Corrective Action Plans

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MANAGEMENT WILL WORK WITH THEIR CONSULTANT AND DEVELOP WRITTEN POLICIES AND PROCEDURES OVER THEIR FEDERAL AWARDS IN ACCORDANCE WITH THE REQUIREMENTS OF THE UNIFORM GUIDANCE
MANAGEMENT WILL WORK WITH THEIR CONSULTANT AND DEVELOP WRITTEN POLICIES AND PROCEDURES OVER THEIR FEDERAL AWARDS IN ACCORDANCE WITH THE REQUIREMENTS OF THE UNIFORM GUIDANCE
Finding 404698 (2023-002)
Significant Deficiency 2023
Ref No. 2023-002 SIGNIFICANT DEFICIENCYI It was noted one instance out of forty that the employee timesheet did not agree with the payroll register. The hours on the timesheet were 45, while the hours on the payroll register were 48 hours. This resulted in an overcharge of $159 to the program. I...
Ref No. 2023-002 SIGNIFICANT DEFICIENCYI It was noted one instance out of forty that the employee timesheet did not agree with the payroll register. The hours on the timesheet were 45, while the hours on the payroll register were 48 hours. This resulted in an overcharge of $159 to the program. It was also noted one out of seventy-one timesheets were not approved by the supervisor. Recommendation: Ke Ola Mamo should exercise greater care in reviewing timesheets and data entered into the payroll system to ensure that only allowable costs are charged to the program. Action Taken: Ke Ola Mamo was in the process of implementing an on-line payroll processing system during Fiscal Year 2023. The implementation was completed during Fiscal Year 2023. This process minimizes potential clerical errors as employees input the hours they work directly into the on-line payroll system, with employees’ supervisors and the Human Resources Specialist approving prior to the payroll being processed.
Responsible Person: Tim Bergsma, CFO - West Michigan Partnership for Children (WMPC). Management View: Management agrees with the finding and is in the process of implementing the recommendation. Corrective Action: WMPC will create a Compensation Adjustement Policy. This policy will reference the co...
Responsible Person: Tim Bergsma, CFO - West Michigan Partnership for Children (WMPC). Management View: Management agrees with the finding and is in the process of implementing the recommendation. Corrective Action: WMPC will create a Compensation Adjustement Policy. This policy will reference the compensation policy, connect to the budget approval process, and identify clear directions regarding the approval process for compensation adjustments. Anticipated Completion Date: August 15, 2024
MANAGEMENT’S CORRECTIVE ACTION PLAN Finding Number: 2023-001 Planned Corrective Action: We concur with the finding. We will continue with retaining documentation of sliding scale determination electronically. The CFO will continue to monitor whether the record retention policy is being followed. In ...
MANAGEMENT’S CORRECTIVE ACTION PLAN Finding Number: 2023-001 Planned Corrective Action: We concur with the finding. We will continue with retaining documentation of sliding scale determination electronically. The CFO will continue to monitor whether the record retention policy is being followed. In regard to the finding, we had usual turnover in the department during the year which resulted in procedures not being followed precisely. We have since hired new employees and have provided additional training to prevent similar documentation errors from occurring. In additional, we have instituted a monitoring process to ensure that all policies and procedures are followed without exception. Anticipated Completion Date: On-going Responsible Contact Person: Cynthia Diaz, Chief Financial Officer
Corrective Action Plan: Atrium Health CMHA management will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT systems specific to the SFA program. Proposed Completion Date: ...
Corrective Action Plan: Atrium Health CMHA management will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT systems specific to the SFA program. Proposed Completion Date: Management will complete the corrective action plan by the end of 2024.
Corrective Action Plan: Atrium Health CMHA management will address the current year finding either through system modifications to allow for electronic saving of the applicable notifications or by implementing a manual process to retain them. Proposed Completion Date: Management will complete...
Corrective Action Plan: Atrium Health CMHA management will address the current year finding either through system modifications to allow for electronic saving of the applicable notifications or by implementing a manual process to retain them. Proposed Completion Date: Management will complete the corrective action plan by October 2024.
Corrective Action Plan: Atrium Health CMHA management will address the gap in SFA transactional review and approval internal controls, arising due to the SFA program size and limited number of subject matter experts, by implementing mitigating controls and policies to ensure accuracy and completene...
Corrective Action Plan: Atrium Health CMHA management will address the gap in SFA transactional review and approval internal controls, arising due to the SFA program size and limited number of subject matter experts, by implementing mitigating controls and policies to ensure accuracy and completeness of transactions. Proposed Completion Date: Management will complete the corrective action plan by October 2024.
Corrective Action Plan: As part of the audit planning for 2024, Atrium Health CMHA management will ensure that the internal controls within the SFA IT Systems are documented and tested, or compensating controls implemented. Proposed Completion Date: In November of 2024, management would intend ...
Corrective Action Plan: As part of the audit planning for 2024, Atrium Health CMHA management will ensure that the internal controls within the SFA IT Systems are documented and tested, or compensating controls implemented. Proposed Completion Date: In November of 2024, management would intend to incorporate and complete this IT systems controls testing into the planning phase of the December 31, 2024 reporting period audit.
Finding 404195 (2023-002)
Significant Deficiency 2023
A new HUD lease will be prepared, presented, and signed at the time of the annual recertification for every tenant.
A new HUD lease will be prepared, presented, and signed at the time of the annual recertification for every tenant.
A new HUD lease will be prepared, presented and signed at the time of the annual recertification for every tenant.
A new HUD lease will be prepared, presented and signed at the time of the annual recertification for every tenant.
Action Taken: NFFCMH plans to implement changes overall to the Federation’s timekeeping processes to ensure that payroll costs accurately reflect the work performed, and to reconcile and true up any budget estimates on a consistent basis.
Action Taken: NFFCMH plans to implement changes overall to the Federation’s timekeeping processes to ensure that payroll costs accurately reflect the work performed, and to reconcile and true up any budget estimates on a consistent basis.
Action Plan: Upon learning of this finding during the FY2022 audit, we worked with our external consultant, our Council auditors and our external auditor to reperform and review the base year and subsequent year calculations of revenue, using financial information in our final audit reports. These...
Action Plan: Upon learning of this finding during the FY2022 audit, we worked with our external consultant, our Council auditors and our external auditor to reperform and review the base year and subsequent year calculations of revenue, using financial information in our final audit reports. These corrected calculations of lost revenue have been clearly documented and will be reported going forward. We will continue to work to ensure that all controls for grants be documented with written procedures. The procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, reperformable manner including the name of each responsible individual, the specific control they performed over compliance for the grant and the date(s) the controls were performed. Contact Names responsible for the plan – Marcia Saulo Anticipated completion date of the plan – September 30, 2024
Action Plan: Upon learning of this finding during the FY2022 audit, we worked with the Neighborhoods Department to ensure wage rate requirement compliance was prioritized going forward. Considering this finding was presented near the completion of the FY2023 year, we expect this finding to be resolv...
Action Plan: Upon learning of this finding during the FY2022 audit, we worked with the Neighborhoods Department to ensure wage rate requirement compliance was prioritized going forward. Considering this finding was presented near the completion of the FY2023 year, we expect this finding to be resolved in FY2024. We will continue to work with our departments to ensure that all controls for grants are documented with written procedures. The procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, reperformable manner including the name of each responsible individual, the specific control they performed over compliance for the grant and the date(s) the controls were performed. Contact Names responsible for the plan – Marcia Saulo Anticipated completion date of the plan – September 30, 2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-002 Head Start Cluster- Federal Assistance Listing Number 93.600 - Significant Deficiency in Internal Control over Allowable Costs Recommendation: Internal Controls should be implemented around expense cutoff to ensure all expenses relate to the appropria...
DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-002 Head Start Cluster- Federal Assistance Listing Number 93.600 - Significant Deficiency in Internal Control over Allowable Costs Recommendation: Internal Controls should be implemented around expense cutoff to ensure all expenses relate to the appropriate period, or in this case, school year. Action taken: We concur with the recommendation. On May 30, 2024, HRCAP drafted Accounting Policy 3.10 to be reviewed for addition to the Finance Policy Manual. This policy would serve to provide internal control procedures for grant-related transactions in accordance with Generally Accepted Accounting Principles (GAAP). Specifically, it outlines precise year end and cut-off procedures tailored to grant revenue and expenses, emphasizing the critical importance of recording these transactions within the appropriate grant period. Sincerely yours, Audrea Lambert, Chief Financial Officer
View Audit 310907 Questioned Costs: $1
Audit Finding Reference: 2023-002 Internal Controls Over Disbursements Planned Corrective Action: No documented review of employee reimbursements charged to grants: Our systems have required review and approvals procedures as described below but the notation of review and approval were not evide...
Audit Finding Reference: 2023-002 Internal Controls Over Disbursements Planned Corrective Action: No documented review of employee reimbursements charged to grants: Our systems have required review and approvals procedures as described below but the notation of review and approval were not evident. Going forward either through email or sign-off, it will show approval. All employee reimbursement expenses are reviewed and approved by the employee’s direct manager, within the payroll system (Paylocity) prior to processing payment (with bi-weekly payroll). In addition, the grant accountant and grant manager will review the timesheets and allocation of employee expenses to confirm that they agree. The approval is submitted via email to the payroll administrator for processing of the payroll. The payroll administrator will create the journal entry in the general ledger from the approval worksheet. In addition, with the implementation of our new general ledger system, the entries are reviewed and approved within the general ledger system by upper management. No documented review of payroll charged to grants: Our systems have required review and approvals procedures as described below but the notation of review and approval were not evident. Going forward either through email or sign-off, it will show approval. Payroll has multiple levels of approval. In FY23, the payroll folder, that includes timesheets, grant allocations, and payroll register, would be submitted for approval to the accounting manager. The accounting manager would review and approve payroll and return the folder to the payroll administrator for payroll submission to the payroll company. Starting in FY24, payroll would be submitted via email to the grant accountant, grant manager, and the assistant controller for multiple levels of review and approval. Corrections and approvals are done via email. In addition to the email approvals, upper management approves payroll by initialing the last page of the payroll register after a complete review. Furthermore, with the implementation of our new general ledger system, the entries are reviewed and approved within the general ledger system by upper management. Planned Implementation Date of Corrective Action: 02/01/2024 Person Responsible for Corrective Action: Vice President – Finance, Development & Administration
Finding 404101 (2023-001)
Significant Deficiency 2023
Federal Agency: Department of Housing and Urban Development Pass Through Agency: Pennsylvania Department of Community and Economic Development Program: Community Development Block Grants/ State's Program and Non-Entitlement Grants in Hawaii (CDBG), ALN 14.228 Criteria: In accordance with 2 CFR Pa...
Federal Agency: Department of Housing and Urban Development Pass Through Agency: Pennsylvania Department of Community and Economic Development Program: Community Development Block Grants/ State's Program and Non-Entitlement Grants in Hawaii (CDBG), ALN 14.228 Criteria: In accordance with 2 CFR Part 200.303, a non-Federal entity must establish and maintain effective internal control over Federal awards that provide reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition: The City did not have a process in place to obtain invoices or other supporting documentation from the subrecipient to ensure that the CDBG funding was spent on activities allowed and allowable costs prior to reimbursing the subrecipient. Subsequent to making the 2023 payments to the subrecipient, the City obtained the invoices for review. Cause: The City did not have procedures in place to ensure that the CDBG invoices to support payments to the subrecipient were obtained and reviewed. Effect: The lack of internal control processes to review supporting documentation to ensure compliance with federal requirements prior to payments being made to subrecipients could result in unallowable costs to occur and not be detected prior to payment of funding to the subrecipient. Questioned costs: Unknown Recommendation: We recommend that the City obtains invoice support for all reimbursement requests from the subrecipient prior to payment. These requests should be reviewed for allowable activities and allowable costs by an individual knowledgeable of the program requirements prior to approving for payment. This review should be documented. View of Responsible Officials and Planned Corrective Action: Mayor and City Clerk will be responsible for corrective action. The City will obtain invoice support for all reimbursement requests from the subrecipient PRIOR to payment. These requests will be reviewed for allowable activities and allowable costs by the Mayor of the City of Butler prior to payment. This review (invoices) will be documented and saved in a file on the clerk's computer. Trigger for the mayor to review invoices will be the email from DCED requesting signatures from the Mayor and the City Clerk. The procedures for reviewing all payment requests shall begin July, 2024 and shall be ongoing.
View Audit 310881 Questioned Costs: $1
Management agrees with the finding that the Period 4 Provider Relief Fund report included expenses for utility and insurance expenditures that were not directly related to the District's prevention, preparation and/or response to the COVID-19 pandemic. Management reviewed HRSA guidance and examples...
Management agrees with the finding that the Period 4 Provider Relief Fund report included expenses for utility and insurance expenditures that were not directly related to the District's prevention, preparation and/or response to the COVID-19 pandemic. Management reviewed HRSA guidance and examples of allowable expenses prior to completing Period 4 Provider Relief Fund reporting and concluded these expenses were considered allowable as general and administrative expenses incurred during our response to the COVID-19 pandemic. Management notes that expenses and lost revenue reported exceed the amount of PRF funding received even if these expenses were excluded. We have taken corrective action for the review of completeness and accuracy for inclusion of allowable expenditures. PRF reporting, subsequent to this audit, will be reviewed prior to submission to ensure accuracy of reporting. Chief Financial Officer, Marie Castro, is responsible for ensuring the corrective action plan is followed. The corrective action plan will be implemented on June 30, 2024.
View Audit 310873 Questioned Costs: $1
Finding 2023-002: Overdrawn Federal Funding Condition The auditors identified duplicated federal award expenditures amounting to $380,644, resulting in overdrawn federal funds by $380,644. The excess cash on hand was not returned to the funding source in a timely manner. Correction action: NACDD has...
Finding 2023-002: Overdrawn Federal Funding Condition The auditors identified duplicated federal award expenditures amounting to $380,644, resulting in overdrawn federal funds by $380,644. The excess cash on hand was not returned to the funding source in a timely manner. Correction action: NACDD has experienced drastic change in size over the past 3-4 years. Current policies and procedures have not been adequate for the size and volume of the transactions experienced in FY 23. In addition, there has been significant finance/accounting staff turnover including leadership of the Finance team. +The impact of this deficiency was isolated to one cooperative agreement which closed out as of 9.30.23. NACDD performed efficient and effective subsequent disbursement procedures after year end to ensure that expenses for this grant and others were recorded in the appropriate fiscal year. In the process of preparing the FFR and researching further additional expenditures related to this grant, expenses included in the initial subsequent disbursement adjustments, related to this grant were duplicated. +The Correction action plan includes previously implemented augmentation of the Finance staff. Since the end of the FY 23 fiscal year, the finance department has been fully staffed with knowledgeable accounting professionals, many who have financial federal grant experience. There is now a financial analyst on staff whose main responsibility is to reconcile and record federal grant expenditures and receivables. This process is done monthly. We believe that this additional procedure will eliminate the recurrence of this and any other like issues. Procedures related to the weekly PMS drawdown have been expanded to include reconciling the accounts receivable by grant with the PMS accounts to allow only amounts listed in PMS which are supported with appropriate expenditures to be drawn. +Implementation of corrective measures: The above expanded procedures and oversight have been in effect for most of the FY 24 fiscal year. PMS drawdowns are now done weekly with worksheets that tie in detail to the weekly expenditures. In addition, a control checklist will be created and utilized by the Finance staff leadership to monitor and document the successful implementation of corrective measures. + Additional over-arching controls – The Finance team will execute an interim audit process inhouse as of 6.30.24 and every year going forward to further identify errors and irregularities that may exist. If necessary, additional policies and procedures will be implemented to provide greater scope and assurance in preventing financial reporting errors. Responsible Person Trish H. Strong, CFO Anticipated completion date June 30, 2024
View Audit 310859 Questioned Costs: $1
Corrective Action: As part of DRW’s internal control revision, we will enhance policies and practices associated with reporting including the semi-annual SF-425. Steps: 1. DRW will review current systems and tools in use for reporting and complying with Federal award reporting requirements and modif...
Corrective Action: As part of DRW’s internal control revision, we will enhance policies and practices associated with reporting including the semi-annual SF-425. Steps: 1. DRW will review current systems and tools in use for reporting and complying with Federal award reporting requirements and modify or implement systems or tools that are more reliably accurate than current systems and tools. 2. DRW will implement internal controls that require the preparation and review of federal reporting requirements by two distinct people at DRW. 3. DRW will implement a reporting calendar and review regularly to ensure activities including preparation and review are being performed regularly and consistently. Anticipated completion September 30, 2024.
Corrective Action: DRW will review and revise it cost allocation and program income documentation. Steps: Review current policies, procedures, and internal control documentation. Review will include agency cost allocation method and implementation as well as program income documentation. 1. DRW will...
Corrective Action: DRW will review and revise it cost allocation and program income documentation. Steps: Review current policies, procedures, and internal control documentation. Review will include agency cost allocation method and implementation as well as program income documentation. 1. DRW will update internal controls based on the suggestions for process, procedural and internal control improvement made by outside consultants. Suggestions will include the use of project codes in payroll documentation. 2. Review supporting records, level of effort and timekeeping systems to ensure proper level of documentation. 3. DRW supervisors will be trained on expectations of oversight and participate in quarterly review of financial status to ensure proper implementation. 4. The process will be implemented by the Fiscal Manager, the Comptroller and the Fiscal and Operations Specialist and overseen by the Executive Director. Anticipated Completion: September 30, 2024
View Audit 310821 Questioned Costs: $1
Expenditures submitted for the Alabama Medicaid Administrative Claiming program included expenditures supported by federal funds and undocumented costs. Contact: Dr. Brock Nolin, Superintendent ...
Expenditures submitted for the Alabama Medicaid Administrative Claiming program included expenditures supported by federal funds and undocumented costs. Contact: Dr. Brock Nolin, Superintendent Corrective Action: Claims will be adjusted to correct the duplication of federal funds and undocumented costs. Policies and procedures will be implemented according to the recommendations found in the Schedule of Findings and Questioned Costs. Proposed Completion Date: Prior to the submission of the July-September 2024 claim.
View Audit 310807 Questioned Costs: $1
Written Policies Required by the Uniform Guidance. Auditor Description of Condition and Effect. The Organization lacks written policies around federal awards for payments, procurement, and allowability of costs charged to federal programs. The Organization is exposed to an increased risk of noncompl...
Written Policies Required by the Uniform Guidance. Auditor Description of Condition and Effect. The Organization lacks written policies around federal awards for payments, procurement, and allowability of costs charged to federal programs. The Organization is exposed to an increased risk of noncompliance due to a lack of established written policies. Auditor Recommendation. The Organization should establish written policies that address how payments, procurement, and allowability of costs charged to federal programs are handled for federal awards. Corrective Action. The Organization is reviewing their policies and drafting new policies to address these areas. Anticipated Completion Date. September 30, 2024
Item 2023-001- Special Tests and Provisions - Wage Rate Requirements Recommendation: 2 CFR 200.303 requires the non-Federal entity to "(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non- Federal entity is managing the Federa...
Item 2023-001- Special Tests and Provisions - Wage Rate Requirements Recommendation: 2 CFR 200.303 requires the non-Federal entity to "(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non- Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award." 2 CFR 200.326 and 29 CFR Part 5, Labor Standards Provisions Applicable to Contracts Governing Federally Financed and Assisted Construction (DOL Regulations) require the contractor or subcontractor to submit to the nonfederal entity weekly, for each week in which any contract work is performed, a copy of the payroll and a statement of compliance (certified payrolls). We recommend the strengthening of controls to ensure the prevailing wage rate clauses are included in the contracts and that certified payrolls are received for each week in which construction work is performed. The Chief School Financial Officer, Jessica Pettway, should review documentation for inclusion of the prevailing wage rate clauses in construction contracts as part of the bid process prior to expenditures being made. She should also review all invoices received from contractors and subcontractors to ensure that the certified payroll information is received for all weeks for which construction work is performed. Action Taken: Management has reviewed the requirements of 2 CFR Section 200.303 and 2 CFR 200.326 relating to wage rate requirements and agrees with the recommendation. Management has already communicated with all contractors and subcontractors regarding the wage rate requirements and has implemented additional procedures, effective July 1, 2023, stating that the Chief School Financial Officer, Jessica Pettway, will review documentation for inclusion of the prevailing wage rate clauses in construction contracts as part of the bid process prior to expenditures being made. She will also review all invoices received from contractors and subcontractors to ensure that the certified payroll information is received for all weeks for which construction work is performed.
View Audit 310758 Questioned Costs: $1
Management acknowledges that there were deficiencies in the process at the beginning of the fiscal year, which is why the organization changed payroll systems. The issue in question is from the time that the organization was transitioning to the new system. This matter was addressed. We also establi...
Management acknowledges that there were deficiencies in the process at the beginning of the fiscal year, which is why the organization changed payroll systems. The issue in question is from the time that the organization was transitioning to the new system. This matter was addressed. We also established a Grants Compliance Team that will be responsible for the compliance oversight of awards and added checks and balance to ensure award expenses are allowable and allocable.
Adjustments to payroll distributions, including changes in pay rates, must be requested and documented in writing by department supervisor and reviewed by the payroll manager as well as the grant accountant responsisble for the grant funding source. All requests will be included in the employee's fi...
Adjustments to payroll distributions, including changes in pay rates, must be requested and documented in writing by department supervisor and reviewed by the payroll manager as well as the grant accountant responsisble for the grant funding source. All requests will be included in the employee's file as part of the HRIS.
View Audit 310726 Questioned Costs: $1
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