Corrective Action Plans

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FINDING 2023-003 – Reporting: Significant Deficiency over Internal Controls over Compliance Condition/context – In a representative sample of monthly, quarterly, and annual reports due during the year ended December 31, 2023, auditors noted six of the six tested annual financial reports (SF-425) did...
FINDING 2023-003 – Reporting: Significant Deficiency over Internal Controls over Compliance Condition/context – In a representative sample of monthly, quarterly, and annual reports due during the year ended December 31, 2023, auditors noted six of the six tested annual financial reports (SF-425) did not agree to the underlying profit and loss detail from the Organization’s General Ledger(s) for the related grants. In addition, the certified authorized official was not an employee of the Organization and there was a lack of documentation for how the certifying official was deemed appropriate. In the sample quarterly reports, the Organization had contradicting responses related to whether reimbursement requests reflect actual spending of designated Supportive Services for Veteran Families (SSVF) funding. Corrective Action Plan: • Internal Controls are being evaluated and addressed with the Board of Directors on clarity of Financial Policy and Procedures • Implement a formal reconciliation process to ensure all grant financial reports agree to the underlying general ledger and profit and loss statements. • Establish a documented policy identifying employees authorized to certify grant reports, ensuring these individuals are employees of the Organization and appropriately trained. • Conduct regular training and internal reviews to confirm consistent understanding of grant-specific reporting requirements, particularly those related to reimbursement-based funding such as SSVF. • Develop a standard operating procedure (SOP) for reviewing and approving financial reports before submission to funders. Prior to sending to funder/portal. Must have reconciliation to numbers prior to next period reporting. • Site Review of reporting will have oversight of Financial Dept and reconciliation communication. Name of Contact Person: Chris Flaherty, Chief Executive Officer 707.890.6491 Laura Williams, Chief Financial Officer 707.335.0010 Projected Completion Date: We cannot alleviate within 12 months
Fusion added a Payroll Coordinator to our staff who has improved the payroll process and is in the process of streamlining how payroll gets allocated in our finance system. HR now approves all payroll before it is submitted. Fusion is also working to implement a new Payroll system in 2025 that will ...
Fusion added a Payroll Coordinator to our staff who has improved the payroll process and is in the process of streamlining how payroll gets allocated in our finance system. HR now approves all payroll before it is submitted. Fusion is also working to implement a new Payroll system in 2025 that will further streamline this process.
We concur with the finding, and a corrective action plan was created and implemented on January 1, 2024. We have modified our Accounting Policies and Procedures and trained all finance staff on reviewing the necessary backup for disbursements and have been loading this backup into our finance system...
We concur with the finding, and a corrective action plan was created and implemented on January 1, 2024. We have modified our Accounting Policies and Procedures and trained all finance staff on reviewing the necessary backup for disbursements and have been loading this backup into our finance system. The creation and implementation of a google submission for disbursements has added the necessary review and approval of all expenses. Additional Partner Engagement Coordinator review of requests and backup documentation has been implemented for weekly approval of disbursements.
Personnel Responsible for Corrective Action: Jim Keeney, CFO Anticipated Completion Date: Completed. Review and Approval continue consistently. Corrective Action Plan: Management has implemented a time and activity method that meets the requirements of federal regulations. It includes the use of JIR...
Personnel Responsible for Corrective Action: Jim Keeney, CFO Anticipated Completion Date: Completed. Review and Approval continue consistently. Corrective Action Plan: Management has implemented a time and activity method that meets the requirements of federal regulations. It includes the use of JIRA Software and an Excel Spreadsheet. Staff are entering time on an ongoing and consistent basis, including both actual and allowable time, for federal and non-federal contracts/agreements. These tools are reviewed and approved by executive management before any billing has transpired. Management is providing ongoing training for existing staff and new staff on an annual basis. This includes review and analysis from the accounting department to ensure proper expense accrual and revenue recognition. Management has also written an improved and detailed policy and procedure on recording actual and allowable time.
Management acknowledges this finding and agrees that during the period under audit-while the organization was experiencing rapid growth and increased program activity-our documentation and approval processes did not consistently keep pace with operational demands. Since that time, we have taken sign...
Management acknowledges this finding and agrees that during the period under audit-while the organization was experiencing rapid growth and increased program activity-our documentation and approval processes did not consistently keep pace with operational demands. Since that time, we have taken significant steps to strengthen accounting procedures and internal controls, reinforce our invoice approval policies, and ensure all expenditures charged to Federal awards are properly reviewed and authorized prior to processing. We have enhanced our Accounts Payable workflow by implementing standardized process approval requirements, added additional leadership staffing and oversight within the Finance and Accounting team and provided targeted training to all personnel involved in invoice processing to ensure understanding of Federal cost principles and documentation standards. These corrective actions have improved our control environment since the audit period, and management is committed to continuing to develop and maintain strong financial controls and to prevent recurrence of this issue.
During this period, Hope the Mission experienced rapid organizational growth in which our internal infrastructure had not yet caught up to support the significant growth in programs and funding. Since then, management changed our 3rd party payroll provider in order to better support our payroll and ...
During this period, Hope the Mission experienced rapid organizational growth in which our internal infrastructure had not yet caught up to support the significant growth in programs and funding. Since then, management changed our 3rd party payroll provider in order to better support our payroll and reporting needs. As part of this transition, we worked closely with our new payroll provider to implement job-costing functionality that will accurately track time across grants funded programs. In addition, we have established a process requiring department leads to review and approve all timesheets prior to submission. We also partnered with our new 3rd party payroll provider to set up time allocation for salaried employees.
Recommendation: We recommended the City establish internal control procedures to ensure that all reimbursement requests are reviewed and approved by an authorized official prior to submission. Views of Responsible Officials: Management concurs with the finding. The City of Adelanto experienced highe...
Recommendation: We recommended the City establish internal control procedures to ensure that all reimbursement requests are reviewed and approved by an authorized official prior to submission. Views of Responsible Officials: Management concurs with the finding. The City of Adelanto experienced higher than expected staff turnover in the finance department during the timeframe noted in this audit, which caused a backlog in audit preparation and submission, along with certain financial controls implementation interruption. At the time of this audit publishing, Management believes that implementation of such procedures is in compliance with the noted recommendation. Persons Responsible for Corrective Action: City Finance Staff (various) City Department Heads applying for grant funding (various) Anticipated Completion Date for Corrective Action: Corrective action has been immediately implemented in response to the auditors’ recommendation. As financial reporting is still in the process of becoming current, the City anticipates finding to be removed in future fiscal years.
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.
SAOP will establish more robust internal contols to guarantee that all non-payoll charges are incurred within the tauthoized period of performance. This should involve consistent monitoring of gran periods, providing staff training on the perfoormance period, and conducting periodic reviews of expen...
SAOP will establish more robust internal contols to guarantee that all non-payoll charges are incurred within the tauthoized period of performance. This should involve consistent monitoring of gran periods, providing staff training on the perfoormance period, and conducting periodic reviews of expenditure documentation.
SAOP will enhance the internal controls over the payroll allocation process by conducting regular reviews and reconiliations to ensure the accuracy of payroll allocations.
SAOP will enhance the internal controls over the payroll allocation process by conducting regular reviews and reconiliations to ensure the accuracy of payroll allocations.
SAOP shall establish a procedure to securely store payment support, ensuring all transactions are supported by proper documentation.
SAOP shall establish a procedure to securely store payment support, ensuring all transactions are supported by proper documentation.
The City will continue to work with the grant administrator who is managing the grant for the funding agency. The Administration will only submit invoices once for reimbursement and identify which invoices are local funding versus grant funding to avoid this in the future.
The City will continue to work with the grant administrator who is managing the grant for the funding agency. The Administration will only submit invoices once for reimbursement and identify which invoices are local funding versus grant funding to avoid this in the future.
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Town of Malden January 1, 2023 through December 31, 2023 This schedule presents the corrective action the Town is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Town of Malden January 1, 2023 through December 31, 2023 This schedule presents the corrective action the Town is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-002 Finding caption: The Town did not have adequate internal controls and did not comply with federal wage rate requirements. Name, address, and telephone of Town contact person: Dan Harwood, Mayor PO Box 248, Malden, Washington 99149 (509) 569-3771 Corrective action the auditee plans to take in response to the finding: We agree with the SAO staff as far as the Town staff being new to federal grants and the requirements of recordkeeping associated with it. It is obvious that the Town staff can not handle the workload of administering all the grants that the town has obtained since the 2020 Babb Road Fire. We are in the process of contracting an outside party that will handle most of the current grants. The Town staff thought they processed all the certified payroll information that was received. We were surprised that there were some missing. The State Department of Commerce has been working with the staff on making sure that the certified payroll process was complete. With any future grants we will make sure that Town staff will pursue training on Certified Payroll to make sure all papers are received. Anticipated date to complete the corrective action: These actions will be done when we receive future federal grants.
The City will work to ensure all reports for grant funding are completed.
The City will work to ensure all reports for grant funding are completed.
2023-003: SFSAC Submission Contact Person – Julie Ketterling, Director Corrective Action Plan – This finding is noted together with the Board. The Unit will work to ensure timely submission of the data collection form in the future. Completion Date – The Unit will work to submit timely for the June ...
2023-003: SFSAC Submission Contact Person – Julie Ketterling, Director Corrective Action Plan – This finding is noted together with the Board. The Unit will work to ensure timely submission of the data collection form in the future. Completion Date – The Unit will work to submit timely for the June 30, 2025 audit.
Finding 2023-002: Written Uniform Guidance Policies Responsible Individuals: Jeannie Walters, Finance Officer Corrective Action Plan: The Association will develop written Uniform Guidance policies. Anticipated Completion Date: December 31, 2025
Finding 2023-002: Written Uniform Guidance Policies Responsible Individuals: Jeannie Walters, Finance Officer Corrective Action Plan: The Association will develop written Uniform Guidance policies. Anticipated Completion Date: December 31, 2025
The City will design and implement controls to ensure that the costs of goods and services charged to federal awards are allowable and in accordance with the applicable cost principles.
The City will design and implement controls to ensure that the costs of goods and services charged to federal awards are allowable and in accordance with the applicable cost principles.
The City will design and implement controls to ensure that federal awards are expended only for allowable activities.
The City will design and implement controls to ensure that federal awards are expended only for allowable activities.
The City has will develop written procedures for determining the allowability of costs in accordance with 2 CFR 200, Subpart E—Cost Principles and the terms and conditions of the Federal award.
The City has will develop written procedures for determining the allowability of costs in accordance with 2 CFR 200, Subpart E—Cost Principles and the terms and conditions of the Federal award.
Response to finding 2023-003 – Lack of Documented Approval for Payroll Transactions Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-003. Due to the organizational pause at the...
Response to finding 2023-003 – Lack of Documented Approval for Payroll Transactions Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-003. Due to the organizational pause at the end of 2024 and the transition period throughout 2025, the Organization discontinued its prior payroll system when staff were laid off and shifted remaining personnel to contractor status. During this period, approval and payment of contractor invoices were processed through Ramp, with documentation maintained but not within a formalized payroll approval workflow. As CSforALL prepares for the 2026 rebuilding phase, management has re-established a structured payroll approval and documentation process aligned with audit recommendations. Corrective Action taken in 2025: Beginning in August 2025, the Organization transitioned to ADP, a trusted payroll service integrated with QuickBooks, in anticipation of restoring full payroll operations in 2026. Since implementation, payroll reporting and documentation have been maintained accurately each month by the Operations Manager and the Accountant, with formal approval granted by the Advisory Consultant. All invoices, payments, and payroll records are shared and stored bi-weekly as payroll is executed, establishing a consistent and documented approval trail. Corrective Action Planned for 2026: Beginning in January 2026, CSforALL will apply standardized supervisory approval procedures within ADP for all payroll transactions. Management will implement periodic monitoring of payroll records, ensure consistent use of the approved timekeeping and approval system, and maintain documentation of all supervisory approvals to ensure compliance with established internal controls throughout the 2026 operating year and beyond.
Finding 2023-003 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June ...
Finding 2023-003 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June 2025 and have been trained and have fully implemented Sanford Health procedures by September 2025, such that the Sanford Health system of controls now extend to MCHS. Specifically with these changes, grants management and accounting duties have also transitioned to the MCHS grant team which extends Sanford Health’s systems of control to MCHS to ensure accurate and timely completion of the Schedule. Completion Date: September 30, 2025.
Finding 2023-002 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and docum...
Finding 2023-002 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and documented approval of employee reimbursed expenditures charged to externally sponsored programs. It can be noted that, subsequent to sample testing, the one transaction in question was reviewed by Management and deemed an allowable cost.Completion Date: December 31, 2024
Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information f...
Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information for each individual employee tested. One for the test order and a second for the test result. Each row was counted and costed as two separate employee tests and therefore a portion of the cost for employee COVID tests was accidentally doubled and overstated in the portal for Period 5. However, although these expenses were overstated by $49,000, the grant was not overcharged as these questioned costs would be fully replaceable by an allowable amount of unused eligible lost revenues of approximately $109,516,000. Management will implement a procedure that requires a second level review of expenditures reported to ensure accuracy of reimbursement claimed for federal- and state-funded expenditures.Completion Date: September 30, 2024
Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition During testing we noted the following:For 1 of 1 vendors tested, the Tribe did not maintain documentation demonstrating that the vendor was verified as not federally suspended or d...
Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition During testing we noted the following:For 1 of 1 vendors tested, the Tribe did not maintain documentation demonstrating that the vendor was verified as not federally suspended or debarred prior to entering into the contract. Corrective Action: Effective January 1, 2026, every proposal or contract that goes out will require all vendors to be active in SAMS.gov for all federal grants. This will be a requirement during the biddingprocess. Anticipated date of completion: January 30, 2026.
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