Corrective Action Plans

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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.
Finding 524563 (2023-001)
Significant Deficiency 2023
Below is Housing Forward’s response to the audit finding for fiscal year 1/1/2023 through 12/31/2023. Federal Award Finding Finding 2023-001: Allowable costs and activities – significant deficiency in internal controls over compliance and compliance finding specific to payroll allocation.  Funding ...
Below is Housing Forward’s response to the audit finding for fiscal year 1/1/2023 through 12/31/2023. Federal Award Finding Finding 2023-001: Allowable costs and activities – significant deficiency in internal controls over compliance and compliance finding specific to payroll allocation.  Funding Source: Coronavirus State and Local Fiscal Recovery Funds ALN 21.027 (CSLFRF).  Condition: During allowable cost and activities testing for the CSLFRF grant, 2 out of 40 timesheets tested did not agree to the number of hours charged to the grant.  Cause: Although the 2 timesheets were filled out completely, signed and reviewed by a supervisor, there was an error in the data entry into the accounting software. Amounts were calculated correctly but inadvertently assigned to the wrong grant. GL detail was provided to the funder as part of the monthly reporting, but neither the funder nor Housing Forward staff noticed this error.  Management’s Response: Management understands the importance of correctly charging time to funders. Housing Forward will continue its timesheet review process and utilize employee timesheets that clearly indicate funding sources and allocate payroll costs based on these records. Housing Forward will implement a second review of the payroll entry at the time it is entered into the accounting system to ensure that errors are corrected before payroll costs are charged to funders. This began in January 2025. The second reviewer will be the VP of Finance/CFO or her designee. In later FY25 the organization also plans to implement a timekeeping software that integrates with the accounting software to prevent future data entry errors. Sincerely, Sarah Kahn Sarah Kahn President & CEO
View Audit 343995 Questioned Costs: $1
Condition: Controls did not identify that expenses submitted to the State were outside of the period of performance. Planned Corrective Action: Background: Sinai began the process of risk assessment in the government grants area at the end of 2022. At that time, Sinai engaged outside counsel to as...
Condition: Controls did not identify that expenses submitted to the State were outside of the period of performance. Planned Corrective Action: Background: Sinai began the process of risk assessment in the government grants area at the end of 2022. At that time, Sinai engaged outside counsel to assist in this process. In December of 2023, Sinai created the Office of Government Grant Administration (OGGA) and developed a comprehensive grant compliance policy and procedure. The Audit and Compliance Committee of the Board was updated on this initiative. In 2024, the OGGA created a Grant Compliance Manual which sets forth processes and procedures in grant management to ensure compliance with government regulations. Unfortunately, these controls were not implemented until after the relevant time period at issue in this audit. In 2025, Sinai is continuing to improve its compliance procedures with respect to government grants, and has developed the following plan: 1. Working Group: Sinai will implement a process of convening a Working Group for each government grant, which will consist of a representative from Finance, the OGGA, and the stakeholder involved (i.e., nursing, medicine, etc.) The Working group will be responsible for, among other things, ensuring that that the reported qualifying expenditures are incurred during the period of performance of the grant. In other words, allowable costs will be discussed early in the process, so that there is fulsome understanding among the key individuals involved. 2. Record-Keeping: The OGGA will also establish shared folders to house all of the pertinent documentation relative to the grant. 3. Invoice/Supporting Documentation Review. The Grant Accounting Manager will review all invoices and other supportive documentation to ensure that allowable costs are submitted for reimbursement. This compliance check will be completed prior to submission of the documentation for reimbursement. Monthly reviews of these activities will be performed by the Grant Accountant, the Compliance Grant Manager, and other OGGA staff as needed. Proactive review to prevent or resolve issues in the upcoming month’s billings should be pursued. 4. Annual Assessment. The Chief Compliance Officer, with the assistance of the General Counsel, will meet with the OGGA team annually to assess procedures and risk controls; a report of this assessment will be made to the Audit and Compliance Committee of the Board of Directors Contact person responsible for corrective action: Dimas Ortega - Vice President of Finance, Deputy Chief Financial Officer Anticipated Completion Date: 06/30/2025
View Audit 343640 Questioned Costs: $1
Finding 524098 (2023-005)
Material Weakness 2023
Action taken in response to finding: Trilogy submitted an application to apply for a new indirect cost rate in January 2024, we also received provisional approval from the federal agency to continue use of our prior approved indirect cost rate. Since then, Trilogy has clearly defined compliance req...
Action taken in response to finding: Trilogy submitted an application to apply for a new indirect cost rate in January 2024, we also received provisional approval from the federal agency to continue use of our prior approved indirect cost rate. Since then, Trilogy has clearly defined compliance requirements for maintaining an up-to-date indirect cost rate. This includes developing a timeline of responsibilities, documents and steps needed for approval. This also includes the development of an annual calendar for Finance to be proactive about expiring NICRA agreements. Name(s) of the contact person(s) responsible for corrective action: Richard Powell, Shunita Rhodes Planned completion date for corrective action plan: August 2023 and January 2024.
Finding 524097 (2023-004)
Material Weakness 2023
Action taken in response to finding: Trilogy will thoroughly review the grant agreements to understand specific start and end dates as well as any allowable cost guidelines. Training will be provided to staff on identifying cut off periods and the reviewing of invoices for expenditures will be moni...
Action taken in response to finding: Trilogy will thoroughly review the grant agreements to understand specific start and end dates as well as any allowable cost guidelines. Training will be provided to staff on identifying cut off periods and the reviewing of invoices for expenditures will be monitored closely when entered into the system to ensure it is entered into the system in the correct period in which the expense is incurred. Documentation will be reviewed by the Controller before posting to the general ledger to ensure expenses are charged to the correct grant period. During the grant invoice preparation there will be an additional review of the expenses in the general ledger to ensure the cut-off for grant expenditures are included in the correct period for the monthly grant vouchers. Trilogy will also implement a quarterly review of expenses charged to grants in preparation of the quarterly reports to ensure proper allocation to grants and cut off grant expenditures during the first and last month of the grant budget period. Name(s) of the contact person(s) responsible for corrective action: Richard Powell, Shunita Rhodes, Hagar Buster, Han Qi Planned completion date for corrective action plan: October 31, 2024, and ongoing as needed.
View Audit 343276 Questioned Costs: $1
Finding 524096 (2023-003)
Material Weakness 2023
Action taken in response to finding: Trilogy implemented a new payroll system in January 2024 that allows staff to change their allocations of time if it varies from the budget when working on grant programs. These changes can be made in blocks of time or by the day. Financial analysts and the FP&...
Action taken in response to finding: Trilogy implemented a new payroll system in January 2024 that allows staff to change their allocations of time if it varies from the budget when working on grant programs. These changes can be made in blocks of time or by the day. Financial analysts and the FP&A manager meet with program directors and program managers monthly to go over allocations and update in the UKG payroll system as well as for the preparation of the monthly grant vouchers. Name(s) of the contact person(s) responsible for corrective action: Richard Powell, Shunita Rhodes, Hagar Buster Planned completion date for corrective action plan: February 2024 and ongoing as needed.
View Audit 343276 Questioned Costs: $1
We agree with the recommendation and moving forward the District will maintain records of all federal expenditures supported by financial reports.
We agree with the recommendation and moving forward the District will maintain records of all federal expenditures supported by financial reports.
View Audit 343203 Questioned Costs: $1
We agree with the recommendation and moving forward the District’s Director of Fiscal Services will implement a review process for indirect costs that will include a review of relevant grant agreements and federal guidance.
We agree with the recommendation and moving forward the District’s Director of Fiscal Services will implement a review process for indirect costs that will include a review of relevant grant agreements and federal guidance.
View Audit 343203 Questioned Costs: $1
We agree with the recommendation and moving forward all expenditure records and financial reports will be maintained for a minimum of three years.
We agree with the recommendation and moving forward all expenditure records and financial reports will be maintained for a minimum of three years.
View Audit 343203 Questioned Costs: $1
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