Corrective Action Plans

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TOFMHS concurs with the finding. The excess drawdowns were the result of accounting entries to record refunds, or other adjustments which reduced previously allowable expenses. Subsequent drawdowns should have been reduced to offset these adjustments. TOFMHS will implement ACF-IM-HS-23-01 (Treatment...
TOFMHS concurs with the finding. The excess drawdowns were the result of accounting entries to record refunds, or other adjustments which reduced previously allowable expenses. Subsequent drawdowns should have been reduced to offset these adjustments. TOFMHS will implement ACF-IM-HS-23-01 (Treatment of Rebates, Refunds, Discounts), and prevent an recurrence of this issue in the future. Corrective Active Taken: TOFMHS returned the $51,664 to the Payment Management System on January 16, 2025 in accordance with the referenced Information Memorandum. Drawdowns will be based upon actual expenses and disbursed within 3 business days. Responsible Person: Finance Director with oversight by the Program Director.
Finding 522783 (2023-009)
Significant Deficiency 2023
2023-009 – Subrecipient Monitoring Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Subrecipient Monitoring). Program. Substance Abuse and Mental Health Services - Projects of Regional and National Significance; U.S. Department of Health and Human ...
2023-009 – Subrecipient Monitoring Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Subrecipient Monitoring). Program. Substance Abuse and Mental Health Services - Projects of Regional and National Significance; U.S. Department of Health and Human Services; Assistance Listing Number 93.243; Award Number 1H79SM084918-01. Auditor Description of Condition and Effect: Subaward contracts review did not contain appropriate information related to the federal program. No assistance listing number or federal program name was noted in the language of the agreements. In addition, no evidence of formal risk assessment was documented. The City is exposed to an increased risk that future noncompliance could occur and not be prevented or detected by the City's internal controls. Auditor Recommendation: We recommend that the City implement necessary internal controls to ensure documentation of its compliance with the requirements of the Uniform Guidance is maintained. Corrective Action: The City will implement the necessary internal controls to ensure the policy for compliance is followed and documented. Part of the solution will be implementing grant management software. Responsible Person: Phillip Moore, Chief Financial Officer Anticipated Completion Date: January 21, 2025
Finding 522781 (2023-010)
Significant Deficiency 2023
2023-010– Special Reporting for Federal Funding Accountability and Transparency Act Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Reporting). Programs. Choice Neighborhoods Implementation Grant; U.S. Department of Housing and Urban Development; ...
2023-010– Special Reporting for Federal Funding Accountability and Transparency Act Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Reporting). Programs. Choice Neighborhoods Implementation Grant; U.S. Department of Housing and Urban Development; Assistance Listing Number 14.889' Award Number MI5F519CNG117. Substance Abuse and Mental Health Services - Projects of Regional and National Significance; U.S. Department of Health and Human Services; Assistance Listing Number 93.243; Award Number 1H79SM084918-01. Auditor Description of Condition and Effect: Despite passing through qualifying amounts, the City could produce no evidence that the subawards had been reported through the FSRS. The City is exposed to an increased risk that future noncompliance could occur and not be prevented or detected by the City's internal controls. Auditor Recommendation: We recommend that the City implement necessary internal controls to ensure that reporting of subawards greater than $30,000 is submitted to the FSRS for all direct grants. Corrective Action: The City will implement the necessary internal controls to ensure the policy for compliance is followed and documented. Responsible Person: Phillip Moore, Chief Financial Officer Anticipated Completion Date: January 21, 2025
2023-012– Support for Payroll Allocations Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control Over Compliance (Allowable Costs/Cost Principles). Program. Community Block Grants/Entitlement Grants; U.S. Department of Housing and Urban Development; Assistance Listing Nu...
2023-012– Support for Payroll Allocations Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control Over Compliance (Allowable Costs/Cost Principles). Program. Community Block Grants/Entitlement Grants; U.S. Department of Housing and Urban Development; Assistance Listing Number 14.218; All awards. Auditor Description of Condition and Effect: During testing it was noted that the actual amounts charged to the grant were initially charged using the allocation rates from the previous pay period, and subsequently adjusted to the proper amount through a manual journal entry. When factoring in the amounts of the journal entries, the amount charged to the grant still differed from the support provided for 3 items of the 29 tested. The City is exposed to an increased risk that future noncompliance could occur and not be prevented or detected by the City's internal controls. Auditor Recommendation: We recommend that the City implement necessary internal controls to ensure that all allocations of personnel cost are allocated according to the support retained. Corrective Action: The City will implement the necessary internal controls to ensure the policy for compliance is followed and documented. Responsible Person: Phillip Moore, Chief Financial Anticipated Completion Date: January 22, 2025
2023-011– Report Filing - 2022 and 2023 CAPER Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Contol Over Compliance (Reporting). Program. Community Block Grants/Entitlement Grants; U.S. Department of Housing and Urban Development; Assistance Listing Number 14.218; All Aw...
2023-011– Report Filing - 2022 and 2023 CAPER Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Contol Over Compliance (Reporting). Program. Community Block Grants/Entitlement Grants; U.S. Department of Housing and Urban Development; Assistance Listing Number 14.218; All Award Numbers. Auditor Description of Condition and Effect: As of the completion of audit fieldwork, the 2022 and 2023 CAPERs have not been filed. The City is exposed to an increased risk that future noncompliance could occur and not be prevented or detected by the City's internal controls. Auditor Recommendation: We recommend that the City implement necessary internal controls to ensure that all required reports are submitted in a timely manner. Corrective Action: The City will implement the necessary internal controls to ensure the policy for compliance is followed and documented. Responsible Person: Phillip Moore, Chief Financial Officer Anticipated Completion Date: January 21, 2025
Management’s response/corrective action plan - We agree the $49,807 was reimbursed twice. We communicated the error to our contact at the USDA and our next grant draw shall be reduced by $49,807.
Management’s response/corrective action plan - We agree the $49,807 was reimbursed twice. We communicated the error to our contact at the USDA and our next grant draw shall be reduced by $49,807.
View Audit 341902 Questioned Costs: $1
Finding #2023-001 Allowable Costs and Cost Principles: Douglas Wilson was unable to determine if the Center complied with the 15% requirement or the $25,000 technical assistance limit for the CCBHC grant. Douglas Wilson was also unable to test a sample of direct costs charged to the program because...
Finding #2023-001 Allowable Costs and Cost Principles: Douglas Wilson was unable to determine if the Center complied with the 15% requirement or the $25,000 technical assistance limit for the CCBHC grant. Douglas Wilson was also unable to test a sample of direct costs charged to the program because transaction details were not provided. Per the recommendation of Douglas Wilson, we have updated the Center’s existing financial policy and procedures to include language specifically related to how the Center will retain documentation to support costs that are charged to the CCBHC grant, and also track and monitor compliance with the 15% and $25,000 maximum requirements for the grant (see Financial Policies and Procedures Policy A-14). Responsible official: Sydney Blair, Chief Executive Officer, 406.791.9603 Expected completion date: June 30, 2025
No payments will be made for purchases until the proper documentation is received and attached to the purchase order
No payments will be made for purchases until the proper documentation is received and attached to the purchase order
View Audit 341776 Questioned Costs: $1
For the coding of expenditures for Federal Awards, State Awards, or Pass-through funding, the appropriate Finance, Program Manager, and Program personnel should review the award packet especially the compliance expenditure section where the agency defines the allowable expenses that can be paid, or ...
For the coding of expenditures for Federal Awards, State Awards, or Pass-through funding, the appropriate Finance, Program Manager, and Program personnel should review the award packet especially the compliance expenditure section where the agency defines the allowable expenses that can be paid, or unallowable expenses cannot be included in the program reporting. There are free webinars provided by the Federal Government that will help personnel understand the criteria under “2 CFR Part 200, Subpart E – Cost Principles “for federal awards. Before expenses are incurred, they should be approved through the Purchase Authorization Process with all appropriate signatures being acquired depending on the amount of the expense planned. We meet on a monthly basis to review allowable expenses and the tracking of funds with departments heads.
View Audit 341763 Questioned Costs: $1
With the changes in the Leadership Team, the staff is currently reviewing and re-allocating personnel costs into direct program costs and indirect allocatable costs to be distributes through an acceptable allocation or De Minimus calculation. These changes are planned for the current contract year ...
With the changes in the Leadership Team, the staff is currently reviewing and re-allocating personnel costs into direct program costs and indirect allocatable costs to be distributes through an acceptable allocation or De Minimus calculation. These changes are planned for the current contract year with the original program budget submissions being amended to reflect these changes and approved by the funding agency. Currently, AUL utilizes two allocation methods when applicable. Those methods are the Federal De Minimus calculation, or the Direct Administrative Cost Recovery Allocation developed in conjunction with Maximus. All direct labor personnel should be recording their time spent on a program in the Paychek’s Payroll System using the appropriate dropdown listing if the program is a Summit County program the personnel should complete a PAR report monthly for the program time and it should be signed and approved by the Program Director or their designee. These forms should be forwarded to the Finance Department to that they are included in any Program Billing that is necessary for reimbursement. We have established a signature coversheet before we send the invoice to the entity for payment. PAR's are part of this reviewing process.
View Audit 341763 Questioned Costs: $1
Corrective Action: Management agrees with the findings. While we have policies and procedures as recommended by the auditors, there is an opportunity to review our policies and procedures related to the review and approval around disbursements. Through the leadership of our Chief Financial Office...
Corrective Action: Management agrees with the findings. While we have policies and procedures as recommended by the auditors, there is an opportunity to review our policies and procedures related to the review and approval around disbursements. Through the leadership of our Chief Financial Officer and our Director of Finance, our internal control policies and procedures will be evaluated and as needed, amended, with an effective date no later than June 30, 2025. Anticipated Completion Date: June 30, 2025 Contact Person: Marco Giordano, Vice President and Chief Financial Officer
The Organization does not agree with this finding. Our cost allocation policies include the following: 1. Payroll – allocated based on time and effort with consideration of the limits of the program contracts 2. OTPS – allocated based on food units with considerations on the program and supporting s...
The Organization does not agree with this finding. Our cost allocation policies include the following: 1. Payroll – allocated based on time and effort with consideration of the limits of the program contracts 2. OTPS – allocated based on food units with considerations on the program and supporting services benefited During the exit meeting/visit to the office, we have provided the auditors with invoices and allocation basis of the expenses. We have also explained to the auditors the allocation in terms of percentage and dollar values for each sample.
Finding 2023‐003 – Reporting Requirements Grantor: U.S. Department of Health and Human Services Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing #: 93.498 Title: COVID-19 Provider Relief Fund Award Year: Fiscal year 2023 9/1/22-8/31/23 Award Number: ...
Finding 2023‐003 – Reporting Requirements Grantor: U.S. Department of Health and Human Services Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing #: 93.498 Title: COVID-19 Provider Relief Fund Award Year: Fiscal year 2023 9/1/22-8/31/23 Award Number: Not Listed Management understands the importance of accurate reporting for the Provider Relief Fund reporting. At the time of Period 5 reporting, one entity included expenses that were previously reported in Period 2 reporting. Corrective Action Plan and Anticipated Completion Date: The total expenses reported in error for Period 5 will be revised in subsequent filings, if required by HRSA. With the correction of the error, total expenses to be used in subsequent filings still exceed payments received. On a going forward basis, Management’s review will include a reconciliation of expenses reported on the current Period submission to ensure it excludes expenses claimed in prior Period.
View Audit 341545 Questioned Costs: $1
Finding 2023‐002 – Reporting Requirements Grantor: U.S. Department of Health and Human Services Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing #: 93.498 Title: COVID-19 Provider Relief Fund Award Year: Fiscal year 2023 9/1/22-8/31/23 Award Number: ...
Finding 2023‐002 – Reporting Requirements Grantor: U.S. Department of Health and Human Services Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing #: 93.498 Title: COVID-19 Provider Relief Fund Award Year: Fiscal year 2023 9/1/22-8/31/23 Award Number: Not Listed Management understands the importance of accurate reporting for the Provider Relief Fund reporting. At the time of the second and third reporting submissions,the proper review and tie out of final net revenue was not completed for August 2021 net revenue. Corrective Action Plan and Anticipated Completion Date: The net revenue amounts reported in error for August 2021 will be revised from the reported estimated amounts in subsequent filings, if required by HRSA. With no lost revenue being claimed beyond what has already been reported to HRSA, management will also update methodology narrative to reference the last month with lost revenues was March 2021 and no additional revenue will be reported.
Finding: The Organization did not have adequate and effective controls over compliance in place as it relates to activities allowed or unallowed and allowable costs. We noted instances where payroll and non-payroll related expenditures did not have documentation of review. Corrective Response: Manag...
Finding: The Organization did not have adequate and effective controls over compliance in place as it relates to activities allowed or unallowed and allowable costs. We noted instances where payroll and non-payroll related expenditures did not have documentation of review. Corrective Response: Management represents that there was not sufficient documentation of controls. Operational and reporting improvements will be pursued to better document expenditure review on a go-forward basis.
Recommendation 1: Comment: We appreciate the recommendation and fully agree with the importance of having a clear documentation process for all deliveries. To address this, we will implement a policy that ensures all deliveries to the Organization and Units are properly documented. A designated empl...
Recommendation 1: Comment: We appreciate the recommendation and fully agree with the importance of having a clear documentation process for all deliveries. To address this, we will implement a policy that ensures all deliveries to the Organization and Units are properly documented. A designated employee responsible for receiving deliveries will be tasked with ensuring that all receipts and receiving reports are accurately matched with the corresponding invoices. This process will enhance our internal controls and improve the tracking and accountability of all deliveries. Recommendation 2: Comment: We will implement a policy requiring Unit Directors to submit daily "End of Day Reports" using a standardized template. This template will capture essential information, including activities conducted, materials distributed, and deliveries received. We will also establish a policy for maintaining and utilizing sign-in sheets at each Unit, outlining the required information such as the activity or event description, number of children involved, materials distributed, and the names of the Unit Director and Assistant Director. These sign-in sheets will be submitted to the appropriate parties promptly and saved in an online repository, organized by Unit and grant year. Additionally, supporting documentation will be collected and stored as part of the overall documentation process. We are committed to enforcing these policies to ensure timely submission and proper maintenance of all required documentation, further reinforcing our dedication to transparency, accountability, and effective use of grant funds.
View Audit 341463 Questioned Costs: $1
The Organization’s Accounting Department, under the direction of the Chief Executive Officer, Connie Franks, will ensure that there’s proactive communication, dedicated resource allocation, and regular status checks on the deadline. He should ensure everyone involved understands the deadlines and re...
The Organization’s Accounting Department, under the direction of the Chief Executive Officer, Connie Franks, will ensure that there’s proactive communication, dedicated resource allocation, and regular status checks on the deadline. He should ensure everyone involved understands the deadlines and responsibilities to avoid any delays. Completion of the referenced corrective action will be implemented by January 2025.
In Finding 2023-003, it was reported that time and activity reports and/or I-9 forms were not maintained for certain employees. Although the Organization’s policies require that time records be maintained by employees, current operating procedures are not in place to ensure the time records are comp...
In Finding 2023-003, it was reported that time and activity reports and/or I-9 forms were not maintained for certain employees. Although the Organization’s policies require that time records be maintained by employees, current operating procedures are not in place to ensure the time records are completed. Procedures will be established to require all employees to maintain time and effort certifications that coincide with the Organization’s payroll cycle (at least on a monthly basis) and that I-9 forms are obtained for each employee in accordance with the Organization’s policies.
Condition: Claims support could only be provided by the School for two months. For one month, support was in the form of spreadsheets with tray counts in lieu of a point-of-sale system. For the other month, the tray count spreadsheets were accompanied by reports from the point-of-sale system. Th...
Condition: Claims support could only be provided by the School for two months. For one month, support was in the form of spreadsheets with tray counts in lieu of a point-of-sale system. For the other month, the tray count spreadsheets were accompanied by reports from the point-of-sale system. The point-of-sale system reports provided did not agree to the amounts claimed for reimbursement. The tray counts did not indicate whether the meal provided was paid, free or reduced. The claims for reimbursement submitted by the School used allocation percentages derived from prior year claims when estimating amounts to be claimed as paid, free and reduced. The tray count spreadsheets for the other months could not be located by the School. Corrective Action Planned: In January 2023 DESE sent an auditor to review the Medford School Nutrition Program. Before this review, there was significantly limited oversight by the central office finance team. Almost no documents were prepared before the review as required by DESE. As a result of this audit a 58-item, 19-page Corrective Action Plan was issued to the district. A new district leader was assigned for departmental oversight. The district then had weekly meetings with DESE to address the corrective action plan, for this was the single largest CAP DESE has issued to any district of our size. Nearly $1.3 million in reimbursements were withheld from the district from approximately November 2022 through the end of the Fiscal Year. DESE issued the reimbursements with a nominal penalty during the summer of 2023. At the end of FY23, the district terminated the director of the program. We are now training several individuals in the MCPPO program for enhanced oversight. DESE forced an immediate return audit for FY24. This was an exceptional action as DESE has only rarely done this. The same reviewer attended and noted significant improvements as a result of district actions undertaken. As relates to this particular finding, the School Department has purchased and is consistently using a point of sale system for students to purchase their meals. The system is used to track all transactions. Anticipated Completion Date: 2/17/2025 Contact: Peter Cushing, Assistant Superintendent
View Audit 341024 Questioned Costs: $1
This has been corrected. The Contracts and Procurement Manager reviews all RFPs and RFQs and is present during the evaluation review.
This has been corrected. The Contracts and Procurement Manager reviews all RFPs and RFQs and is present during the evaluation review.
It is the responsibility of the Finance Supervisor to ensure all contracts entered into includes language indicating if the funding is federal or state. If it is federal funding, the contract must include the federal assistance listing number, which will be reported on the year-end schedule of feder...
It is the responsibility of the Finance Supervisor to ensure all contracts entered into includes language indicating if the funding is federal or state. If it is federal funding, the contract must include the federal assistance listing number, which will be reported on the year-end schedule of federal awards. A single audit will be performed if the federal expenditures reach the maximum allowable per auditing standards. If a single audit is required, it will be completed and submitted to the appropriate grantors within nine months of the end of the fiscal year.
Finding 520779 (2023-003)
Significant Deficiency 2023
Views of responsible officials and corrective action: We have adopted a SEFA worksheet to track federal award expenditures for each individual federal program to include the CFDA or other identifying number when the CFDA information is not available. Included in the SEFA worksheet, tracking of feder...
Views of responsible officials and corrective action: We have adopted a SEFA worksheet to track federal award expenditures for each individual federal program to include the CFDA or other identifying number when the CFDA information is not available. Included in the SEFA worksheet, tracking of federal awards received as a subrecipient, including the name of the pass-through entity and the identifying number assigned by the pass-through entity. All federal expenditures will be categorized per our contract statement on allowable cost expenses. Responsible Individual: Brangwyn Foley, Office Manager Implementation Date: July 2023
Views of responsible officials and corrective action: Payroll Tax administration integration through ADP automats tax deposits and filings – quarterly/annually for federal, state and local jurisdictions. Conducting continual balancing to ensure that tax filing data matches payroll data. ADP identifi...
Views of responsible officials and corrective action: Payroll Tax administration integration through ADP automats tax deposits and filings – quarterly/annually for federal, state and local jurisdictions. Conducting continual balancing to ensure that tax filing data matches payroll data. ADP identifies and corrects reconciliation mistakes throughout the year to help save time and ensure an easier year-end tax audit. expense and accounts payable payroll policy Progress House Inc. contracts with an external company for payroll services. payroll preparation and approval Protocol Payroll Records-Employees are paid on a bi-monthly basis. The payroll company is responsible for preparing payroll checks and maintaining the records in a payroll journal. deductions Progress House Inc. is responsible for providing the external payroll company accurate employee information, and providing changes or corrections as needed. The external payroll company is responsible for ensuring deductions including the appropriate social security taxes (FICA), federal income taxes, state income taxes and state disability insurance. Responsible Individual: Cindy Carlson, Executive Director Implementation Date: September 2023
View Audit 340574 Questioned Costs: $1
Views of responsible officials and corrective action: We have adopted a SEFA worksheet to track federal award expenditures for each individual federal program to include the CFDA or other identifying number when the CFDA information is not available. Included in the SEFA worksheet, tracking of feder...
Views of responsible officials and corrective action: We have adopted a SEFA worksheet to track federal award expenditures for each individual federal program to include the CFDA or other identifying number when the CFDA information is not available. Included in the SEFA worksheet, tracking of federal awards received as a subrecipient, including the name of the pass-through entity and the identifying number assigned by the pass-through entity. All federal expenditures will be categorized per our contract statement on allowable cost expenses. In addition to allocating funds based on the SEFA worksheet properly in our operating system, QuickBooks for tracking purposes. This process will be completed on a monthly basis with a quarterly audit to ensure proper allocation of funds provided. Responsible Individual: Brangwyn Foley, Office Manager Implementation Date: July 2023
2023-003 Inaccurate Schedule of Expenditures of Federal Awards Provider Relief Fund – CFDA #93.498 Condition: Management has all the information to complete the schedule of expenditures of federal awards in compliance with the Uniform Guidance but had inaccuracies discovered during audit procedure...
2023-003 Inaccurate Schedule of Expenditures of Federal Awards Provider Relief Fund – CFDA #93.498 Condition: Management has all the information to complete the schedule of expenditures of federal awards in compliance with the Uniform Guidance but had inaccuracies discovered during audit procedures. Federal expenditures of $1,560,441 were excluded from the schedule but were determined to have been reported as spent during the fiscal year. There were also $99,895 in federal expenditures reported for other grants that were determined to be overstated. Action Taken: • Management will prepare the schedule of expenditures of federal awards as part of the year end closing process each year to determine our audit requirements under Uniform Guidance and provide the schedule to the audit firm during the financial audit process. Anticipated Date of Completion and Name of Contact Person: June 30, 2024 – J.P. Champion, Chief Financial Officer
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