Corrective Action Plans

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Finding No. 2023-010: Lack of Management Oversight to Ensure Retention of Cash Disbursements and Expenses Approval The Health Center has moved to a cloud portal for submitting and processing invoices for approval and payment as well for maintaining vendor files. Under the cloud portal, any requests ...
Finding No. 2023-010: Lack of Management Oversight to Ensure Retention of Cash Disbursements and Expenses Approval The Health Center has moved to a cloud portal for submitting and processing invoices for approval and payment as well for maintaining vendor files. Under the cloud portal, any requests for payments cannot be processed without an invoice and or any other sufficient supporting documents. Approvals of invoices is now also reflected in the portal to indicate readiness for payment. The Health Center does not anticipate to charge expenses to the awards that are not in accordance with budgeted amounts as submitted to its funding sources.
Finding No. 2023-009: Lack of Management Oversight to Ensure Retention of Timesheets Grant timesheets are now being maintained with appropriate charging of time that is related programmatic or administrative functions. The timesheets are signed off by the employee and their related supervisor and ma...
Finding No. 2023-009: Lack of Management Oversight to Ensure Retention of Timesheets Grant timesheets are now being maintained with appropriate charging of time that is related programmatic or administrative functions. The timesheets are signed off by the employee and their related supervisor and maintained in the shared file for immediate availability and reference.
Finding No. 2023-008: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will rec...
Finding No. 2023-008: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will recognize a “full discount” for individuals and families with annual incomes at or below 100% FPL with only nominal fees charged, three levels of discount between 100% and 200%, and no discounts for copays for individuals and families earning over 200% FPL. This policy will be in accordance with Section 330(k)(3)(G) of the PHS Act and 42 CFR Part 51c.303(f) and 42 CFR Part 51c.303(u) which are incorporated herewith. We will charge a nominal fee to individuals and families with annual incomes at or below 100% of the Federal poverty level (FPL). Patients whose incomes are above 100% and at or below 200% of the FPL will be charged according to our sliding fee scale based on income and family size. Discounts will be provided to patients with incomes up to 200% of the FPL for medical visits. Discounts will be provided to patients with incomes up to 250% of the FPL for family planning visits. Staff will assess patients’ incomes based upon a sliding fee scale and no patient will be denied care based upon their inability to pay. The organization also has a policy of non-discrimination in the delivery of health care as stated in its Patient Bill of Rights. Also, the Board of Directors define the income and family size, and has defined the family size to be all parents, minors or guardians that are financially responsible for the household. The tracking and documentation of sliding fees is now maintained with the deposit record of each fee received in the shared file for immediate availability and reference.
August 20, 2026 To: Clausell & Associates, P.C. From: Mary Harrison, Executive Director of CSRA Economic Opportunity Authority, Inc. Below is the Authority’s corrective action plan as it relates to the findings for the fiscal year ending September 30, 2023, Single Audit Act audit. Comment #2023-001 ...
August 20, 2026 To: Clausell & Associates, P.C. From: Mary Harrison, Executive Director of CSRA Economic Opportunity Authority, Inc. Below is the Authority’s corrective action plan as it relates to the findings for the fiscal year ending September 30, 2023, Single Audit Act audit. Comment #2023-001 INTERNAL CONTROLS OVER FINANCIAL STATEMENT PREPARATION, GRANT CLOSE-OUT, AND COMPLIANCE WITH RELATED PROVISIONS OF GRANTS AND CONTRACTS SHOULD BE IMPROVED GENERAL Views of Responsible Officials and Planned Corrective Actions: We concur with this finding. Management is in the process of assessing the organizational structure and capacity to provide adequate financial reporting. With Board review and approval of the Authority’s financial funding sources, the Authority will require additional specialize training for fiscal staff and improve in the segregation of duties to ensure adequate internal controls are fully implemented. The Executive Director will have the overall responsibility of properly reconciling and closing out the accounting system and grant activity each month in an efficient and timely manner to eliminate the risk of significant errors occurring. Budget-to-actual schedules will be an integral part of the grant accountant analyst’s basic responsibilities. The fiscal policies and procedures will be updated with the enhancements implemented within the fiscal department. Staff will be trained on revised policies and procedures and Uniform Guidance regulations. The Executive Director will take the lead in financial reporting to ensure that all reporting meet GAAP and GAS requirements and to provide informative reports for Board and Management. All enhancements will be implemented by September 30, 2026. Concerning the preparation of external reports required by various funding sources (i.e., SF-425, DHS’s reports for LIHEAP, etc.), the Authority will ensure adequate training is performed to improve the skills and knowledge of key personnel. Policies and procedures will also be revised to support external reporting. Implementation Date: The plan correction date will be completed no later than September 30, 2026 Responsible Person: Mary Harrison, Executive Director, will be responsible for the corrective action. Comment #2023-002 INTERNAL CONTROLS OVER FINANCIAL STATEMENT PREPARATION, GRANT CLOSE-OUT, AND COMPLIANCE WITH RELATED PROVISIONS OF GRANTS AND CONTRACTS SHOULD BE IMPROVED HEAD START AND SUPPORTIVE SERVICES FOR VETERAN FAMILIES PROGRAM FAL # 93.600 AND 64.003 (Questioned Costs - None) Views of Responsible Officials and Planned Corrective Actions: We concur with the finding. Management and staff are in the process of assessing and updating the policies and procedures over the accounting and reporting of federal and state grants and contracts. In connection with training staff on grant accounting, we are providing ongoing training on the requirements of the Uniform Guidance and the specific requirements for each individual grant award as outlined in each applicable Compliance Supplement issued by Office of Management and Budget (OMB). We are currently reconciling all cash accounts and completing and amending, where necessary, all SF-425 reports and other external reports required by each funding source (state and federal). We anticipate completing this corrective action by September 30, 2026. See also the response to Comment #2023-001. Implementation Date: The plan correction date will be completed no later than September 30, 2026. Responsible Person: Mary Harrison, Executive Director, will be responsible for the corrective action.
Finding 2023-007: Lack of Internal Control And Noncompliance With Activities Allowed or Unallowed; Allowable Costs/Cost Principles Name of Contact: Josh Verhagen, Patricia Jirsa Corrective Action Plan: Similar answer as it was to 2023-002. A new and rigorous system has been implemented that ensures ...
Finding 2023-007: Lack of Internal Control And Noncompliance With Activities Allowed or Unallowed; Allowable Costs/Cost Principles Name of Contact: Josh Verhagen, Patricia Jirsa Corrective Action Plan: Similar answer as it was to 2023-002. A new and rigorous system has been implemented that ensures all expenses are being reviewed, approved and entered with proper expensing and filing. Proposed Completion Date: December 2026.
Item 2023.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this rec...
Item 2023.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures that it is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant's period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail • Review these procedures annually to ensure they ongoing compliance with the grant's period of performance
Recommendation We recommend that the Center consistently enforce its internal controls over payroll to ensure that the times sheet and pay rates are reviewed and approved by the appropriate supervisor. Additionally, we recommend that the Center consistently reinforces its internal controls over nonp...
Recommendation We recommend that the Center consistently enforce its internal controls over payroll to ensure that the times sheet and pay rates are reviewed and approved by the appropriate supervisor. Additionally, we recommend that the Center consistently reinforces its internal controls over nonpayroll expenditures to ensure all expenditures were approved by the appropriate supervisor. Repeat Finding Yes Action Taken Action Taken Island Health Care will take the following actions to address this recommendation: Timesheet and Payrate Review and Approval: • Standardize timesheet submission and approval process • Utilize an electronic timesheet system to document the verification of employee payrates and ensure there is a detailed audit trail that records all submissions, reviews, and approvals by supervisors • Conduct regular audits to verify timesheets and payrates are reviewed and approved by supervisors Non Payroll Expenditures: • Evaluate and improve upon existing processes to ensure internal controls over non payroll expenditures are working. This includes enforcement of approval policies with mandatory documentation and regular monitoring throughout the process for a clear audit trail • Conduct regular audits to verify nonpayroll expenditures have been reviewed and approved by supervisors
Finding No.: 2023-018 AL Program: 93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance Area: Allowable Costs/Cost Principles Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the finding....
Finding No.: 2023-018 AL Program: 93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance Area: Allowable Costs/Cost Principles Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the finding. While internal verification of disbursements is a standard part of our fiscal workflow, we recognize that our current process has the space to improve. Corrective Action Plan: To ensure that all disbursements are verified and documented prior to payment, PSS will implement the following: I. High Level Review and Approval: Implementation of Comptroller/ Director of Finance review on the Batch Invoice Summary signifying invoice entries on the said batch are verified and correct. After the review, the Comptroller will sign. II. Updated Payment Verification Process: Payments via check or ACH are reviewed by the Comptroller/ Director of Finance through Payment Manager and marking the Batch Invoice Summary that payments matched the invoice. Proposed Completion Date: December 2025 Name of Contact Person and Title: Contact: Jonathan Aguon, Director of Finance Email Address: jonathan.aguon@cnmipss.org
Finding No.: 2023-017 AL Program: COVID-19 84.425A/84.425X Education Stabilization Fund Area: Special Tests and Provisions - Private School Participation Questioned Costs: Undeterminable Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management disagrees with the finding. PS...
Finding No.: 2023-017 AL Program: COVID-19 84.425A/84.425X Education Stabilization Fund Area: Special Tests and Provisions - Private School Participation Questioned Costs: Undeterminable Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management disagrees with the finding. PSS asserts that timely and meaningful consultations were conducted with private school officials prior to making decisions regarding the size, scope, and funding of equitable services for FY2023. Calculations for the equitable share under the Education Stabilization Funds were performed in accordance with federal regulations, ensuring that per-pupil allocations for eligible private school students and teachers were equitable relative to public school expenditures. PSS maintains that consultation timelines, meeting records, and allocation formulas were maintained. While PSS is continuously refining its administrative workflows, the existing documentation and controls were sufficient to satisfy the requirements of 34 CFR § 299.7. Proposed Completion Date: Resolution in progress and on track for completion by August 2026. Name of Contact Person and Title: Contact: Jacqueline Che, Federal Programs Officer Email Address: jacqueline.che@cnmipss.org
Finding No.: 2023-013 AL Program: COVID-19 84.425A/84.425X Education Stabilization Fund Area: Activities Allowed/Unallowed, Allowable Costs/Cost Principles Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the findings. Financial a...
Finding No.: 2023-013 AL Program: COVID-19 84.425A/84.425X Education Stabilization Fund Area: Activities Allowed/Unallowed, Allowable Costs/Cost Principles Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the findings. Financial and Grants Management policies procedures were promulgated in SOPs on September 18, 2024. The financial management system was subsequently changed to Tyler Munis to conform with CNMI central government requirements which will enhance capabilities. The SOPs and the Tyler Munis implementation are under review by an external consultant and recommendations made to improve documentation of cost allowability have been received. Corrective Action Plan: I. Finalization of Allowability and Disbursement SOPs: PSS will finalize comprehensive Standard Operating Procedures (SOPs) and policies specifically governing allowability determinations and vendor payments. II. Enhanced Disbursement Controls: PSS is implementing a documented review and approval controls over the payment process. Before any check or ACH disbursement is finalized, a reviewer must verify that the payment amount agrees exactly with the approved invoice. This verification will be physically or digitally documented on the payment voucher to provide a clear audit trail of the pre-payment review. Proposed Completion Date: In progress for FY 2024 with full implementation and documentation processes expected to be completed in 2026. As part of this improvement, we are designing a standardized, documented review process to ensure all disbursements are verified against approved invoices prior to payment. Name of Contact Person and Title: Contact: Jonathan Aguon, Director of Finance Email Address: jonathan.aguon@cnmipss.org
Finding No.: 2023-010 AL Program: 84.403 Consolidated Grants to the Outlying Areas Area: Allowable Costs/Cost Principles Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the findings. Financial and Grants Management policies proce...
Finding No.: 2023-010 AL Program: 84.403 Consolidated Grants to the Outlying Areas Area: Allowable Costs/Cost Principles Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the findings. Financial and Grants Management policies procedures were promulgated in SOPs on September 18, 2024. The financial management system was subsequently changed to Tyler Munis to conform with CNMI central government requirements which will enhance capabilities. The SOPs and the Tyler Munis implementation are under review by an external consultant and recommendations made to improve documentation of cost allowability have been received. Corrective Action Plan: I. Finalization of Allowability and Disbursement SOPs: PSS will finalize comprehensive Standard Operating Procedures (SOPs) and policies specifically governing allowability determinations and vendor payments. II. Enhanced Disbursement Controls: PSS is implementing a documented review and approval controls over the payment process. Before any check or ACH disbursement is finalized, a reviewer must verify that the payment amount agrees exactly with the approved invoice. This verification will be physically or digitally documented on the payment voucher to provide a clear audit trail of the pre-payment review. Proposed Completion Date: In progress for FY 2024 with full implementation and documentation processes expected to be completed in 2026. As part of this improvement, we are designing a standardized, documented review process to ensure all disbursements are verified against approved invoices prior to payment. Name of Contact Person and Title: Contact: Jonathan Aguon, Director of Finance Email Address: jonathan.aguon@cnmipss.org
Finding No.: 2023-006 AL Program: 84.027 Special Education Cluster - Grants to States (IDEA, Part B) Area: Activities Allowed/Unallowed, Allowable Costs/Cost Principles Questioned Costs: $5,130 Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the audit ...
Finding No.: 2023-006 AL Program: 84.027 Special Education Cluster - Grants to States (IDEA, Part B) Area: Activities Allowed/Unallowed, Allowable Costs/Cost Principles Questioned Costs: $5,130 Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the audit findings and the associated questioned costs. Financial and Grants Management policies procedures were promulgated in a SOPs on September 18, 2024. The financial management system was subsequently changed to Tyler Munis to conform with CNMI central government requirements which will enhance capabilities. The SOPs and the Tyler Munis implementation are under review by an external consultant and recommendations made to improve documentation of cost allowability have been received. Corrective Action Plan: To prevent future occurrences and ensure full compliance with federal cost principles, PSS will implement the following: I. Review of Travel Authorization Requirements: PSS will conduct a review of its travel policy to require a written statement of alignment with program goals or objectives for every travel request. This statement must explicitly document how the travel is necessary and reasonable for the performance of the specific federal award. II. Centralized Digital Documentation Protocol: To resolve the inadequate systematic filing issue, PSS implemented a protocol to improve its digital filing procedures. All supporting documents, including invoices, boarding passes, approved timesheets, and pay rate authorizations, must be uploaded and verified before the final liquidation of any federal drawdowns. III. Strengthening Review Process: Finalize expanded SOPs and policies to include more detail on time and effort reporting (including differential pay) and travel justifications specific to allowability determinations that are currently in draft including an analysis rubric and checklist for review. Where necessary, program specific supplemental guidance for allowability determinations will be provided. PSS central office staff participated in live training in October 2025. Refresher training on cost principles will be required annually for staff making allowability determinations. Proposed Completion Date: PSS is currently in the process of implementing these corrective actions with full implementation by August 2026. Name of Contact Person and Title: Contact: Jacqueline Che, Federal Programs Officer Email Address: jacqueline.che@cnmipss.org
Finding No.: 2023-005 AL Program: 10.555 National School Lunch Program (NSLP) Area: Reporting Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the findings. Financial and Grants Management procedures were promulgated in a SOP on S...
Finding No.: 2023-005 AL Program: 10.555 National School Lunch Program (NSLP) Area: Reporting Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the findings. Financial and Grants Management procedures were promulgated in a SOP on September 18, 2024. The financial management system was subsequently changed to Tyler Munis to conform with CNMI central government requirements which will enhance capabilities. The SOPs and the Tyler Munis implementation are under review by an external consultant and recommendations made to improve coding of grant details and expenditures, increased frequency of reconciliations, and a specific SOP for report preparation. Corrective Action Plan: I. Implementation of a Comprehensive Grant Tracker: PSS will develop and implement a centralized Grant Lifecycle Tracker for all active federal awards. This tool will serve as the primary monitoring mechanism for compliance by recording all financial and programmatic reporting due dates, assigning specific preparers for each report, and establishing automated milestones to ensure sufficient lead time for both the preparation phase and the subsequent supervisory review. II. Deployment of Enhanced Data Analysis Tools: To ensure that quarterly program reporting is both consistent and timely, PSS will develop and implement specialized data analysis tools. these tools will streamline the aggregation of program data, reducing manual entry errors and allowing for more efficient evaluation of program performance against federal benchmarks. Proposed Completion Date: In progress for FY 2024 with completion by August 2026. Name of Contact Person and Title: Contact: Jacqueline Che, Federal Programs Officer Email Address: jacqueline.che@cnmipss.org
Finding No.: 2023-003 AL Program: 10.555 National School Lunch Program (NSLP) Area: Allowable Costs/Cost Principles Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the findings. Financial and Grants Management policies procedures...
Finding No.: 2023-003 AL Program: 10.555 National School Lunch Program (NSLP) Area: Allowable Costs/Cost Principles Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the findings. Financial and Grants Management policies procedures were promulgated in SOPs on September 18, 2024. The financial management system was subsequently changed to Tyler Munis to conform with CNMI central government requirements which will enhance capabilities. The SOPs and the Tyler Munis implementation are under review by an external consultant and recommendations made to improve documentation of cost allowability have been received. Corrective Action Plan: I. Finalization of Allowability and Disbursement SOPs: PSS will finalize comprehensive Standard Operating Procedures (SOPs) and policies specifically governing allowability determinations and vendor payments. II. Enhanced Disbursement Controls: PSS is implementing a documented review and approval controls over the payment process. Before any check or ACH disbursement is finalized, a reviewer must verify that the payment amount agrees exactly with the approved invoice. This verification will be physically or digitally documented on the payment voucher to provide a clear audit trail of the pre-payment review. Proposed Completion Date: In progress for FY 2024 with full implementation and documentation processes expected to be completed in 2026. As part of this improvement, we are designing a standardized, documented review process to ensure all disbursements are verified against approved invoices prior to payment. Name of Contact Person and Title: Contact: Jonathan Aguon, Director of Finance Email Address: jonathan.aguon@cnmipss.org
Management Response: SWIWC concurs with the auditor's finding that adequate supporting documentation was not provided during the audit for 14 of the 40 expenditure transactions selected for testing. SWIWC recognizes that federal expenditures must be supported by sufficient documentation to demonstra...
Management Response: SWIWC concurs with the auditor's finding that adequate supporting documentation was not provided during the audit for 14 of the 40 expenditure transactions selected for testing. SWIWC recognizes that federal expenditures must be supported by sufficient documentation to demonstrate that costs were authorized, incurred for an allowable program purpose, properly allocated to the award, and adequately supported by underlying source documentation. SWIWC respectfully distinguishes, however, between a cost that is questioned because sufficient documentation was not available during the audit and a cost that has been affirmatively determined to be unallowable. The $70,587 reported as questioned costs relates to transactions for which the documentation provided during audit testing was considered insufficient. The finding does not state that the auditors determined that the underlying goods or services were not received, that the expenditures were outside the objectives of the award, or that the expenditures were otherwise affirmatively determined to be unallowable. Corrective Actions Implemented Since the FY2023 period under audit, SWIWC has strengthened its expenditure-processing and documentation controls. SWIWC requires expenditure transactions to be supported by documentation appropriate to the nature of the transaction, which may include invoices, receipts, contracts, agreements, travel documentation, purchasing documentation, evidence of receipt of goods or services, and evidence of required approval. Finance reviews transactions for appropriate funding source, supporting documentation, authorization, and consistency with applicable grant and organizational requirements. SWIWC has strengthened its accounts payable procedures so that supporting documentation is associated with the corresponding accounting transaction and maintained electronically. Documentation deficiencies identified during processing or subsequent review are followed up with the responsible employee or program before the transaction is considered fully documented. SWIWC has also strengthened grant expenditure monitoring through budget-to-actual review and centralized grant records. Grant and financial documentation is maintained in a manner designed to permit transactions to be traced from the accounting records to the underlying supporting documentation and, where applicable, to grant reporting and reimbursement records. Preventive Controls To prevent recurrence, SWIWC has implemented or strengthened the following controls: • Standardized expenditure documentation requirements; • Documented review and approval of expenditures; • Centralized electronic retention of supporting records; • Identification of the applicable funding source; • Review of expenditures for grant allowability and allocability; • Procurement documentation requirements; • SAM.gov verification when applicable; • Budget-to-actual grant monitoring; • Periodic Finance review of supporting documentation; • Staff training regarding expenditure and grant-documentation requirements in February 2026; and • Maintenance of records in an audit-ready format to be completed by 9/30/2026. Resolution of Questioned Costs SWIWC understands that the ultimate resolution of questioned costs rests with the applicable awarding or pass-through entity through the audit-resolution process. SWIWC will therefore maintain the $70,587 as questioned costs pending completion of the applicable resolution process and will not characterize the entire amount as either allowable or unallowable solely on the basis of the audit finding. For transactions for which sufficient supporting documentation is identified or reconstructed, SWIWC will provide that documentation as appropriate to support resolution of the questioned amount. If the awarding or pass-through entity ultimately determines that any portion of the questioned costs is unallowable, SWIWC will take the corrective action required by that determination, including repayment or other financial adjustment if required. Anticipated Completion Date: September 30, 2026, for completion of the historical transaction review; enhanced expenditure controls are currently in effect and will continue on an ongoing basis. Responsible Party: Chief Financial Officer and Director of Finance, with applicable Program Managers responsible for providing programmatic documentation.
The City of Colton Mayor is the contact person responsible for the corrective action plan for this finding. Due to the size of the City of Colton, the municipality is unable to financially support additional staffing necessary to segregate duties in accordance with ideal internal control standards. ...
The City of Colton Mayor is the contact person responsible for the corrective action plan for this finding. Due to the size of the City of Colton, the municipality is unable to financially support additional staffing necessary to segregate duties in accordance with ideal internal control standards. The Mayor, City Council, and Finance Oficer are aware of these limitations and have been working on policies and controls that will help minimize future lapses. This will continue to be an ongoing process with future change of council members as the Council President is currently in place to review funding records and bank reconciliation reports.
Corrective Action Taken: 1. Formalized record retention policies: A formal record retention policy specific to federal grant programs was implemented to ensure full compliance with 2 CFR 200.334. This policy applies regardless of whether documentation is stored internally or by third-party systems. ...
Corrective Action Taken: 1. Formalized record retention policies: A formal record retention policy specific to federal grant programs was implemented to ensure full compliance with 2 CFR 200.334. This policy applies regardless of whether documentation is stored internally or by third-party systems. Any documentation downloaded or transferred from third-party systems will be subject to a review process to verify completeness and accuracy before being finalized for County retention. The County shall also take steps to ensure that information downloads and exports from third-party systems represent complete and accurate records. 2. Auditing timing advocacy and preparedness: The County will continue to maintain timely documentation and preparedness for audits and will also advocate for timely initiation and completion of future audits. Significant delays in the audit process, though no fault of the County, as observed during the FY 2023 audit, substantially impacted the County's ability to access necessary documentation and demonstrate compliance. Although the County made every effort to retain records in accordance with federal requirements, the timing of the audit fieldwork occurred well after the program had concluded in May 2023. Had the audit been conducted in a timely manner, full access to the third-party platform used for program administration would have been available, along with supporting documentation. However, by the time the audit took place, the program had been closed for over 18 months, and access to the external software system had lapsed in accordance with the expiration of the service agreement. 3. Internal audit readiness reviews: Beginning with FY2025, the County conducts internal audit readiness reviews shortly after fiscal year-end to ensure all documentation for closed federal programs is centralized, archived, and accessible for future audit purposes, even if conducted years later. Implementation date of corrective action: October 24, 2025 Person Responsible for corrective action: Charles Nickerson, Senior Director of Finance
Condition: Management lacked adequate controls at the transaction level to ensure compliance with activities allowed or unallowed, allowable cost principles, and period of performance, which resulted in the improper inclusion of duplicate costs and costs from a prior fiscal period. Further, a lack o...
Condition: Management lacked adequate controls at the transaction level to ensure compliance with activities allowed or unallowed, allowable cost principles, and period of performance, which resulted in the improper inclusion of duplicate costs and costs from a prior fiscal period. Further, a lack of effective controls over financial reporting and over preparation of the SEFA resulted in management reporting activity on a cash basis, inconsistent with the basis of reporting established in Note 1 and with requirements established by the passthrough funding agency. Planned Corrective Action: Management will implement a new review, reconciliation and oversight process to ensure that compliance with activities allowed or unallowed, allowable cost principles, and period of performance standards are followed for future grant submissions. Contact person responsible for corrective action: Louise Arzu, Vice President, Finance Anticipated Completion Date: 9/30/2024
Finding Reference Number 2023-001 Finding The Hospital’s internal control processes regarding usage of funds received under the Provider Relief Fund allocation within the American Rescue Plan Act, 2021, did not provide for adequate segregation of duties. Internal controls around approving, tracking,...
Finding Reference Number 2023-001 Finding The Hospital’s internal control processes regarding usage of funds received under the Provider Relief Fund allocation within the American Rescue Plan Act, 2021, did not provide for adequate segregation of duties. Internal controls around approving, tracking, and reporting expenses were not sufficient. Management agrees with the finding. Corrective Action Plan In September 2023, the Hospital implemented a policy regarding the usage of grant funding received through HRSA. This policy includes review of program guidelines, education of responsible staff, maintenance of separate general ledger accounts for program expenditures, approval of purchase orders by appropriate levels of management, and establishment of logs for program expenditures. It also provides for review of general ledger accounts and review of reports submitted to granting agencies. These changes were implemented to ensure allowable costs are properly approved, tracked, reviewed, and reported in accordance with federal requirements and to provide for adequate segregation of duties in these responsibilities. Responsible Personnel Lisa Hart, former Chief Executive Officer (responsible for implementation of corrective action). Megan Corbin, Chief Executive Officer (current contact for any follow-up regarding corrective action). Completion Date Corrective action was completed in September 2023.
Corrective Action: The University will continue to strengthen documentation and retention procedures and internal controls to ensure invoices are properly maintained and readily accessible. The funding source has ended. Responsible Person: Vice President of Finance & Administration (Adrian Petway) C...
Corrective Action: The University will continue to strengthen documentation and retention procedures and internal controls to ensure invoices are properly maintained and readily accessible. The funding source has ended. Responsible Person: Vice President of Finance & Administration (Adrian Petway) Completion Date: September 30, 2026
Corrective Action: The University will implement procedures to ensure grant expenses are properly adjusted, and endowment contributions are transferred in a timely manner. Responsible Person: Vice President of Finance & Administration (Adrian Petway) Completion Date: December 31, 2026
Corrective Action: The University will implement procedures to ensure grant expenses are properly adjusted, and endowment contributions are transferred in a timely manner. Responsible Person: Vice President of Finance & Administration (Adrian Petway) Completion Date: December 31, 2026
Corrective Action: September 30, 2026 The University will implement procedures to ensure expenses are charged to the correct program in a timely manner and all documentation is maintained. Responsible Person: Vice President of Finance & Administration (Adrian Petway) Completion Date: December 31, 20...
Corrective Action: September 30, 2026 The University will implement procedures to ensure expenses are charged to the correct program in a timely manner and all documentation is maintained. Responsible Person: Vice President of Finance & Administration (Adrian Petway) Completion Date: December 31, 2026
Reporting Recommendation: We recommend that the auditee implement procedures to ensure that Form 19-lA reimbursement requests are reviewed prior to submission to confirm that expenditures are charged to the correct approved budget line items. This may include maintaining a reconciliation between the...
Reporting Recommendation: We recommend that the auditee implement procedures to ensure that Form 19-lA reimbursement requests are reviewed prior to submission to confirm that expenditures are charged to the correct approved budget line items. This may include maintaining a reconciliation between the general ledger, the approved grant budget, and the Form 19-lA, as well as implementing supervisory review and approval of reimbursement submissions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. 2026 Action taken in response to finding: Reoccurring bills such as utilities, loan payments, contract services and credit card payments do not require an expense request to be included for on going bills. We will review our procedures and update our financial policy. 2023 Our financial process includes at least two reviews prior to creating a bill in our accounting system, payments are reviewed by the director or the Deputy Director when signed. We do not use a auto signature all checks are reviewed. 2023 The Grantor billing is a P&L detailed report for that grant and provides reconciliation monthly This is sorted into grant line items designated billable and non-billable for compliance. Total program cost and billable to grant are tracked every month, by the grant finance manager for compliance prior to billing any grants. Timecards are reviewed, expense requests are reviewed and payments are reviewed. Prior to submission of the invoice to grantor. 2023 Grant finance manager pulls copy of timecards, bills and checks to ensure compliance with reimbursements are accurate. Name(s) of the contact person(s) responsible for corrective action: Cora Alyea Planned completion date for corrective action plan: July 2023
Allowable Costs/Payroll Disbursements Recommendation: We recommend that the auditee implement procedures to ensure that: all employee pay rates charged to Federal awards are appropriately approved and documented, and complete and accurate timesheets or equivalent time-and-effort records are maintain...
Allowable Costs/Payroll Disbursements Recommendation: We recommend that the auditee implement procedures to ensure that: all employee pay rates charged to Federal awards are appropriately approved and documented, and complete and accurate timesheets or equivalent time-and-effort records are maintained for all payroll costs charged to Federal awards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Most Federal grants are renewed annually and have not requested any salary rate adjustments. Payroll line items are a lump sum. Serenity House since 2020 performs annually in May a market rate survey for all job positions to ensure wage rates are equitable to fair market for our County and Non-Profit job type. The sources are documented in the workbook that the annual raise percentages; wage adjustments are calculated for board approval. Our annual performance raises and adjustments is a pool of 1 to 5%, and 3 to 6 employees are below market rate each year. People with a market adjustment do not receive a merit increase. 2023 Merit increase is% that is allocated based on performance scores and management team comparison to everyone in that job category. People are scored by manager this score is reviewed by all managers that have employees in that grouped job class. The reviewing managers agreed highest performer with a 5% and lowest performer 1% Raise distribution is based on the performance review score. 2022 Employees are hired for a specific job when they are given their first time card grant line items for the grant they work on are on the time sheet. That time sheet is reviewed and corrected by the immediate supervisor then reviewed by the operations manager. Turned into the main office receptionist who checks submission against the employee list. Checks math and signatures, initials the times card takes up to payroll. 2023 Payroll double checks each time card when entering time into the payroll module. After all time is enter another employee checks the system addition to timecard. 2020 When Checks are manually signed the time is on the timecard and each check is reviewed. Each employee Name(s) of the contact person(s) responsible for corrective action: Kristin Cowan Planned completion date for corrective action plan: July 1 2023
Allowable Costs/General Disbursements Recommendation: We recommend that management reinforce the consistent execution and documentation of existing disbursement approval and documentation procedures. This should include ensuring that all expenditure charged to federal awards are appropriately approv...
Allowable Costs/General Disbursements Recommendation: We recommend that management reinforce the consistent execution and documentation of existing disbursement approval and documentation procedures. This should include ensuring that all expenditure charged to federal awards are appropriately approved and supported by sufficient documentation prior to payment, and that management periodically monitors compliance with these procedures to confirm they are operating as designed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Reoccurring bills such as utilities, loan payments, contract services and credit card payments do not require an expense request to be included for on going bills. We will review our procedures and update our financial policy. Our financial process includes at least two reviews prior to creating a bill in our accounting system, payments are reviewed by the director or the Deputy Director when signed. We do not use a auto signature all checks are reviewed. The Grantor billing is a P&L detailed report for that grant. This is sorted into grant line items designated billable and non-billable for compliance. Total program cost and billable to grant are tracked every month, by the grant finance manager for compliance prior to billing any grants. Timecards are reviewed, expense requests are reviewed and payments are reviewed. Prior to submission of the invoice to grantor. Name(s) of the contact person(s) responsible for corrective action: Cora Alyea Planned completion date for corrective action plan: Completed in 2023
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