Corrective Action Plans

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COMMUNITY ACTION CENTER AGREES WITH THE FINDINGS REPORTED AND HAS MADE CORRECTIVE ACTION TO RECTIFY THE FINDING.
COMMUNITY ACTION CENTER AGREES WITH THE FINDINGS REPORTED AND HAS MADE CORRECTIVE ACTION TO RECTIFY THE FINDING.
U.S. Department of Housing and Urban Development Home Investment Partnerships Program – Assistance Listing No. 14.239 Recommendation: CLA recommended that PHFA review their procedures surrounding the division sign-off form utilized in the pre-commitment meeting. Explanation of disagreement with a...
U.S. Department of Housing and Urban Development Home Investment Partnerships Program – Assistance Listing No. 14.239 Recommendation: CLA recommended that PHFA review their procedures surrounding the division sign-off form utilized in the pre-commitment meeting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHFA implemented a new process to ensure the required divisional signoffs are received after the completion of the pre-commitment meeting. The Lending Officer prepares an electronic approval listing in Microsoft Teams to capture the approvals after the pre-commitment meeting. The Lending Officer follows up with the requested signors to ensure that all outstanding questions have been answered and the signer can mark the Microsoft Teams’ listing approved. Name of the contact person responsible for corrective action: Jessica Perry, Director of Development The new Microsoft Teams approval system was implemented in August 2023. To date, approximately 20 developments have been approved via the new system.
Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization has made efforts to ensure that proper documentation is maintained and accessible by necessary staff.
Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization has made efforts to ensure that proper documentation is maintained and accessible by necessary staff.
View Audit 342835 Questioned Costs: $1
Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization conducted a review after the completion of the year end to ensure reconcile the total amounts charged to the grant back to accounting records to ensure compliance, howev...
Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization conducted a review after the completion of the year end to ensure reconcile the total amounts charged to the grant back to accounting records to ensure compliance, however, this was not done in a timely enough manner to correct for misstatements. In the future the Organization will review support and reconcile on a more frequent basis.
View Audit 342835 Questioned Costs: $1
We have reviewed the qualifications for allowable expenses classified as supplies versus capital expenditures that of a 600 code with ODE CCIP representatives for project relate cash requests as well as getting pre-approval if varying from the budget details request.
We have reviewed the qualifications for allowable expenses classified as supplies versus capital expenditures that of a 600 code with ODE CCIP representatives for project relate cash requests as well as getting pre-approval if varying from the budget details request.
View Audit 342736 Questioned Costs: $1
Finding #2023-001 – Material Weakness and Material Noncompliance. Major federal programs: U. S. Department of Treasury, Assistance Listing #21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Passed through Harris County, Texas, Contract #220163, Contract year: 12/01/22 – 12/31/24, ...
Finding #2023-001 – Material Weakness and Material Noncompliance. Major federal programs: U. S. Department of Treasury, Assistance Listing #21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Passed through Harris County, Texas, Contract #220163, Contract year: 12/01/22 – 12/31/24, Assistance Listing #93.788, Opioid STR, Passed through the Texas Health and Human Services Commission, Contract #HHS000357900001, Contract years: 09/01/21 – 08/31/22 and 09/01/22 – 08/31/23, Passed through the University of Texas Health Science Center, San Antonio, Contract #HHS000561800001, Contract year: 09/01/21 – 08/31/22. Other federal programs: U. S. Department of Health and Human Services:, Assistance Listing #93.243, Substance Abuse and Mental Health Services Projects of Regional and National Significance, Contract #5H79TI080624-03, Contract year: 09/30/21 – 09/29/22, Contract #5H79TI080624-04, Contract year: 09/30/22 – 09/29/23, Passed through the City of Houston Health Department, Assistance Listing #93.243, Contract #H79SP080300, Contract years: 11/01/21 – 10/31/22, 11/01/22 – 10/31/23 and 06/08/21 – 06/30/23, Assistance Listing #93.959, Block Grants for Prevention and Treatment of Substance Abuse, Passed through the Texas Health and Human Services Commission, Contract #HHS000130500019, Contract years: 09/01/21 – 08/31/22 and 09/01/22 – 08/31/23. Condition and context: Houston Recovery Center has personnel funded by more than one grant award. The responsibilities for each position are examined and an assessment of time needed to perform each assigned task is made. The time allotment is then converted to a percentage of salary, documented on the personnel action form for each employee, and used to create the personnel section of each grant budget. Each grant is charged based on the percentages documented on the personnel action forms. In fiscal 2022, quarterly time studies were utilized to support that the budgeted estimates per the personnel action forms were reasonable and, if needed, adjustments were made in the general ledger. On July 1, 2022, Houston Recovery Center changed third-party payroll processors and the new processor did not provide the capability to charge time to more than one cost center. Therefore, while allocations are still made in the general ledger based on the percentages documented on the employee’s personnel action form, actual time worked by grant/cost center was not tracked. Additionally, a time study was not performed in the year ended June 30, 2023 to evaluate the reasonableness of time charged to the grants. Recommendation: Houston Recovery Center should establish policies and procedures to ensure that grants are charged based on actual time and effort expended. Planned corrective action: Management believes that the grants were reasonably charged in all material respects although the payroll provider was unable to allow us to use actual time and effort. Comparison of fiscal year 2022 actual time and effort with the fiscal year 2022 time studies revealed very small differences. However, Houston Recovery Center is in the process of changing to a payroll software provider where actual time can be tracked to each grant as supported by a timesheet. In addition, Houston Recovery Center is using Time Distribution Sheets (TDSs) where the employee is required to record their hours worked by grants. Training on the TDSs will be completed by November 1, 2023 for all employees on multiple awards as appropriate. TDSs will be turned in weekly and utilized until the payroll conversion is completed and is working as needed. Responsible officer: Leonard Kincaid, Executive Director. Estimated completion date: November 1, 2023.
Department of Health and Human Services, Passed Through Oklahoma Department of Mental Health and Substance Abuse Services, Block Grants for Community Mental Health Services Listing 93.958, 4529063664/4529063519, 711/2022- 6/30/2023 Allowable Activities or Unallowed and Allowable Costs/Cost Principle...
Department of Health and Human Services, Passed Through Oklahoma Department of Mental Health and Substance Abuse Services, Block Grants for Community Mental Health Services Listing 93.958, 4529063664/4529063519, 711/2022- 6/30/2023 Allowable Activities or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: As part of the audit, Eide Bailly LLP identified that the process for allocating payroll or time worked to respective federal programs was insufficient and did not substantiate allowability under the federal award guidelines. Responsible Individuals: Chief Financial Officer and Chief Human Resources Officer Corrective Action Plan: In December 2024, changes were made to the payroll system to improve tracking of time worked and appropriate allocations to respective federal grant programs. Completion Date: December 2024
View Audit 342657 Questioned Costs: $1
Department of Health and Human Services, Passed Through Substance Abuse and Mental Health Services Administration, Section 223 Demonstration Programs to Improve Community Mental Health Services Listing 93.829, H79SM085287, 8/31/2022- 8/30/2023 Allowable Activities or Unallowed, Allowable Costs/Cost ...
Department of Health and Human Services, Passed Through Substance Abuse and Mental Health Services Administration, Section 223 Demonstration Programs to Improve Community Mental Health Services Listing 93.829, H79SM085287, 8/31/2022- 8/30/2023 Allowable Activities or Unallowed, Allowable Costs/Cost Principles, Cash Management, and Matching, Level of Effort, and Earmarking Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: As part of the audit, Eide Bailly LLP identified that the process for allocating payroll or time worked to respective federal programs was insufficient and did not substantiate allowability under the federal award guidelines. Responsible Individuals: Chief Financial Officer and Chief Human Resources Officer Corrective Action Plan: In December 2024, changes were made to the payroll system to improve tracking of time worked and appropriate allocations to respective federal grant programs. Completion Date: December 2024
Finding 523383 (2023-033)
Significant Deficiency 2023
Finding No.: 2023-033 Reporting Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency acknowledges this finding and recognizes it as an ongoing issue related to the alignment of our reporting with t...
Finding No.: 2023-033 Reporting Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency acknowledges this finding and recognizes it as an ongoing issue related to the alignment of our reporting with the Department of Administration (DOA) financial system. One of the primary challenges arises from transactions that are not processed within the designated reporting period, which impacts on our initial submissions to CMS. Any adjustments or transactions made after the quarter's close, which were not captured in our previous reports, contribute to this issue. We understand that addressing this finding is a critical part of our corrective action measures. We are currently working on updating the existing Standard Operating Procedure (SOP) 2023-01, which governs interactions between the Department of Public Health and Social Services (DPHSS) and DOA/Division of Accounts. Since November 2024, we have been collaborating with DOA to revise this SOP with the goal of reconciling Medicaid and CHIP expenditures, as well as aligning reports from CMS-64 with the new Guam Financial Management Information System (GFMIS). Currently, PMS staff is in the process in finalizing the DRAFT SOP. We intend to have the DRAFT SOP completed and forwarded to DOA by Friday, January 31, 2025. If there are no changes to the SOP, we will work to have the SOP signed by all parties no later than February 14, 2025.
Finding 523371 (2023-029)
Significant Deficiency 2023
Finding No.: 2023-029 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward.
Finding No.: 2023-029 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward.
View Audit 342645 Questioned Costs: $1
Finding 523340 (2023-002)
Significant Deficiency 2023
This condition existed due to multiple payroll systems used during the last two audit periods and untrained personnel. Current staff is fully trained on a new payroll system and capable of maintaining our newly developed processes and controls. Anicipated completion date is at the completion of the ...
This condition existed due to multiple payroll systems used during the last two audit periods and untrained personnel. Current staff is fully trained on a new payroll system and capable of maintaining our newly developed processes and controls. Anicipated completion date is at the completion of the 2024 audit. Responsible contact person is Caitlin Cole, Human Resources manager.
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
We will work to implement a risk assessment plan. We will implement controls to help make sure we are in compliance with all grant requirements and federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance ...
We will work to implement a risk assessment plan. We will implement controls to help make sure we are in compliance with all grant requirements and federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance supplement to work from.
We agree that we have not been reporting on a timely basis current findings and results. We have established a schedule to ensure that the submission of all required annual reports is strictly adhered to. To this end, we aim to complete the year-end closing within the first 30 days after the end of ...
We agree that we have not been reporting on a timely basis current findings and results. We have established a schedule to ensure that the submission of all required annual reports is strictly adhered to. To this end, we aim to complete the year-end closing within the first 30 days after the end of the calendar year, in order to complete the audit within the first 120 days after the end of the calendar year. This plan was implemented in December 2024. However, because the report for the single audit for December 2023 was already past due by the time of implementation, the positive effects of this plan will be reflected in future reporting periods.
Finding Reference: 2023-003 Views of Responsible Officials and Planned Corrective Actions The Agency agrees with this finding and recommendation as presented. Given this finding, the Agency will review monthly its application of the approved provisional indirect cost rate to all grants, contracts, a...
Finding Reference: 2023-003 Views of Responsible Officials and Planned Corrective Actions The Agency agrees with this finding and recommendation as presented. Given this finding, the Agency will review monthly its application of the approved provisional indirect cost rate to all grants, contracts, and other agreements covered by 2 CFR 200. The agency will proceed in the following scope of work:  Ensure indirect chargers follow the applicable cost principles per 2 CFR 200, Appendix IV, and grant agreement.  Receive permission from funders for indirect charges over the allocation of the indirect costs per the grant agreement. Name of the contact person responsible for corrective action: Michael Young, President, (301) 274-4474. Planned completion date for corrective action plan: December 31, 2025
MFIP and TANF Youth – Assistance Listing No. 93.558 Recommendation: The Organization should implement a comprehensive documentation retention policy that includes specific procedures for maintaining records supporting the allocation of individual employees' time. This policy should ensure that all r...
MFIP and TANF Youth – Assistance Listing No. 93.558 Recommendation: The Organization should implement a comprehensive documentation retention policy that includes specific procedures for maintaining records supporting the allocation of individual employees' time. This policy should ensure that all relevant documentation, such as timesheets and work allocation records, is retained for the required period and is easily accessible for audit purposes. Additionally, staff responsible for timekeeping and financial recordkeeping should receive training on the importance of documentation retention and the specific requirements under the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To establish a standardized cost allocation methodology for staff time, CMJTS implemented in-person monthly allocation meetings with the executive team and program managers responsible for programming, staffing, and budget oversight. These meetings provide a thorough review of program expenditures and staff time, ensuring accurate alignment with funding requirements. Conducting payroll allocation reviews in a group setting allows the executive team to validate cost assignments, address changes in percentage allocations across cost categories, and maintain compliance with administrative regulations and funding guidelines. Name(s) of the contact person(s) responsible for corrective action: Jake Humphrey Planned completion date for corrective action plan: Implemented
MFIP and TANF Youth – Assistance Listing No. 93.558 Recommendation: The Organization should implement a comprehensive documentation retention policy that includes specific procedures for maintaining records supporting the calculation of indirect cost allocations. This policy should ensure that all r...
MFIP and TANF Youth – Assistance Listing No. 93.558 Recommendation: The Organization should implement a comprehensive documentation retention policy that includes specific procedures for maintaining records supporting the calculation of indirect cost allocations. This policy should ensure that all relevant documentation is retained for the required period and is easily accessible for audit purposes. Additionally, the Organization should ensure the formal review process for indirect cost allocations is completed to verify their accuracy and compliance with applicable regulations. Staff responsible for financial record-keeping and review should receive training on the importance of documentation retention, review procedures, and the specific requirements under the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To strengthen our financial recordkeeping, CMJTS will update our Document Retention Policy. This updated policy will introduce detailed guidelines for the management, maintenance, and secure storage of records that support indirect cost allocations, ensuring they are retained for the required period and easily accessible for audits. Additionally, we will establish a structured review process, including quarterly reviews by the accounting team and an annual reconciliation, to verify accuracy and compliance with applicable regulations. Any necessary adjustments will be documented and reviewed by the finance manager. The CMJTS Executive meets monthly to review and calculate indirect cost allocations for all active grants. The established process is to determine total indirect costs (like rent, utilities, administrative salaries) for the agency by location and department and then allocate them across different grants using a calculated "indirect cost rate," which is usually a percentage of the direct costs associated with each program, based on factors like staff time, caseload size, or other relevant allocation bases; this ensures that each program bears a proportional share of the shared overhead expenses. Name(s) of the contact person(s) responsible for corrective action: Jake Humphrey Planned completion date for corrective action plan: Policy updates – 12 months; Indirect Cost Rates process – implemented
Head Start - ALN #93.600 Recommendation: We recommend that the Organization should review and approve the indirect costs that are allocated by the preparer and retain support of this review and approval. Explanation of disagreement with audit finding: There is no disagreement with the audit finding...
Head Start - ALN #93.600 Recommendation: We recommend that the Organization should review and approve the indirect costs that are allocated by the preparer and retain support of this review and approval. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: WCCA will implement a policy to ensure a documented review and approval of indirect cost allocations. Name(s) of the contact person(s) responsible for corrective action: Carrie Tripp, Executive Director Planned completion date for corrective action plan: September 30, 2025
Finding 522900 (2023-003)
Significant Deficiency 2023
Management accepts this finding and notes that payrolls effected were at the very end of the current audit period and that the error was identified and corrected independently in the subsequent fiscal year. To further address this repeat issue, payroll will run monthly payroll queries and conduct an...
Management accepts this finding and notes that payrolls effected were at the very end of the current audit period and that the error was identified and corrected independently in the subsequent fiscal year. To further address this repeat issue, payroll will run monthly payroll queries and conduct an internal audit of payroll. Additionally, the Sponsored Research Office will work with PI’s to encourage them to plan their summer research efforts such that a research project is not included on more than one summer salary request forms. Although management feels this was an isolated incidence, the University will implement a set of controls that require a secondary review of all manuals calculation for payroll authorizations.
This was an oversight and has been corrected.
This was an oversight and has been corrected.
Finding 522819 (2023-005)
Significant Deficiency 2023
All payroll transmittals and payroll reporting forms will be reviewed by the Fiscal Administrator and/or Fiscal Officer to ensure the supervisor’s signature is present on all payroll reporting forms and that the Director’s or their designee’s signature is present on all payroll transmittals submitte...
All payroll transmittals and payroll reporting forms will be reviewed by the Fiscal Administrator and/or Fiscal Officer to ensure the supervisor’s signature is present on all payroll reporting forms and that the Director’s or their designee’s signature is present on all payroll transmittals submitted to the Auditor’s Office. Supervisors were notified of the need to make sure their signature is on their forms before submitting. All forms missing signatures will be returned to the supervisor before reporting hours. Digital and wet signatures are both acceptable signatory forms.
TOFMHS concurs with the finding. The excess drawdowns were the result of accounting entries to record refunds, or other adjustments which reduced previously allowable expenses. Subsequent drawdowns should have been reduced to offset these adjustments. TOFMHS will implement ACF-IM-HS-23-01 (Treatment...
TOFMHS concurs with the finding. The excess drawdowns were the result of accounting entries to record refunds, or other adjustments which reduced previously allowable expenses. Subsequent drawdowns should have been reduced to offset these adjustments. TOFMHS will implement ACF-IM-HS-23-01 (Treatment of Rebates, Refunds, Discounts), and prevent an recurrence of this issue in the future. Corrective Active Taken: TOFMHS returned the $51,664 to the Payment Management System on January 16, 2025 in accordance with the referenced Information Memorandum. Drawdowns will be based upon actual expenses and disbursed within 3 business days. Responsible Person: Finance Director with oversight by the Program Director.
Finding 522783 (2023-009)
Significant Deficiency 2023
2023-009 – Subrecipient Monitoring Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Subrecipient Monitoring). Program. Substance Abuse and Mental Health Services - Projects of Regional and National Significance; U.S. Department of Health and Human ...
2023-009 – Subrecipient Monitoring Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Subrecipient Monitoring). Program. Substance Abuse and Mental Health Services - Projects of Regional and National Significance; U.S. Department of Health and Human Services; Assistance Listing Number 93.243; Award Number 1H79SM084918-01. Auditor Description of Condition and Effect: Subaward contracts review did not contain appropriate information related to the federal program. No assistance listing number or federal program name was noted in the language of the agreements. In addition, no evidence of formal risk assessment was documented. The City is exposed to an increased risk that future noncompliance could occur and not be prevented or detected by the City's internal controls. Auditor Recommendation: We recommend that the City implement necessary internal controls to ensure documentation of its compliance with the requirements of the Uniform Guidance is maintained. Corrective Action: The City will implement the necessary internal controls to ensure the policy for compliance is followed and documented. Part of the solution will be implementing grant management software. Responsible Person: Phillip Moore, Chief Financial Officer Anticipated Completion Date: January 21, 2025
Finding 522781 (2023-010)
Significant Deficiency 2023
2023-010– Special Reporting for Federal Funding Accountability and Transparency Act Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Reporting). Programs. Choice Neighborhoods Implementation Grant; U.S. Department of Housing and Urban Development; ...
2023-010– Special Reporting for Federal Funding Accountability and Transparency Act Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Reporting). Programs. Choice Neighborhoods Implementation Grant; U.S. Department of Housing and Urban Development; Assistance Listing Number 14.889' Award Number MI5F519CNG117. Substance Abuse and Mental Health Services - Projects of Regional and National Significance; U.S. Department of Health and Human Services; Assistance Listing Number 93.243; Award Number 1H79SM084918-01. Auditor Description of Condition and Effect: Despite passing through qualifying amounts, the City could produce no evidence that the subawards had been reported through the FSRS. The City is exposed to an increased risk that future noncompliance could occur and not be prevented or detected by the City's internal controls. Auditor Recommendation: We recommend that the City implement necessary internal controls to ensure that reporting of subawards greater than $30,000 is submitted to the FSRS for all direct grants. Corrective Action: The City will implement the necessary internal controls to ensure the policy for compliance is followed and documented. Responsible Person: Phillip Moore, Chief Financial Officer Anticipated Completion Date: January 21, 2025
2023-012– Support for Payroll Allocations Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control Over Compliance (Allowable Costs/Cost Principles). Program. Community Block Grants/Entitlement Grants; U.S. Department of Housing and Urban Development; Assistance Listing Nu...
2023-012– Support for Payroll Allocations Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control Over Compliance (Allowable Costs/Cost Principles). Program. Community Block Grants/Entitlement Grants; U.S. Department of Housing and Urban Development; Assistance Listing Number 14.218; All awards. Auditor Description of Condition and Effect: During testing it was noted that the actual amounts charged to the grant were initially charged using the allocation rates from the previous pay period, and subsequently adjusted to the proper amount through a manual journal entry. When factoring in the amounts of the journal entries, the amount charged to the grant still differed from the support provided for 3 items of the 29 tested. The City is exposed to an increased risk that future noncompliance could occur and not be prevented or detected by the City's internal controls. Auditor Recommendation: We recommend that the City implement necessary internal controls to ensure that all allocations of personnel cost are allocated according to the support retained. Corrective Action: The City will implement the necessary internal controls to ensure the policy for compliance is followed and documented. Responsible Person: Phillip Moore, Chief Financial Anticipated Completion Date: January 22, 2025
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