Corrective Action Plans

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Finding 2022-003Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID 19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs Princ...
Finding 2022-003Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID 19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs PrinciplesFinding Summary: Our special report submitted to the Department of Health and Human Services for Period 1 and 2 for TIN #460242831 did not have the formal documentation of a secondary review or approval. Our lost revenue calculation was based on actual revenue billed and reported within our financial software. It was found that we had immaterial unexplained variances in the Period 1 report. In addition, we did not consider the impact of the retroactive Medicaid reimbursement adjustment applicable to quarter 3 and 4 of 2021 on the Period 2 report.Responsible Individuals: Loren Diekman, Interim President/CEOCorrective Action Plan: We will enhance the review process over special reports and ensure the lost revenue calculation when applicable will include any retro Medicaid reimbursement adjustments.Anticipated Completion Date: March 31, 2023
Finding 2022-002Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Princi...
Finding 2022-002Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and ReportingFinding Summary: During testing, the following were identified:- Expenses were claimed under the program which were incurred prior to the Organization preparing, preventing, and responding to COVID. Actual costs of $51,160.- Payroll expenses claimed under the program were calculated for three employees with the current hourly wage rate rather than the hourly wage rate effective during the period of time COVID hours were claimed under the program. Actual costs of $3,360 with projected costs of $9,751.- One employee?s specific COVID related hours were claimed twice under the program. Actual costs of $24,096.- FICA payroll expenses were claimed twice under the program. Actual costs of $3,685.- Additional COVID payroll expenses were identified by management; however, due to a clerical error, these payroll expenses were not included in the special report submitted to HHS for Period 2 TIN #460233030 totaling $135,096.- The Organization included these expenses in the special reports submitted to the Department of Health and Human Services (HHS) for Period 2 TIN #460233030 and TIN #237072116 which caused the reports to be inaccurate. The Organization?s special reports submitted to HHS had no formal documentation of a secondary review or approval.Responsible Individuals: Stephan Wilson, Chief Financial Officer, Carol Peterson, Director of Finance, Stacy Flahaven, Accounting ManagerCorrective Action Plan: More time and attention will be given to calculating, gathering, and reporting amounts for future awards. Review and approval of federal reports will be performed by separate individuals. Both the review and approval will be formally documented by signing and dating upon completion. There are no future reporting requirements under this federal award.Anticipated Completion Date: June 30, 2023
2022-002 Department of Health and Human ServicesFederal Financial Assistance Listing #93.498COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionApplicable Federal Award Number and Year ? Period 2 and Period 3 TIN #711018775Activities Allowed or Unallowed and Allowable Cost...
2022-002 Department of Health and Human ServicesFederal Financial Assistance Listing #93.498COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionApplicable Federal Award Number and Year ? Period 2 and Period 3 TIN #711018775Activities Allowed or Unallowed and Allowable Costs/Cost PrinciplesMaterial Weakness in Internal Control Over ComplianceReportingMaterial Weakness in Internal Control Over Compliance and Material NoncomplianceCondition: There was a lack of review and approval over Period 2 Provider Relief Funds lost revenue calculation and reporting. For Period 2 and Period 3, the Organization?s lostrevenue calculation did not take into consideration applicable audit adjustments for fiscal years 2021 and 2022. In addition, the Period 2 lost revenue on the Special Report to HHS did not agree to the supporting documentation.Cause: The Organization did not have an internal control process in place to ensure review and approval of the lost revenue calculation claimed under the federal program and the report submitted to the Department of Health and Human Services (HHS) for Period 2. In addition, without the inclusion of the audit adjustments, the revenue included in Period 2 and Period 3 was not materially correct.Management?s Response and Corrective Action Plan:Management placed an internal control process prior to review done for period 3 and approved the lost revenue calculation prior to submittal to the Department of Health and Human Services (HHS).Responsible Individuals: VP of Finance and Administration.Anticipated Completion Date: 1/1/2023
Corrective Action PlanYear Ended June 30, 2022Finding 2022-001: HEERF ReportingCondition Found:In the review of the quarterly reporting requirement for the student aid portion, the auditors noted the University did not modify its student aid portion reporting to the quarterly requirement, but rathe...
Corrective Action PlanYear Ended June 30, 2022Finding 2022-001: HEERF ReportingCondition Found:In the review of the quarterly reporting requirement for the student aid portion, the auditors noted the University did not modify its student aid portion reporting to the quarterly requirement, but rather the University provided updates every 45 days from the date of the first student award made. The University subsequently corrected the reporting in late fiscal year 2022 and posted the quarterly reports; however they were not posted timely, as required. In addition, the auditors noted that the University?s annual report for the year ended December 31, 2021, reported certain data elements that did not agree with supporting documentation.Recommendation:Given the nature of the pandemic funding, and the evolving guidance of the compliance requirements, the auditors recommended management enhance its process level controls over reporting requirements for HEERF to ensure timely and accurate reporting in accordance with the stated reporting requirements.University of Delaware Corrective Action Plan:The University of Delaware (UD or the University) agrees that the evolving guidance created challenges in maintaining compliance. Controls over reporting requirements are expected to function effectively now that the reporting requirements are finalized.The HEERF reporting guidelines final changes required schools to change student reporting from the 15/30-day requirement to quarterly reporting. UD continued to report on a more frequent basis for student reporting. Having conferred with the Department of Education (the Department) contact, UD was required to go back and add the quarterly reports. The required forms were completed and updated on the website in August 2022.The University?s annual report for the year ended December 31, 2021, was submitted in a timely manner. However, the University is required to review and update the reported enrollment and disbursements to students based on a review by the Department. Student Financial Services (SFS) has reviewed the final disbursements as of December 31, 2021, and will only report on those disbursements claimed by students. Unclaimed funds, which have been reallocated to other students, inflated the dollar amount actually provided to students, and will no longer be included. The Department has also provided guidance to the University on the enrollment reporting. The report has been updated and was submitted to the Department of Education during the open period in March 2023.Completion Date:HEERF Student Reporting: August 2022HEERF Annual Report: March 2023Contact Person:Mary Booker, Executive Director, Student Financial Services
Corrective Action PlanYear Ended June 30, 2022Finding 2022-004: AllowabilityCondition Found:In the auditors? testing over allowability of cost, they identified one transaction in a sample of 40 non-payroll transactions for which the University paid and allocated the cost, however, the service contra...
Corrective Action PlanYear Ended June 30, 2022Finding 2022-004: AllowabilityCondition Found:In the auditors? testing over allowability of cost, they identified one transaction in a sample of 40 non-payroll transactions for which the University paid and allocated the cost, however, the service contract period had not yet started. In addition, the auditors identified a second transaction for an intergovernmental personnel agreement (in the same sample of 40 non-payroll transactions) which included an advance on future service.Recommendation:The auditors recommend the University enhance the level of precision around its internal control over compliance related to the timing of allocating and charges costs.University of Delaware Corrective Action Plan:The University agrees with this finding. The questioned costs will be removed from the grant charged. Additionally, the University will provide additional education and awareness over the billing of federal awards to ensure that expenses relate to the period being billed and services being performed.Anticipated Completion Date:July 2023Contact Person:Jeff Friedland, Associate Vice President for Research
View Audit 311956 Questioned Costs: $1
The City of Homewood, Alabama respectfully submits the following corrective action plan for the year ended September 30, 2022.Name and address of independent public accounting firm:BMSS, LLC1121 Riverchase Office RoadBirmingham, Alabama 35244Single Audit Period: September 30, 2022The finding from th...
The City of Homewood, Alabama respectfully submits the following corrective action plan for the year ended September 30, 2022.Name and address of independent public accounting firm:BMSS, LLC1121 Riverchase Office RoadBirmingham, Alabama 35244Single Audit Period: September 30, 2022The finding from the September 30, 2022, schedule of findings and questioned costs is discussed below.The finding is numbered consistently with the number assigned to the schedule.Financial Statement FindingsNoneFederal Awards FindingFinding 2022-001The late completion of the City of Homewood, Alabama?s single audit for the year ended September 30, 2021 is due to the delays in obtaining information necessary to perform testing, which extended the completion date of the single audit and resulted in the late submission of the City?s Single Audit Reporting Package. The City of Homewood, Alabama will strive to submit its Single Audit Reporting Package to the federal audit clearinghouse no later than nine months after the fiscal year end for all future funds received from the federal government.If there are any questions regarding this plan, please call Melody Salter at 205.332.6108.
Finding 409742 (2022-002)
Significant Deficiency 2022
Finding 2022-002 - Documentation of Internal Control to Support Approvals of Payroll Charged to Federal Program.Recommendation: The Organization implement a process to maintain documentation of the Executive Director?s approval for all pay periods.Corrective Action: We have already implemented a pro...
Finding 2022-002 - Documentation of Internal Control to Support Approvals of Payroll Charged to Federal Program.Recommendation: The Organization implement a process to maintain documentation of the Executive Director?s approval for all pay periods.Corrective Action: We have already implemented a process for retaining the emails approving payroll period time cards by the Director and Executive Director.Corrective Action owner: Jennifer Haskett, Senior AccountantCompletion Date: 11/1/2022
Finding 2022-001 - Time and Effort ReportingRecommendation: The Organization implement a process to track employee?s time and effort worked on federal programs.Corrective Action: We will implement a process for employees to certify their time charged to federal programs on a monthly basis. We will t...
Finding 2022-001 - Time and Effort ReportingRecommendation: The Organization implement a process to track employee?s time and effort worked on federal programs.Corrective Action: We will implement a process for employees to certify their time charged to federal programs on a monthly basis. We will then adjust the financials as needed.Corrective Action owner: Jennifer Haskett, Senior AccountantCompletion Date: 12/1/2022
View Audit 311939 Questioned Costs: $1
Finding 406049 (2022-001)
Significant Deficiency 2022
EastWest Food Rescue has since implemented a formal expense approval process that requires electronic signatures from authorized individuals before payments will be processed.
EastWest Food Rescue has since implemented a formal expense approval process that requires electronic signatures from authorized individuals before payments will be processed.
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.
The Division will review allocation and expense workbooks to ensure there are no clerical errors. Anticipated Completion Date: October 2024. Responsible Contact Person: Yohannes Gedlu, Northwest Division Controller & Dani Olsen, Payroll Director
The Division will review allocation and expense workbooks to ensure there are no clerical errors. Anticipated Completion Date: October 2024. Responsible Contact Person: Yohannes Gedlu, Northwest Division Controller & Dani Olsen, Payroll Director
View Audit 311047 Questioned Costs: $1
View of Responsible Officials: As part of the ongoing review of procedures, all wage changes must now be approved in writing by the CEO or her designee for all subordinate staff, and by the Board of Directors for the CEO. All wage changes will be submitted to the payroll processor before any adjustm...
View of Responsible Officials: As part of the ongoing review of procedures, all wage changes must now be approved in writing by the CEO or her designee for all subordinate staff, and by the Board of Directors for the CEO. All wage changes will be submitted to the payroll processor before any adjustments can be made in the system. Additionally, each payroll is reviewed by a second person to ensure compliance. All supporting documentation of compensation changes will also be placed in the employee's personnel file. Policies and procedures and/or the Financial Procedures Handbook will also be updated to reflect the changes.
View of Responsible Officials: A former Board member with finance and operations experience has been tasked with reviewing financial policies and procedures to ensure compliance in all areas. Policies and procedures will be updated with new processes. To date there have been two changes implemented....
View of Responsible Officials: A former Board member with finance and operations experience has been tasked with reviewing financial policies and procedures to ensure compliance in all areas. Policies and procedures will be updated with new processes. To date there have been two changes implemented. Finance staff must now attach electronic copies of invoices within the accounting system to corresponding transactions in order to process payment. In addition, a report of credit card charges missing required documentation is circulated to management monthly, with follow-up to the individual purchasers. Training for all members of the department will occur on an ongoing and regular basis to ensure best practices are being upheld. Policies and procedures and/or the Financial Procedures Handbook will also be updated to reflect the changes.
Corrective Action Plan: After monthly reconciliations, financial statements will be delivered to AJAC Directors monthly. AJAC Accounting Department will hold monthly close calls to collaborate with AJAC Directors to ensure accuracy of financials. Anticipated Completion Date: Completed
Corrective Action Plan: After monthly reconciliations, financial statements will be delivered to AJAC Directors monthly. AJAC Accounting Department will hold monthly close calls to collaborate with AJAC Directors to ensure accuracy of financials. Anticipated Completion Date: Completed
Corrective Action Plan: After monthly reconciliations, AJAC Directors will review all appropriate reimbursable direct expenses related to each grant or contract agreement. After an expense has been included on a reimbursable request, the transaction will be marked appropriately in the accounting sof...
Corrective Action Plan: After monthly reconciliations, AJAC Directors will review all appropriate reimbursable direct expenses related to each grant or contract agreement. After an expense has been included on a reimbursable request, the transaction will be marked appropriately in the accounting software to ensure that transactions are submitted for reimbursement correctly. All necessary reclasses will be performed in the accounting software to match the reimbursement request (invoice). Anticipated Completion Date: Completed
Corrective Action Plan: After monthly reconciliations, AJAC Directors will identify all appropriate indirect expenses specific to each grant or contract agreement and request reimbursement for actual indirect expenses up to the 10% de minimis rate. All items identified as being reimbursable to a spe...
Corrective Action Plan: After monthly reconciliations, AJAC Directors will identify all appropriate indirect expenses specific to each grant or contract agreement and request reimbursement for actual indirect expenses up to the 10% de minimis rate. All items identified as being reimbursable to a specific grant or contract will be reclassed in the accounting software to match the reimbursement request (invoice). Anticipated Completion Date: 09/01/2024
Corrective Action Plan: AJAC Directors will develop and implement policies and procedures for appropriate methods of calculation that ensure benefit allocations are aligned with wage allocations at an employee level. Invoicing will reflect actual benefit expenses up to a predetermined amount or perc...
Corrective Action Plan: AJAC Directors will develop and implement policies and procedures for appropriate methods of calculation that ensure benefit allocations are aligned with wage allocations at an employee level. Invoicing will reflect actual benefit expenses up to a predetermined amount or percentage that is unique to each individual grant or contract agreement. Anticipated Completion Date: Completed
Corrective Action Plan: The deficiencies related to internal control policies and procedures were initially identified in a Federal Desk Monitoring Review conducted in November 2022. Internal control policies and procedures were updated in response to these findings and approved by DOL on October 26...
Corrective Action Plan: The deficiencies related to internal control policies and procedures were initially identified in a Federal Desk Monitoring Review conducted in November 2022. Internal control policies and procedures were updated in response to these findings and approved by DOL on October 26, 2023. All policies and procedures related to federal grant agreement compliance will be reviewed and updated on an annual basis by AJAC Directors and Supervisors. Anticipated Completion Date: Completed
Corrective Action Plan: The deficiencies related to internal control policies and procedures were initially identified in a Federal Desk Monitoring Review conducted in November 2022. Internal control policies and procedures were updated in response to these findings and approved by DOL on October 26...
Corrective Action Plan: The deficiencies related to internal control policies and procedures were initially identified in a Federal Desk Monitoring Review conducted in November 2022. Internal control policies and procedures were updated in response to these findings and approved by DOL on October 26, 2023. All financial reporting policies and procedures will be reviewed and updated on an annual basis by AJAC Directors and Supervisors. Anticipated Completion Date: Completed
The CFO has instituted multiple approvals for each reimbursement or purchase request. Since completion of the fiscal year ended 9/30/2022, the Organization has added a Director of Grants Management, two grant billers, and a purchasing manager to help ensure policies and procedures are being followe...
The CFO has instituted multiple approvals for each reimbursement or purchase request. Since completion of the fiscal year ended 9/30/2022, the Organization has added a Director of Grants Management, two grant billers, and a purchasing manager to help ensure policies and procedures are being followed. For reimbursements, employees will complete an Employee Reimbursement Form which is signed by the employee and employee's direct supervisor. For purchase requests, employees will complete a Purchase Order form which is signed by the employee and the employee's supervisor. The signed form is sent to the finance department where it is entered in Bill.com for payment by accounts payable personnel. The Director of Finance approves the reimbursement or purchase on Bill.com, then the CFO approves and releases for payment. The approved Reimbursement Form or Purchase Order is sent to the Director of Grants Management, and if eligible, attached to the monthly billing to grantor for reimbursement. Anticipated Completion Date: 9/30/2023 Responsible Contact Person: Chris White, CFO
Policies will be placed and adopted by the agency that meet the UG code. These policies will be placed in the fiscal manual. The fiscal manual will be created by using federal guidelines and by using the DDAP fiscal manual as guidance.
Policies will be placed and adopted by the agency that meet the UG code. These policies will be placed in the fiscal manual. The fiscal manual will be created by using federal guidelines and by using the DDAP fiscal manual as guidance.
As of 2023 we will be adding the following policy to the fiscal manual and to the operations manual to read as follows: All monthly program reports shall be completed by the coordinator and sent to the Deputy Director for approval, once approved they will be sent to the Fiscal Coordinator. The Fis...
As of 2023 we will be adding the following policy to the fiscal manual and to the operations manual to read as follows: All monthly program reports shall be completed by the coordinator and sent to the Deputy Director for approval, once approved they will be sent to the Fiscal Coordinator. The Fiscal Coordinator will then complete the billing amount and fiscal narrative then the report will be reviewed by the Deputy Director. Once approved the report will be presented to the Executive Director for final review, approval and signature and date placed on each report before it is sent to the funder. All program coordinators will complete a JFT outcomes report that is placed in an electronic reporting system and these reports will be reviewed quarterly by the Deputy Director. The Deputy Director does data analysis and these reports are placed in narrative form by the Deputy Director quarterly and the year-end report. These are shared with the funders according to the reporting requirements in the grant. All reports must be to funders by the 15th of the following month, unless otherwise stated in funder contract. The following policy will also be added to the fiscal manual: All budget modifications will be written up on the budget modification form and sent to the funder electronically once approved the form will be notated and include the funders signature, written on the form verbal communication from the funder, or a copy of the email with funder approval.
In 2022 and 2023 we have developed a system that better separated and tracked expenditures by grant. We have made the following adjustments already: 1. We have purchased software and a device to read and store receipts into the computer system. We have purchased and are using QuickBooks. All ex...
In 2022 and 2023 we have developed a system that better separated and tracked expenditures by grant. We have made the following adjustments already: 1. We have purchased software and a device to read and store receipts into the computer system. We have purchased and are using QuickBooks. All expenditures and incoming funds will be placed into the QuickBooks system. Any expenditure is then filed by grant, by month with a copy of the invoice, bill, etc. documentation as well as the receipt that corresponds. All files will be kept in a locked cabinet in the fiscal office. At the end of each year all past year records will be stored and kept for 7 years. 2. We have hired a person to do data entry and bookkeeping part time. 3. We have devoted our Administrative Coordinator to take responsibility for HR and fiscal matters to serve as a check and balance system as well as to take the larger load from the Fiscal Coordinator since we have grown. 4. The final thing JFT has done is to hire an accounting firm called Gift CPAs to come in as a final check and balance. Gift CPAs has been able to give our agency training on fiscal matters that were not clear, they have been able to expand our knowledge and use of the QuickBooks System and helped us set up proper checks and balances to better ensure that everything that is charged to each grant is well documented.
View Audit 310733 Questioned Costs: $1
JFT does have all the board minutes on file. However, because we were a small agency, salary rates were not often changed. Additionally, all salary rates and changes were always driven by the ability to obtain the funding needed. Since we were small and there was not always a lot to discuss with ...
JFT does have all the board minutes on file. However, because we were a small agency, salary rates were not often changed. Additionally, all salary rates and changes were always driven by the ability to obtain the funding needed. Since we were small and there was not always a lot to discuss with the board our board only met twice a year. Therefore, all salary was discussed with the board president, then taken to the board. Unfortunately, there is no formal documentation at this time. As of 2023 our board now meets quarterly. Therefore, the following policy will be included in the fiscal manual: the JFT board of directors will hold a public meeting quarterly. All matters of pay rates and salaries will be approved at the start of each grant cycle. State and county grants will be discussed prior to the July 1 start dates, all federal grants will be discussed prior to October 1. Any changes in salary must be approved by the board and documented in official board minutes. All board minutes will be placed in a locked file in the Fiscal Coordinator’s office.
Starting in 2023 all employees of the Organization will complete formal time sheets. These sheets will be signed by the Administrative Coordinator and by the Fiscal Coordinator and then entered into the system each pay period to rectify this finding.
Starting in 2023 all employees of the Organization will complete formal time sheets. These sheets will be signed by the Administrative Coordinator and by the Fiscal Coordinator and then entered into the system each pay period to rectify this finding.
View Audit 310733 Questioned Costs: $1
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