’s Plan of Action Management concurs with the auditor’s recommendations and future CSLFRF reports will be based on the amounts actually expended. The City has committed all the remaining funds as required by the ARPA deadlines. Anticipated Completion Date: December 31, 2024 Name and Title of Responsible Person: Jeanie Dexter, Finance Director Prepared by: Jeanie Dexter, Finance Director Dated 2/20/25
CDS realizes there is a need to better track the grant funding and expenditures. In FY22-FY24 CDS’s Finance Director and staff turned over several times. Due to a very challenging hiring environment, CDS was not able to fill these positions with permanent qualified candidates, creating a delay in ti...
CDS realizes there is a need to better track the grant funding and expenditures. In FY22-FY24 CDS’s Finance Director and staff turned over several times. Due to a very challenging hiring environment, CDS was not able to fill these positions with permanent qualified candidates, creating a delay in timely reconciliations. In FY25 policies have been put in place to monitor and track the progress of each grant with the use of spreadsheets and tying to the general ledger on a monthly basis. Responsible Party: Dan Hemdal, CDS State Director Anticipated Completion Date: February 1, 2025
View Audit 344878 Questioned Costs: $1
CDS notes the sample of 40 files identified, one incidence was found insufficient. CDS documentation includes thousands of data points, and believes the instance identified is an isolated incident. CDS recognizes there are significant challenges with respect to obtaining and inputting children's fin...
CDS notes the sample of 40 files identified, one incidence was found insufficient. CDS documentation includes thousands of data points, and believes the instance identified is an isolated incident. CDS recognizes there are significant challenges with respect to obtaining and inputting children's financial information into CINC. CDS has drafted a request for proposal for a new data system, which should improve service log documentation. Responsible Party: Dan Hemdal, CDS State Director Anticipated Completion Date: July 1, 2025
In FY25, CDS has added a policy whereas any supplier wanting to do business with CDS must first be checked through the SAM (system for award management) website and if there is any issue that supplier will not be allowed to do business of any kind with CDS. Responsible Party: Dan Hemdal, CDS State ...
In FY25, CDS has added a policy whereas any supplier wanting to do business with CDS must first be checked through the SAM (system for award management) website and if there is any issue that supplier will not be allowed to do business of any kind with CDS. Responsible Party: Dan Hemdal, CDS State Director Anticipated Completion Date: February 1, 2025
CDS recognizes there are significant challenges with respect to obtaining and inputting children's financial information into CINC. In response to this finding, CDS moved to improve by continuing to review current policies and procedures and providing CINC data input training for staff. CDS also bud...
CDS recognizes there are significant challenges with respect to obtaining and inputting children's financial information into CINC. In response to this finding, CDS moved to improve by continuing to review current policies and procedures and providing CINC data input training for staff. CDS also budgeted for 1 quality assurance (QA) FTE to centralize the consent to bill workflow and provide payor source validation to improve the accuracy of the data in CINC. Due to a challenging workforce environment, CDS was not able to fill that position with a qualified full-time candidate, hence is utilizing internal staff to supplement. CDS will implement new procedures to clearly update and define timeline expectations at the site level, which will be aided by updating existing forms and full agency staff support. Responsible Party: Dan Hemdal, CDS State Director Anticipated Completion Date: July 1, 2025
CDS recognizes the challenges present in the timelines and authorization of Children’s Service plans. In response to this finding, CDS continues to make strides with the staff to address issues as they occur in the monthly meetings and provide the necessary training. Also, with the new data system, ...
CDS recognizes the challenges present in the timelines and authorization of Children’s Service plans. In response to this finding, CDS continues to make strides with the staff to address issues as they occur in the monthly meetings and provide the necessary training. Also, with the new data system, parameters will be put in place to alert staff when an item is out of date along with reports being run and shared weekly on missing and/or outdated documents. The new data system is planned to be in place for July 2025. CDS has had many struggles with staffing and has added positions to strengthen the controls. Responsible Party: Dan Hemdal, CDS State Director Anticipated Completion Date: July 1, 2025
Finding 525642 (2023-003)
Significant Deficiency 2023
#2023-003 – Significant Deficiency and Other Non-Compliance. Condition and context: Sampling of internal controls over payroll revealed 7 of the 240 transactions did not have timesheets approved by the employee’s supervisor, and for 2 of the 240 transactions, the employee was paid the incorrect am...
#2023-003 – Significant Deficiency and Other Non-Compliance. Condition and context: Sampling of internal controls over payroll revealed 7 of the 240 transactions did not have timesheets approved by the employee’s supervisor, and for 2 of the 240 transactions, the employee was paid the incorrect amount.. Recommendation: Reemphasize current policies and procedures to review timesheets, and payroll transactions. Planned corrective action: Current policies and procedures will be reviewed, and alternative approval procedures will be identified for instances when the employee’s direct supervisor is unavailable for timely approval. Implement additional audits during rollover process to correct administrative gap, which resulted in 2 payment amount errors. Responsible officers: James Dworkin, Chief Financial Officer and Martin Winchester, Chief Human Assets Officer Estimated completion date: March 31, 2024
View Audit 344754 Questioned Costs: $1
Invalid Journal Entries (Compliance) Recommendation: We recommend the Organization perform a thorough year-end review which should include comparing current balances to the prior year, reviewing details of account balances, as necessary, and reviewing journal vouchers posted during the year for reas...
Invalid Journal Entries (Compliance) Recommendation: We recommend the Organization perform a thorough year-end review which should include comparing current balances to the prior year, reviewing details of account balances, as necessary, and reviewing journal vouchers posted during the year for reasonableness, prior to submitting reimbursement requests for federal programs. Management’s Response: We concur with the recommendation, and the corrective action will be implemented as of January 31, 2025.
View Audit 344694 Questioned Costs: $1
Recommendation: We recommend the Organization obtain a better understanding of the accounting system to allow for a thorough year-end close and review process. The year-end review should include reviewing current balances compared to the prior year, reviewing grant drawdowns near year-end to ensure ...
Recommendation: We recommend the Organization obtain a better understanding of the accounting system to allow for a thorough year-end close and review process. The year-end review should include reviewing current balances compared to the prior year, reviewing grant drawdowns near year-end to ensure they are recognized in the fiscal year the related costs were incurred, agreeing federal revenues earned to federal expenditures for cost-reimbursable grants, and reviewing details of account balances, as necessary, prior to providing the trial balance for audit. Management’s Response: We concur with the recommendation, and the corrective action will be implemented as of January 31, 2025.
Recommendation: We recommend the Organization perform a thorough year-end review which should include comparing current balances to the prior year, reviewing details of account balances, as necessary, and reviewing journal vouchers posted during the year for reasonableness, prior to providing the tr...
Recommendation: We recommend the Organization perform a thorough year-end review which should include comparing current balances to the prior year, reviewing details of account balances, as necessary, and reviewing journal vouchers posted during the year for reasonableness, prior to providing the trial balance for audit. Management’s Response: We concur with the recommendation, and the corrective action will be implemented as of January 31, 2025.
Communities In Schools of Georgia acknowledges the audit recommendation and is committed to strengthening internal controls related to journal entries and supporting documentation. During fiscal year 2024, we took the following actions to improve the integrity of our finance processes and controls ...
Communities In Schools of Georgia acknowledges the audit recommendation and is committed to strengthening internal controls related to journal entries and supporting documentation. During fiscal year 2024, we took the following actions to improve the integrity of our finance processes and controls over compliance with federal grant requirements: • Engaged Senior Finance Contractor • Initiated Search for Permanent full-time CFO • Completed implementation of new accounting software Under the leadership of our newly hired CFO, we are continuing to improve our finance processes by implementing the following measures: • Internal Controls for Journal Entries • Segregation of Duties • Workflow Approvals • Training and Process Standardization By implementing these measures, we aim to strengthen financial oversight and ensure accurate financial reporting and compliance with federal grant requirements. We appreciate the auditors’ recommendations and remain committed to establishing and maintaining robust internal controls.
Views of Responsible Officials and Planned Corrective Actions: We acknowledge the finding related to the delayed submission of the Single Audit report and appreciate the recommendation provided. Management is committed to ensuring timely completion and submission of future Single Audit reports in ac...
Views of Responsible Officials and Planned Corrective Actions: We acknowledge the finding related to the delayed submission of the Single Audit report and appreciate the recommendation provided. Management is committed to ensuring timely completion and submission of future Single Audit reports in accordance with the required deadlines. To address this, we will implement the following corrective actions: 1. Enhanced Internal Timeline: We will establish an internal deadline for audit-related documentation and review, allowing sufficient time for finalization before the official reporting deadline. 2. Increased Coordination: Management will work closely with auditors and key stakeholders throughout the audit process to ensure timely responses and resolution of outstanding items. 3. Resource Allocation: Additional internal resources will be dedicated to supporting the audit process, ensuring that necessary documentation and financial records are prepared in advance. 4. Regular Progress Monitoring: We will implement periodic check-ins during the audit period to track progress and address any potential delays proactively. We are confident that these measures will improve our ability to meet future reporting deadlines and enhance overall efficiency in the audit process.
Finding 2023-003 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U.S. Department of Health and Human Services Minnesota Department of Human Services Condition: The sys...
Finding 2023-003 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U.S. Department of Health and Human Services Minnesota Department of Human Services Condition: The system used for processing transactions does not include documentation that transactions have been reviewed for compliance with OMB regulations, before they are charged to a federal grant. Actions Planned in Response to the Finding: With the hiring of a full-time staff accountant within the next 2 weeks, the organization will engage in the design, documentation, and implementation of a system of internal control measures that meet the requirement of OMB Uniform Guidance. The in-house accountant will obtain additional training in Uniform Guidance and federal grant management so that a system of internal control over compliance can be installed. Specifically, the new in-house accountant will ensure that transactions have been reviewed for compliance with OMB regulations before they are charged a federal grant. Official Responsible for Ensuring the CAP: Chief Operating Officer Planned Completion Date for the CAP: June 30, 2025
View Audit 344524 Questioned Costs: $1
Finding 2023-002 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: Emplo...
Finding 2023-002 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: Employee time sheets do not identify the hours charged to each federal grant, and do not identify hours worked by employees on non-federal grants. Actions Planned in Response to the Finding: The timeline for hiring an in-house accountant is very compressed. The in-house accountant will undergo various training on Uniform Guidance and federal grant management. These training programs will help the organization to create a system of time and effort reporting that will meet the Standards for Documentation of Personnel Expenses included in OMB Uniform Guidance. Specifically, time sheets will be redesigned to ensure that employees record hours charged to each federal grant, any other projects, and administrative time. Official Responsible for Ensuring the CAP: Chief Operating Officer Planned Completion Date for the CAP: June 30, 2025
View Audit 344524 Questioned Costs: $1
To: U.S. Department of Health and Human Services-Passed through Minnesota Department of Human Services RE: Single Audit Corrective Action Plan (CAP) for the fiscal year ended December 31, 2023 Name and address of independent accounting firm: BWK Rogers PC 431 South Seventh Street, Suite 2424 Minn...
To: U.S. Department of Health and Human Services-Passed through Minnesota Department of Human Services RE: Single Audit Corrective Action Plan (CAP) for the fiscal year ended December 31, 2023 Name and address of independent accounting firm: BWK Rogers PC 431 South Seventh Street, Suite 2424 Minneapolis, MN 55415 African American Child Wellness Institute submits the following corrective action plan for the year ended December 31, 2023. Please contact Akinyele Akinsanya at 763-522-0100. Finding 2023-001 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: Expenses charged to the federal grant cannot be traced into the Organization’s general ledger. Invoices submitted to the pass-through agency for reimbursement also cannot be traced into the general ledger. Actions Planned in Response to the Finding: It is clear to management that the Organization needs to boost its accounting team to fulfil effective reporting that could easily be traced into the organization’s general ledger. As a result, the organization will recruit and hire a full-time accountant to work with the current team. Further steps may be required including replacing the organization’s current accounting software that will identify and record expenditure specific to each cost centers for each federal grant. The in-house accountant will also be required to obtain additional training in Uniform Guidance and federal grant management and create a system of financial reporting to record expenditure directly to each federal grant award. Official Responsible for Ensuring the CAP: Chief Operating Officer Planned Completion Date for the CAP: March 15, 2025
View Audit 344524 Questioned Costs: $1
Recommendation – We recommend that management ensure that non-payroll costs charged to the program are allowable costs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – All non-payroll costs are reviewed by a supervisor be...
Recommendation – We recommend that management ensure that non-payroll costs charged to the program are allowable costs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – All non-payroll costs are reviewed by a supervisor before being approved. This supervisor review includes which programs are being charged along with other internal coding. Management has emphasized the requirements for supervisors to review invoices to verify programs are being properly charged along with other internal coding.
View Audit 344486 Questioned Costs: $1
Recommendation – We recommend that management ensure that supporting reports are current and accurate for expenses charged to federal programs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – Reports will be reviewed and ...
Recommendation – We recommend that management ensure that supporting reports are current and accurate for expenses charged to federal programs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – Reports will be reviewed and retained to support expenses in the future.
Recommendation – We recommend that management ensure that non-payroll costs charged to the program are allowable costs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – All non-payroll costs are reviewed by a supervisor be...
Recommendation – We recommend that management ensure that non-payroll costs charged to the program are allowable costs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – All non-payroll costs are reviewed by a supervisor before being approved. This supervisor review includes which programs are being charged along with other internal coding. Management has emphasized the requirements for supervisors to review invoices to verify programs are being properly charged along with other internal coding.
View Audit 344486 Questioned Costs: $1
Recommendation – We recommend that management ensure that supporting documentation for expenses charged to federal programs be maintained to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – Expense documentation will be main...
Recommendation – We recommend that management ensure that supporting documentation for expenses charged to federal programs be maintained to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – Expense documentation will be maintained to support expenses in the future.
View Audit 344486 Questioned Costs: $1
Recommendation — We recommend that management ensure that records are retained to support the validity of expenses charged to federal programs. Views of Responsible Officials and Planned Corrective Actions — Management agrees with the finding and in the future will take steps to retain or insure tha...
Recommendation — We recommend that management ensure that records are retained to support the validity of expenses charged to federal programs. Views of Responsible Officials and Planned Corrective Actions — Management agrees with the finding and in the future will take steps to retain or insure that access to records continues to be available in instances of system migrations.
Management has assessed that all supporting documentation that was unable to be provided for audit support was related to transactions that occurred on the legacy accounting system. The legacy accounting system did not allow for centralized/shared data storage, and as a result, caused personnel to s...
Management has assessed that all supporting documentation that was unable to be provided for audit support was related to transactions that occurred on the legacy accounting system. The legacy accounting system did not allow for centralized/shared data storage, and as a result, caused personnel to store information in different locations. In May 2023, the organization made the transition to the new accounting system where data can easily be centralized/shared. Management has also implemented policies and procedures that require review of documents within the accounting system prior to approval, thus creating internal controls to prevent a lack of supporting documentation for future reporting periods. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller
Management acknowledges that the organization operated with provisional rates in 2023 and did not update to actual indirect rates. Management has calculated actual rates for 2023, will update its NICRA for new provisional rates for 2025 and will institute a policy of updated rates on an annual basis...
Management acknowledges that the organization operated with provisional rates in 2023 and did not update to actual indirect rates. Management has calculated actual rates for 2023, will update its NICRA for new provisional rates for 2025 and will institute a policy of updated rates on an annual basis including computing actual indirect cost rates at the conclusion of each audit. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller
Management has assessed that all supporting documentation that was unable to be provided for audit support was related to transactions that occurred on the legacy accounting system. The legacy accounting system did not allow for centralized/shared data storage, and as a result, it caused personnel t...
Management has assessed that all supporting documentation that was unable to be provided for audit support was related to transactions that occurred on the legacy accounting system. The legacy accounting system did not allow for centralized/shared data storage, and as a result, it caused personnel to store information in different locations. In May 2023, the organization made the transition to the new accounting system where data can easily be centralized/shared. Management has also implemented policies and procedures that require review of documents within the accounting system prior to approval, thus creating internal controls to prevent a lack of supporting documentation for future reporting periods. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller
View Audit 344384 Questioned Costs: $1
Finding 2023-005 Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 5 TIN# 910171250 Activities Allowed or Unallowed, Allowable Cost...
Finding 2023-005 Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 5 TIN# 910171250 Activities Allowed or Unallowed, Allowable Cost/Cost Principles Material Weakness in Internal Control over Compliance and Noncompliance Finding Summary: Confluence Health claimed and reported expenditures that contained errors based upon the underlying documentation. Context: A nonstatistical sample of 60, supplies, services, and payroll transactions out of a population of approximately 5,215 totaling $5,006,903 were selected for testing. The sample contained errors in two transactions in which the amounts claimed on the Period 5 report were not supported by payroll records. The amounts claimed not supported by payroll records totaled $89,582 out of a total sample value of $2,615,445. Corrective Action Plan: Confluence Health will tract with separate payroll codes for employee working on federal grants that involve inpatient facing care for the next pandemic to allow for accurate tracking of costs. Responsible Individual: Eric Caldwell, VP of Finance is responsible for this corrective action plan that was put into place on January 15, 2025.
View Audit 344374 Questioned Costs: $1
We agree with the finding. Management is in the process of assessing the operational controls to prepare adequate financial reporting. The financial staff will be trained to the various steps in monitoring the financial position and operations of the Agency. Additional staff with be hired and traine...
We agree with the finding. Management is in the process of assessing the operational controls to prepare adequate financial reporting. The financial staff will be trained to the various steps in monitoring the financial position and operations of the Agency. Additional staff with be hired and trained to assist with the performance of accurate and timely reporting. We plan to complete these processes by May 31, 2025.
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