Corrective Action Plans

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Corrective Action: 1. Review and revise existing policies and procedures for the application of indirect rates with the appropriate oversight by the Finance/Accounting department across federal grants to ensure accuracy and compliance with relevant regulations. 2. Review the allowable indirect rate ...
Corrective Action: 1. Review and revise existing policies and procedures for the application of indirect rates with the appropriate oversight by the Finance/Accounting department across federal grants to ensure accuracy and compliance with relevant regulations. 2. Review the allowable indirect rate methodologies to ensure the method used is based upon an equitable distribution across federal and non-federal programs. 3. Provide training to relevant staff on the revised policies, procedures to ensure the proper application of the indirect rate and calculation of indirect costs.
View Audit 364224 Questioned Costs: $1
Finding 573484 (2024-007)
Material Weakness 2024
Reference Number: 2024-007 – Delays in Financial Reporting Name of Contact Person: Chia Lor, Accounting Manager Corrective Action: Management agrees with the finding. The City has filled all of its vacant positions in Accounting and anticipates a timely completion of the 2024/25 Audit. Proposed...
Reference Number: 2024-007 – Delays in Financial Reporting Name of Contact Person: Chia Lor, Accounting Manager Corrective Action: Management agrees with the finding. The City has filled all of its vacant positions in Accounting and anticipates a timely completion of the 2024/25 Audit. Proposed Completion Date: December 31, 2025
Finding 573444 (2024-002)
Significant Deficiency 2024
Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will establish procedures to ensure compliance with guidelines and policies outlining the time and effort reporting and documentation requirements that department heads must adhere with to ensure co...
Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will establish procedures to ensure compliance with guidelines and policies outlining the time and effort reporting and documentation requirements that department heads must adhere with to ensure compliance with federal and state time and effort reporting requirements. Management will also implement proper training to ensure that the program managers fully understand the time and effort reporting requirements. Management intends to implement these procedures in fiscal 2025.
Finding 573426 (2024-001)
Significant Deficiency 2024
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Olympia January 1, 2024 through December 31, 2024 This schedule presents the corrective action planned by the City for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 2...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Olympia January 1, 2024 through December 31, 2024 This schedule presents the corrective action planned by the City for findings reported 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: 2024-001 Finding caption: The City had inadequate internal controls for ensuring compliance with federal requirements for subrecipient monitoring. Name, address, and telephone of City contact person: Kim Kondrat, Homeless Response Coordinator P.O. Box 1967, Olympia WA 98507 (360) 753-8101 Corrective action the auditee plans to take in response to the finding: The City takes seriously the use of federal funds and the compliance requirements associated with them. While there were no compliance violations found due to this lack of controls, the Homelessness Response team is committed to continuing to improve controls to ensure compliance requirements are met, and improve the documentation surrounding these control procedures. Improvements to control procedures has been in progress since the prior year audit, but implementation is not fully complete due to staff turnover. We will be scheduling additional trainings and implementing additional required documentation into our processes, including a secondary review for necessary contract elements prior to executing contracts involving federal awards. We thank the auditors for bringing these requirements to our attention. Anticipated date to complete the corrective action: 12/31/2024
Name of Contact Person Nathan Black, Auditor-Controller Management's Response and Corrective Action The County agrees with the finding. Due to extenuating circumstances resulting in delays from the ERP implementation, the County made efforts to inform the cognizant agencies and requested a filing...
Name of Contact Person Nathan Black, Auditor-Controller Management's Response and Corrective Action The County agrees with the finding. Due to extenuating circumstances resulting in delays from the ERP implementation, the County made efforts to inform the cognizant agencies and requested a filing extension. Unfortunately, the extension request was denied. The County does not anticipate these delays will affect future reporting periods as they were one-time occurrences due to system conversion and post go-live difficulties. The County has been compliant with Single Audit submission deadline for at least the 9 prior years. Proposed Completion Date 08/08/2025
Finding 573319 (2024-005)
Significant Deficiency 2024
Finding 2024-005 Internal Controls Over Compliance for Subrecipient Monitoring 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding The City will adopt the referenced policies in order to comply with Uniform Guida...
Finding 2024-005 Internal Controls Over Compliance for Subrecipient Monitoring 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding The City will adopt the referenced policies in order to comply with Uniform Guidance. 3. Official Responsible Ms. Sony Lubrecht, Finance Director, is the official responsible for ensuring corrective action. 4. Planned Completion Date December 31, 2025. 5. Plan to Monitor Completion The City Council will be monitoring this Corrective Plan.
Finding 573289 (2024-010)
Significant Deficiency 2024
The City has a Grants Administrator on staff that monitors and advises when reports are due to external entities. SOP's are being reviewed with staff for implementation. This activity is ongoing. Responsible Partv: Ms. Niema Gantt, Finance Director, and Ms. Yesly Guillen, Grants Administrator
The City has a Grants Administrator on staff that monitors and advises when reports are due to external entities. SOP's are being reviewed with staff for implementation. This activity is ongoing. Responsible Partv: Ms. Niema Gantt, Finance Director, and Ms. Yesly Guillen, Grants Administrator
Corrective action planned: Department managers and others involved in grants will be educated on the importance of understanding the types of grants they are requesting or receiving including any reporting requirements. Accounting staff will assist with the matching of grant revenues and expenses...
Corrective action planned: Department managers and others involved in grants will be educated on the importance of understanding the types of grants they are requesting or receiving including any reporting requirements. Accounting staff will assist with the matching of grant revenues and expenses to verify that they are appropriate and in the correct accounting period. A procedure will be implemented to ensure that at year-end, all grant revenues and expenses are double-checked to verify they are posted in the correct period. Anticipated completion date: July 31, 2025 Contact person responsible for corrective action: Steve Lindemann, Interim CFO
2024-005 Lack of Written Allocation Plan for Shared Costs Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the finding. A plan has been written for FY25.
2024-005 Lack of Written Allocation Plan for Shared Costs Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the finding. A plan has been written for FY25.
2024-004 Lack of Documented Approval Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has implemented various approval and documentation procedures.
2024-004 Lack of Documented Approval Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has implemented various approval and documentation procedures.
B. Actions Planned or Taken: As of October 2024, the Town has adopted a Federal Procurement Policy.
B. Actions Planned or Taken: As of October 2024, the Town has adopted a Federal Procurement Policy.
Finding 573174 (2024-003)
Significant Deficiency 2024
Views of Responsible Officials: Despite difficulty preparing the report within the timeframe requested, the grant was administered in accordance with Uniform Guidance and no questioned costs were identified. To assist with more efficient and accurate reports, AcademyHealth will begin implementing a ...
Views of Responsible Officials: Despite difficulty preparing the report within the timeframe requested, the grant was administered in accordance with Uniform Guidance and no questioned costs were identified. To assist with more efficient and accurate reports, AcademyHealth will begin implementing a new accounting system (Sage Intaact) in August 2025 which includes an integrated SEFA module to ensure complete and accurate reporting in future years.
Finding 573173 (2024-002)
Significant Deficiency 2024
Views of Responsible Officials: One out of the two drawdowns for the major program during 2024 was not supported with a P&L to substantiate the costs were expended against the program. This drawdown was initiated and executed by the previous CFO, Deborah Edwards, and the appropriate documentation wa...
Views of Responsible Officials: One out of the two drawdowns for the major program during 2024 was not supported with a P&L to substantiate the costs were expended against the program. This drawdown was initiated and executed by the previous CFO, Deborah Edwards, and the appropriate documentation was not available. In 2025, AcademyHealth initiated a new control under the direction of the Director of Grants and Contracts, Tamika King. On a monthly schedule, the Grants and Contracts Associate will prepare each payment request by reviewing timecard reports and reconciling costs to the Job Cost Transactions report. The Director of Grants and Contracts will subsequently review and log the prepared request. The log will be reviewed with the CFO and Senior Accounting Manager during the weekly cash flow meetings.
Condition: Controls in place did not ensure a foreign national employee's involvement on a project were communicated to the Contracts Manager for tracking. Planned Corrective Action: Management takes its responsibility to comply with the terms and conditions of awards seriously, and, while this part...
Condition: Controls in place did not ensure a foreign national employee's involvement on a project were communicated to the Contracts Manager for tracking. Planned Corrective Action: Management takes its responsibility to comply with the terms and conditions of awards seriously, and, while this particular finding did not result in noncompliance with the terms of an award, a repeat occurrence could result in noncompliance. To prevent future occurrences, management will enhance internal controls to ensure consistent tracking and reporting of foreign nationals working on Department of Energy sponsored projects by taking the following corrective actions by July 31, 2025: 1) Update the company’s policy for tracking and reporting foreign nationals to include: a) A requirement that all team members must be approved by Contract Services before starting work on a DOE project. b) A requirement that Contract Services review a payroll report monthly to ensure all individuals who charged time to DOE projects were pre-approved. 2) Train business unit leaders, project managers, and contract services staff on the revised policy and procedures for tracking and reporting foreign nationals. Contact person responsible for corrective action: Prerna Russell Anticipated Completion Date: 07/31/2025
The Corporation identified a subrecipient’s misuse of grant funds during a regular audit of draws and a scheduled monitoring review/technical assistance consultation for the agency. Ethic complaints were received by the Corporation during the same timeframe regarding the subrecipient’s management wh...
The Corporation identified a subrecipient’s misuse of grant funds during a regular audit of draws and a scheduled monitoring review/technical assistance consultation for the agency. Ethic complaints were received by the Corporation during the same timeframe regarding the subrecipient’s management which expanded the scope of the financial review. As a result of these monitoring efforts, the Corporation identified ineligible and questioned costs, and efforts are underway to recapture ineligible and unsupported costs. The Corporation has put the following policies and procedures in place to mitigate future risk: 1. Biennial Risk Assessment with Annual Updates 2. Annual Project Compliance Report (APCR) required by subrecipient agencies (with the exception of subrecipients receiving only Department of Energy and LIHEAP grants for the Weatherization Assistance Program, which are governed by separate monitoring procedures). 3. Enhanced Draw Monitoring and draw documentation requirements 4. Expansion of the Corporation’s Compliance and Training Team Given the policies, procedures, and changes outlined above, the Corporation feels confident it will be able to comply with its Compliance Monitoring Plan going forward and identify any concerns with subrecipient compliance in a timely manner. Curtis Stauffer, Managing Director, Housing Contract Administration, and applicable compliance staff will implement by October 1, 2024.
View Audit 363980 Questioned Costs: $1
West MI Regional Medical Consortium respectfully submits the following corrective action plan for the year ended September 30, 2024. Auditor: Maner Costerisan 2425 E. Grand River Ave., Suite 1 Lansing, Michigan 48912 Audit Period: Year ended September 30, 2024 Organization Contact Person: Jerry Evan...
West MI Regional Medical Consortium respectfully submits the following corrective action plan for the year ended September 30, 2024. Auditor: Maner Costerisan 2425 E. Grand River Ave., Suite 1 Lansing, Michigan 48912 Audit Period: Year ended September 30, 2024 Organization Contact Person: Jerry Evans, MD; Medical Director The findings from the September 30, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding ‐ Federal audit Finding 2024‐001 ‐ Significant Deficiency Recommendation: West MI Regional Medical Consortium currently has procedures and controls in place to effectively monitor the status of the submission of the data collection form and the reporting package to ensure that the required information is submitted in a timely manner. The cause related to this finding was not due to failure in internal controls, therefore, we have no further recommendation for the Organization at this time. Action to be Taken: The Organization concurs with the facts of this finding and has procedures in place to ensure the timely submission of the data collection form and the reporting package.
Corrective Action Plan for FYE December 31, 2024 Finding 2024-001 Corrective Action Plan: Management will implement periodic time studies throughout contract durations to support accurate allocation of personnel costs. Staff will be reminded of relevant compliance requirements, and internal proces...
Corrective Action Plan for FYE December 31, 2024 Finding 2024-001 Corrective Action Plan: Management will implement periodic time studies throughout contract durations to support accurate allocation of personnel costs. Staff will be reminded of relevant compliance requirements, and internal processes will be adjusted as needed. We will continue to monitor this area and document efforts to ensure ongoing alignment with applicable regulations. Contact Person Responsible for Corrective Action Plan: Lottie Albrecht, Director of Administration Phone Number: 607-940-0102 Email: lalbrecht@acbcservices.org Anticipated Completion Date of Corrective Action Plan: December 2025 (as part of preparation for fiscal year ending December 31, 2025)
View Audit 363928 Questioned Costs: $1
2024 – 002 Lack of Segregation of Duties - Lack of Supervisory Review - Allow-ability of Expenses Charged to Grants The corrective action proposed for the above finding should be sufficient to account for any area of non-compliance in the evidence of supporting documentation for all disbursemen...
2024 – 002 Lack of Segregation of Duties - Lack of Supervisory Review - Allow-ability of Expenses Charged to Grants The corrective action proposed for the above finding should be sufficient to account for any area of non-compliance in the evidence of supporting documentation for all disbursements. Additionally, the Business Operations Manager and Executive Director will implement a systematic review of all grant awards, contracts, and develop an addendum document charting all allowable expenses within each funding stream that will be utilized by the team when to determine proper allocation of disbursements. This chart will provide a quick guide to monitor compliance and allow-ability of expenditures to each funder at the time a check request is submitted. Checks
View Audit 363925 Questioned Costs: $1
Uniform Grant Guidance Implementation Recommendation: We recommend the County finalize the assessment of its financial management system and related internal controls over federal awards during the 2021 fiscal year. This assessment should include an evaluation of existing policies and procedures to ...
Uniform Grant Guidance Implementation Recommendation: We recommend the County finalize the assessment of its financial management system and related internal controls over federal awards during the 2021 fiscal year. This assessment should include an evaluation of existing policies and procedures to determine where additional enhancements should be made or new policies created, a plan to communicate these policies to County employees, and procedures to periodically review and update, as considered necessary. Action Planned/taken in response to the finding: Kewaunee County agrees with the finding. An assessment of all grants, requirements, and related policy and procedures is in progress and will continue to:  Evaluate existing policy and procedures for needed revisions  Document revisions to policy and procedures as necessary  Communicate any new policies to employees responsible for awards  Identify awards covered by the Uniform Guidance  Set and document a schedule for periodic review and revision Policy and procedures, as well as related documentation, are being revised as necessary to ensure compliance with the Uniform Guidance. Progress continues into 2024. The Finance Director will continue to coordinate and provide assistance and guidance to departments receiving grants subject to the Uniform Guidance. Names(s) of the contact person(s) responsible for corrective action: Paul Kunesh Planned completion date for corrective action: December 31, 2025
Finding 573036 (2024-001)
Material Weakness 2024
Internal control deficiency over activities allowed or unallowed and allowable costs/cost principles related to review of contract labor expenditures. Banner requires control labor resources to utilize the same time keeping system used by Banner employees to track worked time. Banner creates ‘reve...
Internal control deficiency over activities allowed or unallowed and allowable costs/cost principles related to review of contract labor expenditures. Banner requires control labor resources to utilize the same time keeping system used by Banner employees to track worked time. Banner creates ‘reverse invoices’ using the time tracked in Banner’s timekeeping system by contract labor resources and presents those hours/dollars to contract labor agencies for approval prior to remitting payment to those agencies. These invoices are reviewed by Banner’s staffing services team for reasonableness prior to being presented to the agencies for approval. There is an expectation that managers review and formally approve the timecards of contract labor resources in the timekeeping system, however, the reverse invoicing process moves forward even in the absence of a documented formal approval. Banner will implement a periodic monitoring process that provides a report of ‘forced sign offs’ (timecards without documented manager approval) to senior leadership in an effort to increase compliance with the timecard approval policy. Contact: Paul Nolde-Morrissey, Vice President and Corporate Controller Expected completion date: September 30, 2025
Item: 2024-002 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Arizona Department of Health Services Compliance Requirement: Allowable Activities and Costs Criteria or ...
Item: 2024-002 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Arizona Department of Health Services Compliance Requirement: Allowable Activities and Costs Criteria or Specific Requirement: In accordance with 2 CFR 200.405 - Allocable Costs - (d) If a cost benefits two or more projects or activities in proportions that can be determined without undue effort or cost, the cost must be allocated to the projects based on the proportional benefit. Condition: Costs charged to the federal program were based on an allocation methodology that was not properly updated for the current period Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2025 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. The Organization will update allocations timely going forward.
View Audit 363873 Questioned Costs: $1
Item: 2024-001 Assistance Listing Number: 93.914 Programs: HIV Emergency Relief Project Grants Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Maricopa County Department of Public Health Services Compliance Requirement: Allowable Activities and Costs Criteria or...
Item: 2024-001 Assistance Listing Number: 93.914 Programs: HIV Emergency Relief Project Grants Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Maricopa County Department of Public Health Services Compliance Requirement: Allowable Activities and Costs Criteria or Specific Requirement: In accordance with 2 CFR 200.405 - Allocable Costs - (d) If a cost benefits two or more projects or activities in proportions that can be determined without undue effort or cost, the cost must be allocated to the projects based on the proportional benefit. Condition: Costs charged to the federal program were based on an allocation methodology that was not properly updated for the current period. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2025 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. The Organization will update allocations timely going forward.
View Audit 363873 Questioned Costs: $1
Formula Grants for Rural Areas – Assistance Listing No. 20.509 Recommendation: We recommend the Organization revise its suspension and debarment policy to include process for retaining timestamp of search performed. Explanation of disagreement with audit finding: There is no disagreement with the a...
Formula Grants for Rural Areas – Assistance Listing No. 20.509 Recommendation: We recommend the Organization revise its suspension and debarment policy to include process for retaining timestamp of search performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will take the steps necessary to properly document timing of suspension and debarment search performed. Names of the contact persons responsible for corrective action: Rich Pavek, Executive Director, and Kris Burkey, Finance Manager Planned completion date for corrective action plan: Ongoing
Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categori...
Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization made changes to improve the process and procedure based on the 2023 audit finding, but they were not implemented until midyear 2024 based on the completion of the audit. It is expected that 100% improvement in findings would not take place with this late implementation. There was an improvement over the prior year, especially in the lack of documentation on file. The monthly audit process to spot check applications for accuracy and ensure complete documentation in the chart was also implemented mid-year in 2024.
To Government Officials: The Town of Branford, Connecticut respectfully submits the following corrective action plan for the year ended June 30, 2024. Significant Deficiency in Internal Control over Financial Reporting Recommendation: We recommend that the Town review its formal policies to ens...
To Government Officials: The Town of Branford, Connecticut respectfully submits the following corrective action plan for the year ended June 30, 2024. Significant Deficiency in Internal Control over Financial Reporting Recommendation: We recommend that the Town review its formal policies to ensure that they cover the year-end closing process and ensure that the Town can adjust and close out the general ledger timely, despite personnel changes and/or other extenuating circumstances. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Town has appointed an audit firm and anticipates scheduling field work to begin in early fall with the goal of publishing the FY 24-25 financial statements by the end of January 2026. While we recognize that the recommendation seeks for the Town to be immune from personnel changes and other extenuating circumstances it is also important to underscore that despite our best efforts this plan relies on all parties (Town, BOE and the auditor firm) having adequate resources in place throughout the process. Name(s) of the contact person(s) responsible for corrective action: James P. Finch; Kathryn H. LaBanca Planned completion date for corrective action plan: January 31, 2026
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