Corrective Action Plans

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Finding 392492 (2022-001)
Significant Deficiency 2022
Finding 2022-001 – Segregation of Duties Statement of Condition: The Foundation does not have adequate segregation of duties present for the approval of payments to subcontractors, which is reflected as federal subcontracts expense on the financial statements. The project manager, who was responsib...
Finding 2022-001 – Segregation of Duties Statement of Condition: The Foundation does not have adequate segregation of duties present for the approval of payments to subcontractors, which is reflected as federal subcontracts expense on the financial statements. The project manager, who was responsible for reviewing and approving the subcontractor’s invoices in preparation for payment authorization by members of the Foundation’s Board, was employed by the subcontractor. Management Response: In August of 2022, the RTOG Foundation Inc. executed a Financial Management Services Agreement with the NSABP Foundation Inc. to provide oversight and management of financial statement preparation. The independent resources provided under this contract include day to day financial support from a Director of Finance with a supporting staff of accountants, financial analysts, and top-level oversight by a Senior Director of Finance with extensive experience in the financial management of clinical trials. The prior project manager referenced above has relinquished all financial accounting responsibilities and appropriate segregation of duties has been achieved, including, but not limited to, internal controls surrounding the payment of invoices. Routine financial analysis, account reconciliations, treasury functions, audit support and budgeting are also included under this services agreement. Monthly financial results are reviewed with the Board of Directors at regularly scheduled meetings.
Noncompliance with Uniform Guidance Late Filing of Single Audit Reporting Package Criteria: Under the Single Audit Act of 1996 and Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), ...
Noncompliance with Uniform Guidance Late Filing of Single Audit Reporting Package Criteria: Under the Single Audit Act of 1996 and Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), §200.512, Report Submission, the Single audit reporting package is required to be filed within the earlier of 30 calendar days after receipt of the auditors' report, or 9 months after the end of the audit period. Cause/Condition: Numerous audit adjustments to the Community Development Special Grant Fund were required, causing a delay in financial reporting. The required deadline was not met on a timely basis for the year ended December 31, 2021. Effect: The City was not incompliance with §200.512 of the Uniform Guidance. Recommendation: We recommend the requirements of §200.512 of the Uniform guidance be adhered to by striving to have all information required for the audit available on a timely basis. This will help to ensure timely audit report issuance and compliance with the filing deadline. Questioned Costs: None. Context: The 2021 Single Audit reporting package was filed on October 11, 2022, 11 days after the required filing date. Response: Management agrees with this finding. There has been significant turnover in key positions of the Community Development Department. It is the City's goal to provide all information required for future audits on a timely basis in order to complete financial statements for submission deadlines outlined in Uniform Guidance, §200.512. Corrective Action Plan: Management will direct the Community Development Department to ensure a monthly review and reconciliation of general ledger balances be performed and reviewed by a responsible official. Differences will be investigated and adjustments made on a timely basis to ensure accurate and timely financial reporting. Additionally, training will be provided to those individuals charged with recording the financial activities of the Community Development Special Grant Fund, and serious consideration will be given to hiring an outside accounting consultant. Anticipated Completed Date: April 15, 2024.
Finding 2022-002 Internal Controls over Allowable Costs ...
Finding 2022-002 Internal Controls over Allowable Costs The auditors recommend the following: 3. Management implement procedures to ensure all expenditures are properly reviewed and approved, and supporting documentation maintained in accordance with federal regulations. Context SDA was unable to produce backup for several invoice payments and evidence of one Time & Effort Certification for allocation to specific grants. Staffing Corrective Action SDA continues to have an outside accounting firm conduct a semi-annual review of financial statements and invoice documentation in advance of the official audit process. The addition of internal staff provides audit support needed to validate that the new systems, procedures and processes implemented by SDA to correct the 2022 audit findings. Process Corrective Action In 2023, SDA introduced training for managers on the requirement of Time & Effort Certification submission for all staff and contractors who are working on grant-funded projects. The updated process requires Mangers to approve a signed Time & Effort Certification with any invoice approval. The Director of Finance and Administration will rigorously enforce the SDA policy that all invoices, receipts, and Time and Effort Certifications must be submitted to receive payment for any work completed. Systems Corrective Action In mid-2023, SDA implemented a centralized and password protected e-filing system to hold all important records for all programs and every area of the business including finance, human resources, and administration. To further ensure that all payments made by the organization have appropriate invoice backup, Bill.com, an invoice and payables tracking system, was implemented fully in 2023 with an approval chain that houses evidence of all transactions.
View Audit 302802 Questioned Costs: $1
Payroll and Personnel Files Significant Deficiency in Internal Control over Payroll and Personnel Files - Accurate and Completeness of Personnel Files During the month of August, the Office of Human Resources and Labor Relations was audited by the ADA. It is to this that we respond to the findings...
Payroll and Personnel Files Significant Deficiency in Internal Control over Payroll and Personnel Files - Accurate and Completeness of Personnel Files During the month of August, the Office of Human Resources and Labor Relations was audited by the ADA. It is to this that we respond to the findings indicated in the audit, as follows: Over the past few years we have developed an internal control, using a document entitled Check sheet, which contains the list of documents required for the appointment of employees and another for the audit of files. It contains three columns for the collation of documents required by the Analysts of the Appointments and Changes Section and ends with the collation of the Division Supervisor, before being referred to the Personnel Officers of our regions. This document has been modified according to needs, changes, procedures and new regulations. It is important to mention that many of our audited personnel records pertain to employees appointed in years where the required requirements or documents were minimal, and no evidence was required or maintained in the personnel file. Related to the academic preparation contained in the personnel files, they are documents required by the Recruitment and Selection Section and these respond to the minimum requirements and alternatives of the class, according to the Agency's Classification Plan. Each class specification sets minimum requirements for the position the candidate will hold. On the other hand, when the previously known Administration of Health Services Facilities (AFASS) closed in 1999, its employees went to the Department of Health with the file they had, whose procedures and processes were not uniform to those of our Agency. The Regions and Hospitals have delegated the verification of documents, to work on appointments and other personnel transactions, such as job reclassifications, promotions and others. This delegation brings the process of standardizing and authorizing DSP-29 by the Recruitment and Selection Section, to ensure that it is complied with as established in the Classification Plan. The agency is in the process of updating these documents as long as a change in the employee's job classification is applied. These are transactions that allow us to update the employees’ record to the new class they will occupy. In the case of Doping Test results, we mention that these are found in the Medical Record of each employee. By HIPPA law, these are not filed in the personnel file. Of the aspects pointed out in the audit, the Department of Health has developed greater review and audit measures by the analysts of our agency, before the defunct Quality Control Section, who watched over and audited the personnel files of the Regions, providing control and compliance with the documents required according to the Regulations and Standards that govern the Office of Human Resources and Labor Relations. The Office of Human Resources presented a work plan to implement an effective and efficient personnel file review procedure to comply with and improve the agency's personnel processes and transactions.
Finding 392392 (2022-001)
Significant Deficiency 2022
Recommendation: We recommend Ozarks Regional YMCA draft and adopt written procedures in accordance with Uniform Guidance requirements. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and is in process of developing and implementing the appropriate poli...
Recommendation: We recommend Ozarks Regional YMCA draft and adopt written procedures in accordance with Uniform Guidance requirements. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and is in process of developing and implementing the appropriate policies and procedures. The board of directors will vote to approve the policies during the second quarter of 2024.
The leadership at IHR takes this finding very seriously and to ensure more accurate record keeping, has hired additional support with the skills necessary for maintaining a more comprehensive and accessible electronic record keeping system. This will also be accomplished by enforcing IHR’s existing...
The leadership at IHR takes this finding very seriously and to ensure more accurate record keeping, has hired additional support with the skills necessary for maintaining a more comprehensive and accessible electronic record keeping system. This will also be accomplished by enforcing IHR’s existing procedures of authorizing, scanning, and properly coding documents by Accounts Payable.
The leadership at IHR takes this finding very seriously and to ensure more accurate record keeping, has hired additional support with the skills necessary for maintaining a more comprehensive and accessible electronic record keeping system. This will also be accomplished by enforcing IHR’s existing...
The leadership at IHR takes this finding very seriously and to ensure more accurate record keeping, has hired additional support with the skills necessary for maintaining a more comprehensive and accessible electronic record keeping system. This will also be accomplished by enforcing IHR’s existing procedures of authorizing, scanning, and properly coding documents by Accounts Payable.
At the onset of the pandemic, certain employees were sent to work remotely. During this period of time, the Organization experienced larger than usual turnover, including the CFO position, which remained unfilled for a significant period of time. Due to these factors, many employees were forced to h...
At the onset of the pandemic, certain employees were sent to work remotely. During this period of time, the Organization experienced larger than usual turnover, including the CFO position, which remained unfilled for a significant period of time. Due to these factors, many employees were forced to handle new responsibilities for the first time in a new remote setting, as the Organization worked diligently to continue operations. Since many of the shows were being cancelled or modified from their traditional format, smaller projects related to design buildout, maintenance, and advertising were taken on. Many of these projects involved smaller retail purchases for which documentation was not properly retained. The Organization acknowledges the findings and has since hired a new CFO and instituted policies and procedures surrounding documentation of all cash disbursements and expenditures of federal awards.
The Organization had not previously been subjected to the Uniform Guidance standards. The internal controls over time and effort reporting did not operate as designed resulting in instances of noncompliance with the reconciliation of actual time worked versus vouchered reimbursement requests. The Or...
The Organization had not previously been subjected to the Uniform Guidance standards. The internal controls over time and effort reporting did not operate as designed resulting in instances of noncompliance with the reconciliation of actual time worked versus vouchered reimbursement requests. The Organization plans to enhance its controls over time and effort reporting and ensure that payroll costs are reported and vouchered based on actual rather than budgeted allocations.
Finding: 2022-005: Significant Deficiency in Internal Controls over Compliance – Allowability– Payroll Transactions Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Corrective Action: • All payroll journal entries will be reviewed and ...
Finding: 2022-005: Significant Deficiency in Internal Controls over Compliance – Allowability– Payroll Transactions Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Corrective Action: • All payroll journal entries will be reviewed and approved by program staff and the Controller since the Staff Accountant prepares the journal entries. • CCS will implement a process for Controller to review payroll entries after they are imported for accuracy between Paycor and the accounting system. • CCS will be looking into whether program staff should start direct charging their time. CCS will set up an after- payroll review to be done by program and finance/HR to review for any possible errors missed prior to running payroll. If errors are found, corrective entries will be made immediately. Also, we will be looking into whether an indirect rate would simply our very complicated allocation system we currently use. Additionally, program staff will review all new or adjusted allocations in Paycor. • Program staff will review all new or changed payroll allocations for employees they supervise. • Detailed allocation reports will be sent to program staff for review. • Program staff are to review preliminary and final reports monthly to check for any discrepancies. • The finance staff currently looks at reports monthly for discrepancies. Proposed Completion Date: 2/28/23
US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable ...
US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable to be recreated. The organization was lacking appropriate internal controls to ensure records were retained for the required period of time. Responsible Individual: Dawn Helmowski, Finance Director Corrective Action Plan: Subsequent to the audit period under review, the affiliated entity of Luther Social Services of North Dakota has been replaced with Beyond Shelter, Inc. Upon this change, the new LSS Jamestown Housing, Inc. Board of Directors, implemented a Document Retention and Destruction Policy that includes retention or required documents for the required time periods that will ensure documents are retained. This policy was put into place on April 19, 2023. Anticipated Completion Date: April 2023
March 27, 2024 2022-004: Significant Deficiency in Internal Control / Immaterial Noncompliance – Activities Allowed/Allowable Cost (repeat Finding) Condition: Allocations of non-direct charged wage time (i.e., paid time off, bereavement, jury duty, holiday, medical paid time off, medical waivers) ar...
March 27, 2024 2022-004: Significant Deficiency in Internal Control / Immaterial Noncompliance – Activities Allowed/Allowable Cost (repeat Finding) Condition: Allocations of non-direct charged wage time (i.e., paid time off, bereavement, jury duty, holiday, medical paid time off, medical waivers) are managed through a labor allocation whereby amounts of non-direct charged wage time are charged to various programs incorrectly. Corrective Action: We agree with the finding. We have addressed this issue with management within the consortium to properly allocate non-direct wage time. This includes the current (March of 2024) procurement of a sufficient payroll and time keeping software to assist in the remediation of this finding. Contact Person: Shamar Herron: Sherron@mwse.org Completion Date: August 2025, procurement will be completed and system implemented. Respectfully, Shamar Herron
Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be revie...
Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be reviewed and approved by management prior to submission. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: 12/31/2023
Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be revie...
Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be reviewed and approved by management prior to submission. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: 12/31/2023
Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be revie...
Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be reviewed and approved by management prior to submission. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: 12/31/2023
Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all disbursements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Reviewed and updated existing controls. Comm...
Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all disbursements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Reviewed and updated existing controls. Communicate with leadership on controls and proper approval process. Cash disbursement request will be reviewed and approved by supervisor prior to submissions. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: 9/30/2022
Recommendations: The Board should strive to submit the Single Audit Reporting Package to the federal audit clearinghouse no later than nine months after the fiscal year end. Views of Responsible Officials and Planned Corrective Actions: The Board will strive to submit its Single Audit Reporting Pac...
Recommendations: The Board should strive to submit the Single Audit Reporting Package to the federal audit clearinghouse no later than nine months after the fiscal year end. Views of Responsible Officials and Planned Corrective Actions: The Board 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.
Management's Response: We concur with the recommendation, and the corrective action will be implemented as of March 6, 2024.
Management's Response: We concur with the recommendation, and the corrective action will be implemented as of March 6, 2024.
View Audit 301535 Questioned Costs: $1
Management concurs with the audit finding. Capital Region Medical Center has sufficient unreimbursed lost revenues to replace the unallowable expenses reported. Capital Region Medical Center federal grant processes will begin to follow the University of Missouri grant policies beginning January 1,...
Management concurs with the audit finding. Capital Region Medical Center has sufficient unreimbursed lost revenues to replace the unallowable expenses reported. Capital Region Medical Center federal grant processes will begin to follow the University of Missouri grant policies beginning January 1, 2024.
View Audit 301078 Questioned Costs: $1
Finding 390130 (2022-004)
Significant Deficiency 2022
1. The Center will retain evidence of competitive bidding, unless an emergency or other situation precluding the delay of competitive bidding has arisen (in which case, the Center will retain the evidence and rationale justifying the sole source contract). The Center will retain verification of susp...
1. The Center will retain evidence of competitive bidding, unless an emergency or other situation precluding the delay of competitive bidding has arisen (in which case, the Center will retain the evidence and rationale justifying the sole source contract). The Center will retain verification of suspension and debarment for all potential contract service providers. The Center notes that one of the contracts selected for testing arose during an emergency situation (flooding). 2. CFO will ensure that all invoices and supporting documentation are retained. ED and/or Director of Legal Services (depending on amount of expenditure, both may be required) will approve electronic payments in Bill.com. Approval of expenses paid with paper checks will be indicated by signature of checks after reviewing accompanying support.
View Audit 301014 Questioned Costs: $1
Finding 390129 (2022-003)
Significant Deficiency 2022
Personnel costs will be charged to the program based on actual time recorded in the organization’s case management software. Hours will be audited quarterly to ensure accuracy and completeness. The Center notes that the grantor, the State Bar of California, never requested the Center to charge payro...
Personnel costs will be charged to the program based on actual time recorded in the organization’s case management software. Hours will be audited quarterly to ensure accuracy and completeness. The Center notes that the grantor, the State Bar of California, never requested the Center to charge payroll expenses to the program based on actual time documents, nor had they ever noted this discrepancy during their periodic audits of the program.
View Audit 301014 Questioned Costs: $1
Recommendation: We recommend the Agency draft and adopt written procedures in accordance with Uniform Guidance requirements. Action Taken: Management agrees with the finding and adopted the appropriate policies and procedures in December 2023.
Recommendation: We recommend the Agency draft and adopt written procedures in accordance with Uniform Guidance requirements. Action Taken: Management agrees with the finding and adopted the appropriate policies and procedures in December 2023.
Finding 2022-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: ...
Finding 2022-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: July 1, 2020 to June 30, 2022 Corrective Action Planned: Management agrees that certain expenses to the COVID department were not reviewed and approved at the order entry level in specific cases. Although evidence of review was not retained for every charge to the COVID department, we believe the appropriateness of the charge was reasonable. Additionally, based on monthly review of departmental expenses and full-time equivalent (FTE) analysis at the facility level, we believe that these expenditures are subject to the appropriate level of review to identify unexpected variances. As it relates to the COVID Activity Code, this code was created as a means to track certain COVID hours worked, but was not configured to calculate the amounts associated with those hours, resulting in the need to make reasonable estimates. Even using the base pay rate at the time the hours were incurred would not have been accurate since it would omit adjustments for shift differentials, weekend hours, and overtime. We performed internal analyses and reviewed the results of samples selected by the auditors and concluded that the risk of a material overcharge to the program was minimal. Further, we have almost $40 million of unused lost revenues after our final PRF submission for Period 5, such that any questioned costs would easily be covered by other eligible uses of PRF funds. We have reviewed our processes related to the retention of expense documentation to improve audit evidence should this program ever be awarded in future periods. Responsible party: Lee Sonne, Vice President of Finance and Controller Implementation Date: Procedures were reviewed and analysis completed along with the Period 5 portal filing in September 2023.
View Audit 300148 Questioned Costs: $1
Finding 387785 (2022-001)
Material Weakness 2022
Hayim Prero, as lead person for the SFSP program for Machne Naarim, will ensure that all expenditures show proper approval before purchases are made. This recommendation was made in the fall of 2022 and went into effect in the summer of 2023. As this was the procedure until now, however, there was n...
Hayim Prero, as lead person for the SFSP program for Machne Naarim, will ensure that all expenditures show proper approval before purchases are made. This recommendation was made in the fall of 2022 and went into effect in the summer of 2023. As this was the procedure until now, however, there was no signature to verify the approval, and this took minimal time to correct. As part of yearly training, the director of each site will be directed to ensure that there is a signature indicating proper approval for all expenditures before purchases are made. This will also be verified for all the sites by the Machne Naarim bookkeeping staff when the invoices are submitted to Machne Naarim for verification of the integrity of their programs.
County had additional funds available in Other Allowable Costs to offset the premuim pay to exempt workers. County will not offer premium pay to employees classified as exempt.
County had additional funds available in Other Allowable Costs to offset the premuim pay to exempt workers. County will not offer premium pay to employees classified as exempt.
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