Corrective Action Plans

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Contact Person – Superintendent, Dr. Erich Heise Corrective Action Plan – The District will review their payroll procedures to ensure the correct amounts are charged to grants and all supporting documentation is maintained. Completion Date – Ongoing
Contact Person – Superintendent, Dr. Erich Heise Corrective Action Plan – The District will review their payroll procedures to ensure the correct amounts are charged to grants and all supporting documentation is maintained. Completion Date – Ongoing
Corrective Action/Management Response: The accounting for employee hours requires the review of timesheets to verify employees are recording scheduled hours appropriately. In conjunction with this review, changes may be required to timesheets. To verify that changes need to be made and then have be...
Corrective Action/Management Response: The accounting for employee hours requires the review of timesheets to verify employees are recording scheduled hours appropriately. In conjunction with this review, changes may be required to timesheets. To verify that changes need to be made and then have been made correctly, the review of a “Time Entry Hours Report” has been incorporated into our payroll processing. This report records the number of hours an employee is being paid. This report is reviewed numerous times within the payroll process, prior to the “true up” changes and after changes for verification of accuracy. Proposed Completion Date: May 2023
1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: Management is aware of the condition and has taken the proper steps to ensure compliance in the future. 3. Official Responsible for Ensuring CAP: Tegan Gillu...
1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: Management is aware of the condition and has taken the proper steps to ensure compliance in the future. 3. Official Responsible for Ensuring CAP: Tegan Gillund, Director of Operations, is the official responsible for ensuring corrective action. 4. Planned Completion Date for CAP: June 30, 2024. 5. Plan to Monitor Completion of CAP: The report that is generated each month to report expenditures to the Board will now be monitored each month by the accounting staff and Board finance committee to ensure all transactions are included in the report.
1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: Management is aware of the condition and has taken the proper steps to ensure compliance in the future. 3. Official Responsible for Ensuring CAP: Tegan Gillu...
1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: Management is aware of the condition and has taken the proper steps to ensure compliance in the future. 3. Official Responsible for Ensuring CAP: Tegan Gillund, Director of Operations, is the official responsible for ensuring corrective action. 4. Planned Completion Date for CAP: June 30, 2024. 5. Plan to Monitor Completion of CAP: The report that is generated each month to report expenditures to the Board will now be monitored each month by the accounting staff and Board finance committee to ensure all transactions are included in the report.
Agency: Child Care Resource Center, Inc. Name of contact person and title: Jennifer Dodge, Executive Director Anticipated completion date: December 31, 2023 Agency’s response: Concur Child Care Resource Center, Inc. agrees with this finding and will implement the following: • Distribute and train th...
Agency: Child Care Resource Center, Inc. Name of contact person and title: Jennifer Dodge, Executive Director Anticipated completion date: December 31, 2023 Agency’s response: Concur Child Care Resource Center, Inc. agrees with this finding and will implement the following: • Distribute and train the staff on what costs are allowable and unallowable under federal programs. • During the review process of billing for reimbursement increased oversight of credit card disbursements submitted with the billings.
Finding 7068 (2023-006)
Significant Deficiency 2023
Finding 2023-006 Name of contact person: Corrective Action: Proposed completion date: Jessica Hill, Food and Nutrition Services Supervisor Training will be conducted in December 2023 in the following noted areas: Reviewing OVS ESC tab for all household members and related quarters to question each e...
Finding 2023-006 Name of contact person: Corrective Action: Proposed completion date: Jessica Hill, Food and Nutrition Services Supervisor Training will be conducted in December 2023 in the following noted areas: Reviewing OVS ESC tab for all household members and related quarters to question each employer listed in related quarters. Training of documentation of termination wages and verification sources to verify earned income. Conduct a documentation training exercise to ensure verification of all expenses given as a deduction. Review acceptable forms of verification for deductions given. Conduct an earned income exercise to review base period requirements and calculation of correct gross amount to determine correct earned income for the FNS unit. Review of documentation procedures and referencing to The Work Number verifying employment terminations for applicable employers. Review of policy sections 305, 300, and 310. Second party reviews focused around income calculations, verifications, correct base period used and documentation, and verification of deductions given to FNS unit. Ensure staff understands base period for earned income, the importance of documenting case file and providing correct verification to support action taken on case file. December 2023 Section IV - State Award Findin
The Company agrees with the finding. The Company will implement a process for a member of the finance staff to prepare lost revenues calculations. The Director of Finance will then provide a second layer of detailed review on the lost revenue calculations and the financial reporting to ensure amount...
The Company agrees with the finding. The Company will implement a process for a member of the finance staff to prepare lost revenues calculations. The Director of Finance will then provide a second layer of detailed review on the lost revenue calculations and the financial reporting to ensure amounts captured are accurate and categorized appropriately. Sign off on preparation and review will be documented appropriately.
Dec 19, 2023 Donovan CPAs 5151 E. U.S. HWY 36 Avon, IN 46123 Detailed below is the Official Response to Audit Results and Comments relative to the review of Muncie Public Charter School of Inquiry, Inc.’s (“the School”) compliance with provisions of the Accounting and Uniform Compliance Guidelines M...
Dec 19, 2023 Donovan CPAs 5151 E. U.S. HWY 36 Avon, IN 46123 Detailed below is the Official Response to Audit Results and Comments relative to the review of Muncie Public Charter School of Inquiry, Inc.’s (“the School”) compliance with provisions of the Accounting and Uniform Compliance Guidelines Manual for Indiana Charter Schools issued by the Indiana State of Accounts. Audit Results and Comment: III. Federal Award Findings and Questioned Costs FINDING 2023-001 TIME AND EFFORT RECORDS SIGNIFICANT DEFICIENCY Federal Program: Education Stabilization Fund Assistance Listing Numbers: 84.425D and 84.425U Condition: The School applied employee salary expenses to the program. While employees were applied to the grant in line with the approved budget, proper time and effort records were not maintained. Semi-annual certification forms did not reflect a six-month period and were not signed at the end of the six-month period. Criteria: Charges for Federal awards for salaries and wages must be based on records that accurately reflect work performed (2 CFR 200.430(i)). Cause: The School was not aware of the requirement outlined in the Criteria section above. Effect: The School is unable to document certification of employee time spent in the program. Recommendation: We recommend the School develop internal controls to ensure that proper semi-annual certifications are maintained. Views of Responsible Officials and Planned Corrective Actions: The School’s Corrective Action Plan is included on page 2. Response: The financial manager, Ana Maric, will submit completed semi-annual certification forms for all employees paid from Title I, Part A; IDEA, Part B (611), and ESSER III for the period of July 01, 2023 to Dec 31,2023 to Donovan CPA for review by January 15, 2024. In addition, semi-annual certification forms will be completed for individuals paid by federal grants and will reflect six-month certification periods to be signed by the employee’s supervisor at the end of the six-month period. In order to maintain this, there will be internal checks and balances every six months to review with the Executive Director, Leslie Draper. Leslie Draper Executive Director Inspire Academy- A School of Inquiry 2801 E. 16th St. Muncie, IN 47302
Finding 7005 (2023-001)
Significant Deficiency 2023
Views of Responsible Officials: The Foundation informed the auditors prior to the start of the audit fieldwork that staffers who worked on the federal program did not code their time, on their timesheet, to the grant. However, the Foundation has alternative tracking mechanisms to identify the federa...
Views of Responsible Officials: The Foundation informed the auditors prior to the start of the audit fieldwork that staffers who worked on the federal program did not code their time, on their timesheet, to the grant. However, the Foundation has alternative tracking mechanisms to identify the federal and nonfederal program work (by week) via a staffing list that specifically identifies the federal program weeks. The Foundation did not effectively communicate the requirement for the newly hired staffers for the spring program, even though it was communicated to other various programs throughout the year. The Foundation made the determination to not open closed timesheet periods to make the necessary changes and instead, made an allocation entry for the proper amount. The Foundation has made managers aware of the issue so that they can be mindful during the timesheet approval process. Moving forward, Finance will request a staffing list, monthly, to confirm hours are properly coded and ensure proper timesheet training. For the record, the Foundation always bills the federal government correctly.
Segregation of Duties - ESSER Assistance Listing Number(s) 84.425D, 84.425U Recommendation: CLA recommends the District review its processes related to general disbursements for grants and implement a control where someone other than the Finance Director is reviewing disbursements coded to grant pro...
Segregation of Duties - ESSER Assistance Listing Number(s) 84.425D, 84.425U Recommendation: CLA recommends the District review its processes related to general disbursements for grants and implement a control where someone other than the Finance Director is reviewing disbursements coded to grant project codes to help ensure compliance with grant requirements. We also recommend that the District implement a formal review process over the reporting requirement relating to ESSER annual reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: For each Federal or State award another administrator other than the Finance Director will be identified as a reviewer. The reviewer will assist in the budget development for the grant, if applicable, and review claim documentation prior to being submitted. Name(s) of the contact person(s) responsible for corrective action: Kevin Yeske. Planned completion date for corrective action plan: June 30, 2024.
Finding Number: 2023-001 Condition: Controls in place did not identify an inaccurate calculation of assistance. Planned Corrective Action: The grant is complete for payment for direct assistance to eligible participants. Contact person responsible for corrective action: Gail Montgomery, Vice Preside...
Finding Number: 2023-001 Condition: Controls in place did not identify an inaccurate calculation of assistance. Planned Corrective Action: The grant is complete for payment for direct assistance to eligible participants. Contact person responsible for corrective action: Gail Montgomery, Vice President of Finance Anticipated Completion Date: August 30, 2023
2023-002 Application of Sliding Fee Discount Corrective action planned: Management has implemented an improved education and training procedures for the registration staff to ensure all required patient information is recorded properly. Management will perform random audits throughout the year to en...
2023-002 Application of Sliding Fee Discount Corrective action planned: Management has implemented an improved education and training procedures for the registration staff to ensure all required patient information is recorded properly. Management will perform random audits throughout the year to ensure 100 percent compliance. Anticipated completion date: January 31, 2024 Contact person responsible for corrective action: John Church, Chief Financial Officer
Landesa has changed it's timesheet approval process so now all employee timecards are approved prior to payroll being paid. Additionally, the approval process was changed from being a manual process to an electronic system that is integrated with other payroll and timekeeping processes. Contact pe...
Landesa has changed it's timesheet approval process so now all employee timecards are approved prior to payroll being paid. Additionally, the approval process was changed from being a manual process to an electronic system that is integrated with other payroll and timekeeping processes. Contact person: Director of Finance and Anticipated completion date: November 2023
Deficiency Identified: Federal Award Findings and Questioned Costs: Significant Deficiency – Controls Related to Charging Expenses to Programs Response to Deficiency: We concur with the finding. Corrective Action Plan (Action taken to correct specific deficiency identified): Worker’s Compensation ...
Deficiency Identified: Federal Award Findings and Questioned Costs: Significant Deficiency – Controls Related to Charging Expenses to Programs Response to Deficiency: We concur with the finding. Corrective Action Plan (Action taken to correct specific deficiency identified): Worker’s Compensation and State Unemployment Tax expenses will be reallocated based on the methods outlined in the Correction Action Plan for Finding 2023-001. Preventative Action Plan: (Action taken to prevent the reoccurrence of this problem in the future): We will perform a periodic review of cost allocation practices to ensure that costs are being allocated properly and any further corrective action will be taken timely on any discrepancies. Responsible Personnel: Tina Bonner, Controller Projected Completion Date: March 31, 2024
Deficiency Identified: Federal Award Findings and Questioned Costs: Question Costs – Charges in Excess of Costs Incurred Response to Questioned Costs: We concur with the question costs. Corrective Action Plan (Action taken to correct specific deficiency identified): We have made applicable credits...
Deficiency Identified: Federal Award Findings and Questioned Costs: Question Costs – Charges in Excess of Costs Incurred Response to Questioned Costs: We concur with the question costs. Corrective Action Plan (Action taken to correct specific deficiency identified): We have made applicable credits to respective Federal programs for the questioned costs. Preventative Action Plan: (Action taken to prevent the reoccurrence of this problem in the future): In the future, we plan to recalculate Worker’s Compensation expense quarterly and make adjustments as needed and we plan to allocate State Unemployment Tax quarterly based upon direct labor hours. Responsible Personnel: Tina Bonner, Controller Projected Completion Date: December 31, 2023
View Audit 8855 Questioned Costs: $1
Finding Number: 2023-001 Condition: The Hospital's controls in place for submitting expenses did not identify that several invoices and related expense amounts were duplicated in the addendum to the period 1 submission. As a result, period 1 addendum submission included expenses that were deemed una...
Finding Number: 2023-001 Condition: The Hospital's controls in place for submitting expenses did not identify that several invoices and related expense amounts were duplicated in the addendum to the period 1 submission. As a result, period 1 addendum submission included expenses that were deemed unallowable as they had already been utilized to support funding received. Reimbursement for, the original period 1 submission contained retention bonus costs that exceeded 20% of total funds awarded. Planned Corrective Action: The Hospital will review its processes surrounding submission of expenses to MHA and implement additional layers of review. Contact person responsible for corrective action: Brenda Winn and Alex Roehling Anticipated Completion Date: 9/30/2023
2023-002 Compliance and Internal Controls over Allowable Costs (Significant Deficiency) Assistance Listing Number 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds 2022-2023 Funding U.S. Department of Treasury Recommendation: The Agency should update its payroll allocation spr...
2023-002 Compliance and Internal Controls over Allowable Costs (Significant Deficiency) Assistance Listing Number 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds 2022-2023 Funding U.S. Department of Treasury Recommendation: The Agency should update its payroll allocation spreadsheets to agree with the approved timesheets per payroll period to ensure only allowable payroll costs are charged to grants. Corrective Action: The Agency had a turnover of finance staff in 2022-23 that created an inconsistent review of the allocation spreadsheet. The Agency did not receive reimbursements from any grantor due to an error in the allocation calculations. The allocation spreadsheet and timesheets will be reconciled as part of the monthly close. Responsible Party: Senior Accountant and Director of Human Resources Date Expected to be Corrected: Immediately If the U.S. Department of Treasury and U.S. Department of Veteran Affairs have any questions regarding this plan, please contact Nkechi “Nikki” Agwuenu, new CEO, at 713.754.7083
View Audit 8806 Questioned Costs: $1
2023-002 Compliance and Internal Controls over Allowable Costs (Significant Deficiency) Assistance Listing Number 64.033 VA Supportive Services for Veteran Families, VA Supportive Services for Veteran Families – Shallow Subsidy, and VA Supportive Services for Veteran Families – Legal Services 20...
2023-002 Compliance and Internal Controls over Allowable Costs (Significant Deficiency) Assistance Listing Number 64.033 VA Supportive Services for Veteran Families, VA Supportive Services for Veteran Families – Shallow Subsidy, and VA Supportive Services for Veteran Families – Legal Services 2021-2022 and 2022-2023 Funding U.S. Department of Veteran Affairs Recommendation: The Agency should update its payroll allocation spreadsheets to agree with the approved timesheets per payroll period to ensure only allowable payroll costs are charged to grants. Corrective Action: The Agency had a turnover of finance staff in 2022-23 that created an inconsistent review of the allocation spreadsheet. CRR did not receive reimbursements from any grantor due to an error in the allocation calculations. The allocation spreadsheet and timesheets will be reconciled as part of the monthly close. Responsible Party: Senior Accountant and Director of Human Resources Date Expected to be Corrected: Immediately If the U.S. Department of Treasury and U.S. Department of Veteran Affairs have any questions regarding this plan, please contact Nkechi “Nikki” Agwuenu, new CEO, at 713.754.7083
View Audit 8806 Questioned Costs: $1
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Kelso Housing Authority April 1, 2022 through March 31, 2023 This schedule presents the corrective action the Authority is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regula...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Kelso Housing Authority April 1, 2022 through March 31, 2023 This schedule presents the corrective action the Authority 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: 2023-001 Finding caption: The Housing Authority had inadequate internal controls for ensuring compliance with depository agreement requirements for its Section 8 Housing Choice Voucher program. Name, address, and telephone of Authority contact person: Joleen Reece, Executive Director 360-423-3490 1415 S. 10th Avenue Kelso, WA 98626 Corrective action the auditee plans to take in response to the finding: The Authority has initiated the change to an interest-bearing arrangement for the HCV bank account as of December 5, 2023. Anticipated date to complete the corrective action: January 1, 2024.
Responsible Party Name: Fred Gibbs Position: President, Management Agent Telephone Number: (913) 709-1811 Federal Agency U.S. Department of Housing and Urban Development Federal Program Supportive Housing for the Elderly (Section 202) Compliance Requirements A/B – Activities Allowed or Unallowed and...
Responsible Party Name: Fred Gibbs Position: President, Management Agent Telephone Number: (913) 709-1811 Federal Agency U.S. Department of Housing and Urban Development Federal Program Supportive Housing for the Elderly (Section 202) Compliance Requirements A/B – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Auditee’s Comments on Finding We agree with the auditors’ finding. Corrective Action We will follow procedures to ensure expenditures include supporting documentation before they are posted to the general ledger, and we will review the accuracy / completeness of the documentation prior to making payment. Anticipated Completion Date December 31, 2023
Finding 2023-005 Activities Allowed or Unallowed – Child Nutrition Cluster Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: The District does not have an internal control system designed to review and maintain documentation for federal expenditures, s...
Finding 2023-005 Activities Allowed or Unallowed – Child Nutrition Cluster Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: The District does not have an internal control system designed to review and maintain documentation for federal expenditures, specifically documentation of changes to contract wage rates or evidence of approved timesheets. Responsible Individuals: Shannon Hunstad, Superintendent Corrective Action Plan: The District will review and strengthen the controls surrounding the review and approval of allowable costs in the Child Nutrition Cluster to ensure they are supported, approved, and accurate. Anticipated Completion Date: June 30, 2024
View Audit 8699 Questioned Costs: $1
Finding 6653 (2023-004)
Material Weakness 2023
Finding 2023-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The operations of HealthCenter Northwest, LLC (HC) were consolidated into Kalis...
Finding 2023-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The operations of HealthCenter Northwest, LLC (HC) were consolidated into Kalispell Regional Medical Center d/b/a Logan Health Medical Center (LHMC) as of December 31, 2020. When LHMC calculated their lost revenues, they included HC’s revenue for both 2020 and 2021 instead of only the 2021 information. This resulted in LHMC reporting higher lost revenues than the detailed reports supported in Period 3. This was corrected in Period 4 reporting. Responsible Individuals: Craig Lambrecht, CEO and Cole Turner, CFO Corrective Action Plan: The lost revenue calculation will be re-evaluated and the amount of lost revenue reported on the HHS reporting portal has been updated in Period 4. Completion Date: 12/31/23
Finding 6652 (2023-003)
Material Weakness 2023
Finding 2023-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: In some of the quarters for certain entities, it was noted that bad debt expens...
Finding 2023-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: In some of the quarters for certain entities, it was noted that bad debt expenses were higher than revenues, creating a negative revenue for the quarter. As the HHS reporting portal would not allow negative amounts to be entered, a zero was entered into the HHS reporting portal. These negative amounts should have been offset to other quarters or other revenue line items, but were not, which resulted in higher revenue amounts being reported than the detailed reports supported for two locations for Period 3. Responsible Individuals: Craig Lambrecht, CEO and Cole Turner, CFO Corrective Action Plan: The lost revenue calculation for these two locations will be re-evaluated and the amount of lost revenue reported on the HHS reporting portal will be updated in future periods. Anticipated Completion Date: Ongoing
Finding 6651 (2023-002)
Significant Deficiency 2023
Finding 2023-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: There was no formal documentation of review and approval for overall expenses c...
Finding 2023-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: There was no formal documentation of review and approval for overall expenses claimed, calculation of lost revenue, or the Corporation’s special report by a separate individual outside of the preparer at 1 entity. Responsible Individuals: Craig Lambrecht, CEO and Cole Turner, CFO Corrective Action Plan: All tracking documents and reports will be reviewed by someone other than the preparer at all locations. The reviewer will sign off by email or by physical signature that they have reviewed and agree with the support. Anticipated Completion Date: 12/31/2023
Condition: Semi-annual time and effort certifications were not maintained for a grant employee whose salaries and wages were not supported by detailed time records. Corrective Action Planned: Management is aware of the missing time and effort certifications for the single grant employee. This err...
Condition: Semi-annual time and effort certifications were not maintained for a grant employee whose salaries and wages were not supported by detailed time records. Corrective Action Planned: Management is aware of the missing time and effort certifications for the single grant employee. This error was in part due to the transition of both the Payroll Coordinator and Budget Analyst positions within Canton Public Schools. Controls have been put in place to ensure all time and effort certifications are completed and submitted to the business office in a timely manner. Anticipated Completion Date: Completed Contact: Stephen Marshall, Assistant Superintendent of Finance & Operations
View Audit 8590 Questioned Costs: $1
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