Corrective Action Plans

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FINDING # TITLE OF FINDING CONTACT PERSON ANTICIPATED COMPLETION DATE 2022-002 INADEQUATE APPROVALPROCESS FOR RHONDA THOMAS/KEITH STEWART 06/30/23 ...
FINDING # TITLE OF FINDING CONTACT PERSON ANTICIPATED COMPLETION DATE 2022-002 INADEQUATE APPROVALPROCESS FOR RHONDA THOMAS/KEITH STEWART 06/30/23 EXPENDITURES OF FEDERAL AWARDS BRENDA SHUMATE/GRANT CAMPBELL CORRECTIVE ACTION PLANNED TO BE TAKEN: THE CHILD NUTRITION DIRECTOR, ESSERF DIRECTOR, SPECIAL ED DIRECTOR AND CSBO WILL WORK TOGETHER TO ENSURE THAT ALL PROCEDURES FOR THE SPENDING OF FEDERAL AWARDS ARE FOLLOWED. ALL INVOICES WILL PROPERLY HAVE APPROVAL PRIOR TO THE EXPENSING OF FUNDS. MORE CARE WILL BE INSTITUTED TO ENSURE FULL COMPLIANCE.
Finding 12367 (2022-004)
Significant Deficiency 2022
Finding 2022-004 ? A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, H. Period of Performance and N. Special Tests and Provisions Identification of the federal program: Federal Program: COVID-19 Disaster Grants ? Public Assistance (Presidentially Declared Disasters) (Assistance...
Finding 2022-004 ? A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, H. Period of Performance and N. Special Tests and Provisions Identification of the federal program: Federal Program: COVID-19 Disaster Grants ? Public Assistance (Presidentially Declared Disasters) (Assistance Listing No. 97.036) Federal Agency: U.S. Department of Homeland Security, Federal Emergency Management Agency (FEMA) Pass-Through Entities: Missouri State Emergency Management Agency and Illinois Emergency Management Agency BJC HealthCare Location: Various Pass-Through Award Numbers: PA-07-MO-4490-PW-00281(0) PA-07-MO-4490-PW-00492(664) PA-07-MO-4490-PW-00508(688) PA-05-IL-4489-PW-00787(0), PA-05-IL-4489-PW-00787(1) PA-05-IL-4489-PW-00788(0), PA-05-IL-4489-PW-00788(1) PA-05-IL-4489-PW-00789(0), PA-05-IL-4489-PW-00789(1) PA-05-IL-4489-PW-01324(1704) PA-05-IL-4489-PW-01329(1701) PA-05-IL-4489-PW-01330(1702) Pass-Through Award Periods: 08/01/2020?09/30/2021 01/01/2020?05/11/2023 01/21/2020?03/31/2021 07/01/2020?12/31/2021 07/01/2020?12/31/2021 07/01/2020?12/31/2021 01/01/2020?05/11/2023 01/01/2020?05/11/2023 01/01/2020?05/11/2023 Views of responsible officials and planned corrective actions: BJC HealthCare agrees with the findings as reported. BJC HealthCare is committed complying with program requirements and meeting program objectives as defined in Section 200.303(a) of the Uniform Guidance, regarding auditee internal controls. To facilitate these requirements, BJC HealthCare will implement controls and documentation 1) to demonstrate when the controls was performed and by whom, 2) to ensure that invoices allocated between multiple project worksheets do not exceed the claim in total, and 3) to include a reconciliation to ensure the population ties to the expenses claimed and expenses to be claimed. Responsible Parties: Lori Schreiner, Vice-President, Finance, BJC HealthCare Mark Melliere, Director, System Finance, BJC HealthCare Completion Date: 4th Quarter 2023
Finding 12365 (2022-005)
Material Weakness 2022
Finding 2022-005 ? A. Activities Allowed or Unallowed and B. Allowable Costs/Cost Principles Identification of the federal program: Federal Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (Assistance Listing No. 93.498)(PRF) Federal Agency: U.S. Department of...
Finding 2022-005 ? A. Activities Allowed or Unallowed and B. Allowable Costs/Cost Principles Identification of the federal program: Federal Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (Assistance Listing No. 93.498)(PRF) Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) BJC HealthCare Location: Various Tax Identification Numbers: Various Payment Received Periods: July 1, 2021 through June 30, 2021 (Period 3) and July 1, 2021 through December 31, 2021 (Period 4) Views of responsible officials and planned corrective actions: BJC HealthCare agrees with the finding as reported. BJC HealthCare is committed to complying with program requirements and meeting program objectives as defined in Section 200.303(a) of the Uniform Guidance, regarding auditee internal controls. BJC HealthCare does not expect to report expenses in any future reporting period. If, at some future date, additional funds are received and expenses are utilized for the PRF funds, BJC HealthCare will implement appropriate internal controls around review and approval of allowable activities and allowable costs. Responsible Parties: Lori Schreiner, Vice President, Finance, BJC HealthCare Completion Date: Expenses will not be utilized in future PRF reporting periods.
Finding 12361 (2022-001)
Significant Deficiency 2022
Finding 2022-001 ? N4. Enrollment Reporting Identification of the federal program: Federal Program: Student Financial Assistance Cluster: Federal Pell Grant Program (Assistance Listing No. 84.063) and Federal Direct Student Loans (Assistance Listing No. 84.268) Federal Agency: United States Departme...
Finding 2022-001 ? N4. Enrollment Reporting Identification of the federal program: Federal Program: Student Financial Assistance Cluster: Federal Pell Grant Program (Assistance Listing No. 84.063) and Federal Direct Student Loans (Assistance Listing No. 84.268) Federal Agency: United States Department of Education BJC HealthCare Location: Goldfarb School of Nursing Award Periods: January 1, 2022 through June 30, 2022 (included in award year July 1, 2021 through June 30, 2022) and July 1, 2022 through December 31, 2022 (included in award year July 1, 2022 through June 30, 2023) Views of responsible officials and planned corrective actions: BJC HealthCare agrees with the findings as reported. The Goldfarb School of Nursing is at Barnes-Jewish College (GSON) is committed to ensuring that student enrollment changes are reported accurately and timely to the National Student Loan Data Systems (NSLDS) in accordance with federal regulations. Procedures and processes have been implemented (to date) to address and correct GSON enrollment reporting compliance. To facilitate the completeness of the enrollment reporting process, the following steps will be incorporated into the GSON?s procedures: ? A second-tier review of student enrollment status reports (SFRNSLC), as prepared by the GSON Registration Technical Specialist, will continue to be completed by the GSON Registrar before submission of data to the National Student Clearinghouse (NSC). The GSON Registrar will randomly select a sample of students to compare enrollment report data to the student information system (Banner) and document their findings. This control was implemented in October 2022. Responsible Parties: Kristina Rieger, Registrar, Goldfarb School of Nursing at Barnes-Jewish College Edward Gricius, Associate Dean, Student Experience & Development, Goldfarb School of Nursing at Barnes-Jewish College Completion Date: The corrective action plan was implemented in October 2022.
FA2O22-001 Improve/Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principles Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency...
FA2O22-001 Improve/Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principles Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.4250 - Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425U - American Rescue Plan Elementary And Secondary School Emergency Relief Fund Federal Award Number: 5425D2000L2 (Year: 2020), 5425U2L0072 (Year: 202L) Questioned Costs: $61,000.00 Repeat of Prior Year Finding: None Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over expenditures as it relates to the Elementary and Secondary School Emergency Relief Fund program. Corrective Action Plans: We concur with this finding. The process used to pay retention pay to staff has been reviewed and will only be a paid to staff employed by the Atkinson County Board of Education. Estimated Completion Date: 3/13/2023 Contact Person: Lessie Youngblood Telephone: 912- 422-7878 Email: lyoungblood@atkinson.k12. ga.us
View Audit 16730 Questioned Costs: $1
Maderia Ellison, Vice President for Administrative Services/CFO Jeremy Raisor, Dean of Career & Technical Education Anticipated completion date: June 30, 2023 Corrective Action Plan: The District has been made aware of the issues related to the federal awards and concurs with the finding and recom...
Maderia Ellison, Vice President for Administrative Services/CFO Jeremy Raisor, Dean of Career & Technical Education Anticipated completion date: June 30, 2023 Corrective Action Plan: The District has been made aware of the issues related to the federal awards and concurs with the finding and recommendations. The District will develop and implement student refund procedures to ensure that written or electronic consent is received from students before applying emergency financial assistance to the student?s outstanding account balance, and that if the consent cannot be obtained within the appropriate time period funds will be released to the student. The district will also make any necessary adjustments on the three accounts where emergency financial assistance was misapplied.
Recommendation We recommend that the Municipality should start the process of compiling and preparing the financial information to complete the Governmental-Wide and Governmental Funds Financial Statements and the Schedule of Expenditures of Federal Awards with enough time to assure that such in...
Recommendation We recommend that the Municipality should start the process of compiling and preparing the financial information to complete the Governmental-Wide and Governmental Funds Financial Statements and the Schedule of Expenditures of Federal Awards with enough time to assure that such information is available for the audit process, before March 31, and to provide it with enough time so the audit process can be completed before such due date.
Finding 2022-005: Material Weakness over Cash Management and Allowable Costs - Review of Cash Drawdowns Information on the Federal Program: Department of Human and Health - Center for Disease Control: Improving Epilepsy Programs, Services and Outcomes Through Partnerships. Finding: The Uniform Gu...
Finding 2022-005: Material Weakness over Cash Management and Allowable Costs - Review of Cash Drawdowns Information on the Federal Program: Department of Human and Health - Center for Disease Control: Improving Epilepsy Programs, Services and Outcomes Through Partnerships. Finding: The Uniform Guidance requires organizations to establish internal controls to detect potential noncompliance. The Uniform Guidance also requires organizations who receive funds on a cost reimbursement basis to only draw down funds for allowable expenditures under the grant. Management has an established control in place, in that the VP of Finance reviews the calculation of expenditures not drawn down prior to the submission of the drawdown request. However, the control was ineffective to prevent and detect an erroneous expense journal entry, considered an unallowable expense and is an instance of noncompliance, from being included in the drawdown. Planned Corrective Action: A corrective action was taken and the Foundation returned the funds drawn down to the Department of Treasury. The Foundation has implemented an additional confirmation process where reimbursable expenses will be reviewed along with the draw down prior to draw down. This additional step will ensure that erroneous coding does not result in a funds draw down. Name and Person Responsible: Caro Marie Brown (Senior Director of Finance), June Nolan (Accounts Payable Accountant), and Lindey Camerata (Controller). Anticipated Completion Date: February 2023.
View Audit 16547 Questioned Costs: $1
Finding 2022-004: Material Weakness over Allowable Costs - Review of Non-Payroll Expenditures Information on the Federal Program: Department of Human and Health - Center for Disease Control: Improving Epilepsy Programs, Services and Outcomes Through Partnerships. Finding: The Uniform Guidance req...
Finding 2022-004: Material Weakness over Allowable Costs - Review of Non-Payroll Expenditures Information on the Federal Program: Department of Human and Health - Center for Disease Control: Improving Epilepsy Programs, Services and Outcomes Through Partnerships. Finding: The Uniform Guidance requires organizations to establish internal controls to detect potential noncompliance. Management has an established control in place, in that all expenditures paid through the Concur system were reviewed and approved by an appropriate project manager, but did not retain evidence of this approval occurring during the year for 9 non-payroll expenditures chosen for testing. Planned Corrective Action: We had a number of technical issues with Concur which resulted in a cessation of use in January 2022 and a transition to PN3 which was being used for payables. We transitioned to PN3 in January 2022 and are no longer using Concur. PN3 maintains all audit trails. Name and Person Responsible: Caro Marie Brown (Senior Director of Finance), June Nolan (Accounts Payable Accountant), and Lindey Camerata (Controller). Anticipated Completion Date: January 2022.
Recommendation We recommend that the Authority implement additional review procedures over invoices to verify the allocation according to the cost allocation plan. View of responsible officials and planned corrective action We agree that there were some expenses that did not follow the cost allocat...
Recommendation We recommend that the Authority implement additional review procedures over invoices to verify the allocation according to the cost allocation plan. View of responsible officials and planned corrective action We agree that there were some expenses that did not follow the cost allocation and that in all cases noted, we undercharged the HCV program. We will implement further review processes that reference expenses directly back to the cost allocation plan.
2022-001 - Block Grants for Community Mental Health Services- 93.958 and Section 223 Demonstration Programs to Improve Community Mental Health Services - 93.829 Condition During testing, we identified unallowable staff meals that were paid with grant funding. One such transaction was identified out ...
2022-001 - Block Grants for Community Mental Health Services- 93.958 and Section 223 Demonstration Programs to Improve Community Mental Health Services - 93.829 Condition During testing, we identified unallowable staff meals that were paid with grant funding. One such transaction was identified out of the sample tested for the Section 223 Demonstration Programs to Improve Community Mental Health Services, and it totaled to $11. Another such transaction was identified out of the sample tested for the Block Grants for Community Mental Health Services, and it totaled to $25. Recommendation We recommend that High Plains Mental Health Center review its policies to ensure that unallowable expenses are not expensed under federal grant programs. Action Taken As of the date of this notice, funding has been returned for all meals reimbursed under the grants.
Finding 12236 (2022-001)
Significant Deficiency 2022
Finding 2021-001 Federal program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing 93.498 Statement of Condition During our testing over reporting, we observed management did not have effective internal controls in place to ensure lost revenues reported in th...
Finding 2021-001 Federal program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing 93.498 Statement of Condition During our testing over reporting, we observed management did not have effective internal controls in place to ensure lost revenues reported in the Portal were not duplicated between a subsidiary entity and the parent entity, resulting in an overstatement of lost revenues reported in the Portal. Lost revenues attributable to Coronavirus in the amount of $2,382,081 were reported in both the parent entity?s PRF reports for the general distribution report for Period 2 and for Ashland Community Healthcare Services and Asante Three Rivers, subsidiary entities, targeted distribution reports for Period 2 (i.e., lost revenues were duplicated). Actions Taken and Status As noted within the portal filing summary for the general reporting Period 2, the Corporation?s consolidated lost revenue totaled $113,690,616. Payments from the PRF for Period 1 and 2 totaled $25,713,324 for the consolidated parent, $5,571,616 for Ashland Community Healthcare Services, and $1,810,465 for Asante Three Rivers per Period 2 targeted reports. As a result, there were sufficient qualifying lost revenues to receive and earn all PRF funds received, regardless of the reporting error identified and described in the ?condition found? section above. Therefore, management believes no repayment of PRF funds received would be required. Management is implementing a process to add additional review steps prior to finalizing future reporting submissions. Person responsible for the implementation of the corrective action plan: Heather Rowenhorst, Chief Financial Officer Asante Health System
Condition: During compliance testing of the District's accounting records to the expenditure reports filed with the Illinois State Board of Education, we noted the District claimed one expenditure of which was not allowable per the budget detail function code, resulting in questioned costs of $279. ...
Condition: During compliance testing of the District's accounting records to the expenditure reports filed with the Illinois State Board of Education, we noted the District claimed one expenditure of which was not allowable per the budget detail function code, resulting in questioned costs of $279. Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. Anticipated Date of Completion: 6/30/23. Name of Contact Person: Dr. Dwayne E. Evans, Superintendent of Schools. Management Response: While this grant program was already finalized, the District will consider amending future budgets with ISBE prior to the grant end date.
View Audit 16420 Questioned Costs: $1
Finding #2022-001: Internal Controls Over Compliance Related to Payroll; Federal Program: Provider Relief Fund (93.498); Response: We will review department documentation of hours allocated to grants; Responsible party: Kevin Sander, Controller; Estimated Completion: The very next payroll submission...
Finding #2022-001: Internal Controls Over Compliance Related to Payroll; Federal Program: Provider Relief Fund (93.498); Response: We will review department documentation of hours allocated to grants; Responsible party: Kevin Sander, Controller; Estimated Completion: The very next payroll submission.
Contact Person(s) Responsible for Corrective Action: Dr. Tiffany Hardrick, Superintendent and Sharon Wilson, Federal Coordinator Corrective Action Planned: All services prepaid for professional development were rendered and properly documented, i.e participant sign in sheets and agendas which i...
Contact Person(s) Responsible for Corrective Action: Dr. Tiffany Hardrick, Superintendent and Sharon Wilson, Federal Coordinator Corrective Action Planned: All services prepaid for professional development were rendered and properly documented, i.e participant sign in sheets and agendas which is required as part of the districts control procedures to ensure that services paid for are in fact received . It should be noted that the district prepaid for services based on verbal and email guidance of the Public-School Program Manager from DESE public school accountability department. The purpose of prepayment was to avoid returning funds as advised. (Email Documentation can be provided). In addition, Solution Tree, a state approved partner, sent an email as recently as April 3, 2023 encouraging districts to "Pre-pay years of PD with federal funds". (Documentation can be provided). However, the district will implement procedures to review payments to vendors in the future to ensure that services have been rendered prior to payment. Anticipated Completion Date: The corrective actions are anticipated to be complete and in place immediately after the completion date of this audit.
View Audit 16316 Questioned Costs: $1
Finding: 2022-002 Agency: City of Dunsmuir Responsible person name/title: Blake Michaelsen, Finance Director Anticipated completion date: 06/30/2024 Agency?s response: Concur Corrective action plan: The City?s Finance Director will submit the written policies and procedures for all 12 com...
Finding: 2022-002 Agency: City of Dunsmuir Responsible person name/title: Blake Michaelsen, Finance Director Anticipated completion date: 06/30/2024 Agency?s response: Concur Corrective action plan: The City?s Finance Director will submit the written policies and procedures for all 12 compliance requirements found in the Uniform Guidance to City Council for approval and codification. The policies and procedures will be distributed to City staff and staff will be trained on the new policies and procedures.
View Audit 16299 Questioned Costs: $1
Management?s Response to 2022 Audited Financial Statements Findings and Corrective Action Plan: Rural Resources Community Action agrees with the findings reported and has identified corrective action to rectify the findings. The Organization management and Board of Di...
Management?s Response to 2022 Audited Financial Statements Findings and Corrective Action Plan: Rural Resources Community Action agrees with the findings reported and has identified corrective action to rectify the findings. The Organization management and Board of Directors understand the requirement and importance of submitting audited financial statements to the Federal Audit Clearinghouse in a timely matter. This will be monitored closely by the Board of Directors and management of the Organization for future audits to make sure that the audits are submitted timely.
Corrective Action Plan: The organization is implementing new software for tracking client expense, which has functionality to import copies of credit card receipts and check requests into each client?s record. We have emphasized to case managers the importance of keeping receipts. Reasonable complet...
Corrective Action Plan: The organization is implementing new software for tracking client expense, which has functionality to import copies of credit card receipts and check requests into each client?s record. We have emphasized to case managers the importance of keeping receipts. Reasonable completion date: June 1, 2023 Responsible Party: Tanya DeWolf, Director of Refugee Services
Corrective Action Plan: The organization has implemented a new payroll system, which includes time tracking. It has also changed its policy to pay overtime rather than accruing comp-time, as well as an implementing an unlimited PTO policy. These changes will eliminate charging grants for undocumente...
Corrective Action Plan: The organization has implemented a new payroll system, which includes time tracking. It has also changed its policy to pay overtime rather than accruing comp-time, as well as an implementing an unlimited PTO policy. These changes will eliminate charging grants for undocumented accrued time. Reasonable completion date: October 1, 2022 Responsible Party: Rick Rummel, Director of Finance & Administration
View Audit 16282 Questioned Costs: $1
Contact Person Jolene Palme, Finance Manager Corrective Action Plan We are in the process of updating the Center?s written policies and procedures to include the requirements of the Uniform Guidance. Completion Date Fiscal year end 2023
Contact Person Jolene Palme, Finance Manager Corrective Action Plan We are in the process of updating the Center?s written policies and procedures to include the requirements of the Uniform Guidance. Completion Date Fiscal year end 2023
Views of responsible officials and planned corrective actions: The Organization agrees with this finding. The Chief Financial Officer will prepare the required reports and the Executive Director will review the grant terms and conditions and the draft of the required reports before approving the sub...
Views of responsible officials and planned corrective actions: The Organization agrees with this finding. The Chief Financial Officer will prepare the required reports and the Executive Director will review the grant terms and conditions and the draft of the required reports before approving the submission of the required reports.
Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with requirements for time-and-effort documentation. Name, address, and telephone of District contact person: Benjamin Rarick, Associate Superintendent of Finance 12033 SE 256th...
Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with requirements for time-and-effort documentation. Name, address, and telephone of District contact person: Benjamin Rarick, Associate Superintendent of Finance 12033 SE 256th Kent, WA 98031 Corrective action the auditee plans to take in response to the finding: The Grants Administrator, under the supervision of the Director of Budget, will do interim and year-end reviews to identify any instances of positions funded by multiple federal funding sources for the purpose of assessing applicability of multi-cost objective T&E requirements and following through as appropriate. The Grants Administrator, under the supervision of the Director of Budget, and in collaboration with the program administrator, will initiate time & effort documentation in every case where there is debatable fact pattern, with the intent of adopting an “abundance of caution” approach to T&E, and will additionally seek written clarification from OSPI and/or the ESD in instances where T&E requirements are not dispositive from the relevant federal compliance supplements and guidance documents. Anticipated date to complete the corrective action: October, 2024
HFP Views of Responsible Officials - Hope for Prisoners’ CEO presently reviews and approves all RFR forms in writing prior to submission. Oversight by specific board members will be provided through a review of the submitted RFR to compare it to the monthly financial reports already being provided.
HFP Views of Responsible Officials - Hope for Prisoners’ CEO presently reviews and approves all RFR forms in writing prior to submission. Oversight by specific board members will be provided through a review of the submitted RFR to compare it to the monthly financial reports already being provided.
Grady’s corrective action plan: 1. Going forward, Grady will have a formal agenda to discuss and approve the SEFA prior to submission. 2. The SEFA will be reviewed, approved and attested by the Grady’s VP Of Fiscal Services and the Executive Director of Internal Audit. 3. Differences above establish...
Grady’s corrective action plan: 1. Going forward, Grady will have a formal agenda to discuss and approve the SEFA prior to submission. 2. The SEFA will be reviewed, approved and attested by the Grady’s VP Of Fiscal Services and the Executive Director of Internal Audit. 3. Differences above established thresholds will be reviewed and addressed
Planned Corrective Action: Family First Health will review its Time and Effort policy to ensure continued compliance with federal regulations in maintaining records of personnel time and effort to substantiate salary costs associated with its federal grants. We will add steps to our process to ensu...
Planned Corrective Action: Family First Health will review its Time and Effort policy to ensure continued compliance with federal regulations in maintaining records of personnel time and effort to substantiate salary costs associated with its federal grants. We will add steps to our process to ensure that the certifications by employees whose time is allocated to one federally funded program will sign an after-the-fact certification on a semi-annual basis confirming that the employee worked on a single award for the given period. The transition from ADP (our past payroll processor) to Paycom (our new payroll processor) will provide additional levels of timekeeping detail that will enable time and effort to be more closely monitored and reported. Completion Date 5/1/23 Accounting Name of Contact Person: Jenny Englerth, President/CEO; Brent Doores, CFO
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