Corrective Action Plans

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View of Responsible Official: We agree with the auditors' comments, and the following action has been taken to improve the situation. We have adjusted the agency’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accountin...
View of Responsible Official: We agree with the auditors' comments, and the following action has been taken to improve the situation. We have adjusted the agency’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accounting personnel will ensure the agency’s General Ledger specifically details the month of rent and utility allowance being provided so eligible costs are clearly delineated. Someone other than the preparer will perform a review of each drawdown request to ensure that costs are not being drawn down prior to the operating start date of each individual grant. This issue was discussed with HUD in March 2024 at which time procedural changes were implemented. Additionally, as noted above, our agency was able to repay and redraw the funds drawn outside of the aforementioned period of performance without further penalty. Corrective Action: Effective March 2024 the preparer is required to include the month of rent and utility allowance being provided in the General Ledger detail. A review of the General Ledger detail supporting each draw request will be performed by someone other than the preparer to ensure that costs are not being drawn down prior to the operating start date of each individual grant.
AUDIT FINDINGS 2023-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, there was a system pr...
AUDIT FINDINGS 2023-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, there was a system pricing issue that resulted in an incorrect amount of expenses related to inventory that were submitted to FEMA for reimbursement. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: FEMA has been notified and the amount has been updated as part of the project closeout. Anticipated Completion Date: September 2024 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2023-001.
View Audit 323033 Questioned Costs: $1
Finding 2023-003 Grantor: Department of Health and Human Services Federal Program: Oral Diseases and Disorders Research Maternal and Child Health Federal Consolidated Programs Assistance Listing #: 93.121 93.110 Title: Effort Certification Award Year: Fiscal year 2023 1/1/2023 – 12/31/2...
Finding 2023-003 Grantor: Department of Health and Human Services Federal Program: Oral Diseases and Disorders Research Maternal and Child Health Federal Consolidated Programs Assistance Listing #: 93.121 93.110 Title: Effort Certification Award Year: Fiscal year 2023 1/1/2023 – 12/31/2023 Award Number: 1R01DE031756-01A1 2 U03MC28844-09-00 Corrective Action Plan and Anticipate Completion Date • In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has been remediated. Management implemented a new procedure to ensure timely time and effort certification. Management implemented the process for first quarter 2024 to allow time for system updates and training. Responsible person: Aaron Ufferman, Director, Sponsored Projects Completion Date: February 1, 2024
Finding 2023-002 Grantor: Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Title: Fringe Rate Analysis – Formula Error Award Year: Fiscal year 2023 1/1/2023 – 12/31/2023 Award Number: Various Management agrees with the recommendation. Ho...
Finding 2023-002 Grantor: Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Title: Fringe Rate Analysis – Formula Error Award Year: Fiscal year 2023 1/1/2023 – 12/31/2023 Award Number: Various Management agrees with the recommendation. However, while there was an error in the underlying data used to evaluate the annual fringe rate, the federal government was not overcharged for fringe benefits. Corrective Action Plan and Anticipate Completion Date Management’s corrective action plan includes: • Management will ensure a more robust review of the underlying formulas. Responsible Person: Natasha Collins, Director of Research Accounting Completion Date: December 31, 2024
Management is committed to enhancing staff knowledge of Uniform Guidance requirements, particularly concerning allowable costs and cost principles. To achieve this, we will implement additional training sessions for all relevant personnel. These sessions will cover key aspects of compliance, ensurin...
Management is committed to enhancing staff knowledge of Uniform Guidance requirements, particularly concerning allowable costs and cost principles. To achieve this, we will implement additional training sessions for all relevant personnel. These sessions will cover key aspects of compliance, ensuring that staff are well-informed about federal regulations and their implications for our grant management processes. The Controller will ensure the calculation of payroll costs are based solely on the actual hours worked and certified by grant personnel. This practice will help maintain accuracy and accountability in our financial reporting. In addition, the Technical and Internal Controls Accountant will conduct quarterly internal reviews to monitor and verify that payroll costs reported on cost reimbursement invoices are consistent with the actual hours certified by grant personnel. These regular reviews will serve as a critical check to uphold the integrity of our financial processes and ensure compliance with federal guidelines. Through these initiatives, management aims to foster a culture of compliance and accountability, equipping our team with the knowledge and tools necessary to effectively manage grant funds.
View Audit 323015 Questioned Costs: $1
Management is committed to enhancing our federal grant policy by incorporating a requirement for an annual review and recalculation of the indirect cost recovery rate. The Controller will take responsibility for recalculating the indirect rate each year, making necessary adjustments—whether upward o...
Management is committed to enhancing our federal grant policy by incorporating a requirement for an annual review and recalculation of the indirect cost recovery rate. The Controller will take responsibility for recalculating the indirect rate each year, making necessary adjustments—whether upward or downward—to ensure it accurately reflects our current cost structure. To maintain compliance and integrity in our financial processes, the Technical and Internal Controls Accountant will oversee the review of costs included in the indirect cost pool to ensure they meet the criteria for allowability. Additionally, this role will involve verifying that invoices utilize the most current indirect cost recovery rate. Furthermore, management will prepare and submit the required indirect cost proposal to the appropriate cognizant agency to finalize our provisional billing rates used in fiscal year 2023, that aligns with our operational needs and complies with federal guidelines. This proactive approach will strengthen our financial management practices and support our ongoing commitment to transparency and accountability in the administration of federal grants.
View Audit 323015 Questioned Costs: $1
US Department of Health and Human Services Federal Financial Assistance Listing #93.600 Head Start Cluster Applicable Federal Award Number and Year – 07CH011832-04-00 11/1/2023 – 10/31/2024, 07CH011832-03-00 11/1/2022 – 10/31/2023, 07CH011832-02-00 11/1/2021 – 10/31/2022 Activities Allowed or Unallo...
US Department of Health and Human Services Federal Financial Assistance Listing #93.600 Head Start Cluster Applicable Federal Award Number and Year – 07CH011832-04-00 11/1/2023 – 10/31/2024, 07CH011832-03-00 11/1/2022 – 10/31/2023, 07CH011832-02-00 11/1/2021 – 10/31/2022 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control Over Compliance Material Noncompliance Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: The Organization requested drawdowns of grant funds in excess of amounts awarded for the grant years ended 10/31/2023 and 10/31/2022 that were denied by the passthrough agency, Omaha Public Schools, resulting in an overstatement in grant revenue and receivables, and federal awards expended included in the schedule of expenditures of federal awards. Corrective Action Plan: Management is in the process of reviewing its accounting policies and procedures over grant monitoring to ensure amounts are tracked appropriately. Management has hired a new fiscal services director to oversee this process. Individual Responsible For Corrective Action: Veronica Jones, Fiscal Services Director Anticipated Completion Date: December 31, 2024
View Audit 322999 Questioned Costs: $1
Corrective Action: Name of Contact Person Wayne Moyer and Brenda Chandler To further prevent the issues regarding employee clearances, CSC HR department will have an in-depth discussion with the grantor at time of grant renewal to ensure that the contract language states that the clearances for hir...
Corrective Action: Name of Contact Person Wayne Moyer and Brenda Chandler To further prevent the issues regarding employee clearances, CSC HR department will have an in-depth discussion with the grantor at time of grant renewal to ensure that the contract language states that the clearances for hiring will be the responsibility of the grantor. While the grantor placed the instructions for clearances in the scope of work for Safe Passage, it was not clearly outlined in the grant under personnel requirements. Proposed Completion Date August 31, 2024
View Audit 322995 Questioned Costs: $1
Program: AL No. 10.523 Centers of Excellence at 1890 Institutions Significant Deficiency and Noncompliance over Allowable Costs/Costs Principles Corrective Action Plan for Significant Deficiency and Noncompliance over Reporting Foundation employees’ time and effort reports are submitted monthly to t...
Program: AL No. 10.523 Centers of Excellence at 1890 Institutions Significant Deficiency and Noncompliance over Allowable Costs/Costs Principles Corrective Action Plan for Significant Deficiency and Noncompliance over Reporting Foundation employees’ time and effort reports are submitted monthly to the Director of Finance. The Director of Finance reviews time and effort reports and compiles the data to allocate personnel expenditures, however, the time stamp of approvals was not effectively documented during 2023. The Foundation has implemented procedures to effectively time stamp the review and approval process, each month. Contact Person: Calece Hilliard, CFAO 1890 Universities Foundation Completion Date: September 30, 2024
The County Human Services department noted that the service providers were paid at their negotiated rates agreed upon by contract terms, however no reconciliation was completed for the remainder eligible cost adjustments to the service providers for the fiscal year ended June 30, 2023. The County Hu...
The County Human Services department noted that the service providers were paid at their negotiated rates agreed upon by contract terms, however no reconciliation was completed for the remainder eligible cost adjustments to the service providers for the fiscal year ended June 30, 2023. The County Human Services department will complete the reconciliation of the service providers costs reports for the fiscal year ended June 30, 2024 before March 2025.
The County Human Services department has requested approval from PA DHS of its 2021-2022 fiscal year re-submission in September 2024. Following approval of the 2021-2022 submission and re-investment the County Human Services department will complete the submission of the 2022-2023 fiscal year report...
The County Human Services department has requested approval from PA DHS of its 2021-2022 fiscal year re-submission in September 2024. Following approval of the 2021-2022 submission and re-investment the County Human Services department will complete the submission of the 2022-2023 fiscal year report. The County Human Services department will reconcile the underlying expenditure detail in the accounting system to the expenditures reported. Internal approvals prior to submission and underlying records for reports will be maintained by the County Human Services department.
Condition: The Township's March 31, 2024 report overstated expenses incurred for the reporting period by approximately $600,000. Planned Corrective Action: Molly Phillips and Katelyn Massey are working together to ensure that the expenses will be reported within the year they are incurring, and allo...
Condition: The Township's March 31, 2024 report overstated expenses incurred for the reporting period by approximately $600,000. Planned Corrective Action: Molly Phillips and Katelyn Massey are working together to ensure that the expenses will be reported within the year they are incurring, and allocated into the correct funds as approved by the Township Board. Contact person responsible for corrective action: Molly Phillips and Katelyn Massey Anticipated Completion Date: 12/31/2024
Federal Funding Accountability and Transparency Act- CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various grant requirements and laws surrounding the CDBG grant program and ensure that any written internal...
Federal Funding Accountability and Transparency Act- CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various grant requirements and laws surrounding the CDBG grant program and ensure that any written internal control or procedure manuals include all of the required compliance requirements. We also recommend that the City ensure multiple individuals are trained on the administration of the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This process will be added to the CDBG Policy and Procedure Manual to address the audit findings and improve reporting oversight. Name(s) of the contact person(s) responsible for corrective action: Tammy Stratz Planned completion date for corrective action plan: 10/14/2024
Finding 500098 (2023-001)
Significant Deficiency 2023
Reporting and Environmental Reviews – CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various requirements of the CDBG grant program and identify individuals who can act as a reviewer and approver of the repo...
Reporting and Environmental Reviews – CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various requirements of the CDBG grant program and identify individuals who can act as a reviewer and approver of the reporting process. We also recommend the City document these procedures and internal controls as required by Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Community Development Manager and/or Community Development Specialist will prepare all Draw Requests and complete CDBG reports, including, but not limited to, the Annual Action Plan, CAPER, 5-Year Consolidated Plan, Labor Standards Report, and Minority/Women-Owned Business Reports. All Draw Requests will be reviewed by the Finance Director or Assistant Director, while other reports will be reviewed by the Development Director prior to submission to ensure accuracy and compliance. This process will be added to the CDBG Policy and Procedure Manual to address the audit findings and improve reporting oversight. Name(s) of the contact person(s) responsible for corrective action: Tammy Stratz, Randy Fifrick Planned completion date for corrective action plan: 9/30/2024
Finding 2023-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple Workday allows costing allocations, which automatically split salaries above and below the cap. This process ensures that only appropriate salaries are charged to the grant. Management...
Finding 2023-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple Workday allows costing allocations, which automatically split salaries above and below the cap. This process ensures that only appropriate salaries are charged to the grant. Management will update the salary cap in the system in a timely manner and validate that the system is calculating correctly. Going forward, management will do a quarterly review of the effort distributions, and make adjustments when needed in a timely manner. Responsible Official: Robert Stanton, Assistant Vice President, Research and Financial Operations, NSH Research Central Office
View Audit 322924 Questioned Costs: $1
Finding 2023-005 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple As soon as the annual rate is calculated and reviewed after the annual audit is complete, Research will provide the approved fringe rate to accounting. Accounting will use the approved...
Finding 2023-005 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple As soon as the annual rate is calculated and reviewed after the annual audit is complete, Research will provide the approved fringe rate to accounting. Accounting will use the approved rate prospectively. Accounting will assess the variance between the new approved rate and the prior rate used. Research will approve the adjustment based on materiality and document the adjustment process. Management will develop a policy around the fringe allocation and adjustment Responsible Official: Robert Stanton, Assistant Vice President, Research and Financial Operations, NSH Research Central Office and Annaliza Villamin, System Director of Accounting, Endeavor Health
Finding 2023-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple The new Workday time and effort certification is now operational. Each individual is able to certify their own time and effort in the system, which eliminates manual tracking and paper...
Finding 2023-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple The new Workday time and effort certification is now operational. Each individual is able to certify their own time and effort in the system, which eliminates manual tracking and paperwork. Management will follow up and validate the effort certification is occurring in a timely manner. Management is currently drafting the policy to align with the new process. There will be continuous staff training and monitoring in this area. Responsible Official: Robert Stanton, Assistant Vice President, Research and Financial Operations, NSH Research Central Office
FINDING 2023-003 (Medicaid Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number: 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The...
FINDING 2023-003 (Medicaid Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number: 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Federal Cost report beginning 2022 will be done by a new firm. The firm is Blue & Co. They are a wellestablished CPA. The information that is supplied to the CPA firm will be maintained by Wayne Township and will be put the finished cost report. This is for the financial and other metrics that are needed for the report. The cost report will be reviewed for accuracy by the Township Office. The Ambulance payment adjustment is received about two- and one-half years in arrears. This comment would be repeated until we receive the funds for ambulance activity completed in 2023, which will occur in 2026. The payments received by the Medicaid program will be reviewed by the Township Accounting Specialist. After the person agrees it is then inputted into the accounting software and coded to the proper account. Before the Cost report is signed and submitted it will be reviewed by the Township and will ask questions as needed. Anticipated Completion Date: 12/31/24
Finding 499961 (2023-010)
Significant Deficiency 2023
SOCIAL SERVICES ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the County continue to be diligent in their review of what is allowable when coding to certain account codes that flow into the DHS reports. Explanation of disagreement with audit finding: There is no disagreem...
SOCIAL SERVICES ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the County continue to be diligent in their review of what is allowable when coding to certain account codes that flow into the DHS reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to better capture disallowed costs getting reported. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024
View Audit 322900 Questioned Costs: $1
Finding 499960 (2023-009)
Significant Deficiency 2023
SSIS ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the County implement procedures to document review of disbursements when not able to show an electronic approval in the SSIS system. Explanation of disagreement with audit finding: There is no disagreement with the audit ...
SSIS ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the County implement procedures to document review of disbursements when not able to show an electronic approval in the SSIS system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to document review for all SSIS disbursements. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024
Finding 499956 (2023-006)
Significant Deficiency 2023
TIME STUDY – ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the county streamline the payroll change process between the payroll department and human services department. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Acti...
TIME STUDY – ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the county streamline the payroll change process between the payroll department and human services department. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024
Management will develop a more comprehensive detailed written procedures related to federal award requirement by 12/31/2024
Management will develop a more comprehensive detailed written procedures related to federal award requirement by 12/31/2024
We will provide additional training to our fiscal staff to ensure that complete accounting records are maintained. We will conduct periodic internal reviews of our records to ensure that those records support the grant expenditures claimed during the year.
We will provide additional training to our fiscal staff to ensure that complete accounting records are maintained. We will conduct periodic internal reviews of our records to ensure that those records support the grant expenditures claimed during the year.
View Audit 322898 Questioned Costs: $1
FINDING 2023-003 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Town submitted one P&E report during the audit period timely; however, a single employee prepared and submitted the P&E report withou...
FINDING 2023-003 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Town submitted one P&E report during the audit period timely; however, a single employee prepared and submitted the P&E report without a review or oversight process in place to prevent or detect and correct errors. Only one annual report was required to be submitted by the Town. For the report tested, all activity for the reporting period was not included, information submitted was not supported by the Town's records, and the reports were not fairly presented. Contact Person Responsible for Corrective Action: Matt Sumner Contact Phone Number and Email Address: 317-732-4532, msumner@whitestown.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: For applicable reports that are to be submitted for federal grants, we will implement a control/review and ensure the information being reported is correct prior to submission. Anticipated Completion Date: November 1, 2024
We now have a dedicated grants reviewer in finance to support project management's reporting since January 2024 with cross training in the finance team. We will update our practices guide to include the documentation process for compliance by October 2024. Lynn Ketch, Executive Director, is the pers...
We now have a dedicated grants reviewer in finance to support project management's reporting since January 2024 with cross training in the finance team. We will update our practices guide to include the documentation process for compliance by October 2024. Lynn Ketch, Executive Director, is the person responsible for the plan.
View Audit 322891 Questioned Costs: $1
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