Corrective Action Plans

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2021-002: Auditee has improperly tracked grant awards and expenditures. Recommendation: We recommend the WDBEA maintains an effort to properly track and report federal awards and expenditures. Action Taken: Finance Manager, Frances-Tribble Adams, has taken appropriate action and has reconciled ac...
2021-002: Auditee has improperly tracked grant awards and expenditures. Recommendation: We recommend the WDBEA maintains an effort to properly track and report federal awards and expenditures. Action Taken: Finance Manager, Frances-Tribble Adams, has taken appropriate action and has reconciled accounting records to ensure grant revenues and expenditures are adequately tracked in the future. Name of Person Responsible for Corrective Action: Frances Tribble-Adams, Finance Manager. Anticipated Completion Date of Corrective Action: July 1, 2021.
Corrective Action Plan For Year Ended December 31, 2021 Contact Person: Jason Feldhaus, Executive Director jason@thresholdcoc.org 402.290.6106 FINDING 2021-003: Allowable Costs All receipts for expenses of the Organization are attached to the transaction in bill.com, which then gets transferred to t...
Corrective Action Plan For Year Ended December 31, 2021 Contact Person: Jason Feldhaus, Executive Director jason@thresholdcoc.org 402.290.6106 FINDING 2021-003: Allowable Costs All receipts for expenses of the Organization are attached to the transaction in bill.com, which then gets transferred to the accounting system, QuickBooks Online. Additionally, backup for landlord payments is saved in a separate folder for reference. Prior to payment approval of an expense, the approver confirms there is adequate backup for the allowable costs. A policy will be included in the updated Financial Policies and Procedures manual in 2024. Reasonable completion date: Already implemented (October 31, 2024 for policy updates) Responsible Party: Jason Feldhaus, Executive Director
View Audit 317998 Questioned Costs: $1
Finding No.: 2021-040 AL Program: 97.050 - Presidential Declared Disaster Assistance to Individuals and Households – Other Needs Area: Allowable Costs/Cost Principles Questioned Costs: $247,774 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: The CNM...
Finding No.: 2021-040 AL Program: 97.050 - Presidential Declared Disaster Assistance to Individuals and Households – Other Needs Area: Allowable Costs/Cost Principles Questioned Costs: $247,774 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: The CNMI disagrees with this finding. The Lost Wages Assistance Program is not a reimbursement program. A drawdown of funds obligated was needed prior to services being rendered. After all payments were made, eligible expenses were calculated and submitted in the Lost Wages Assistance Program Final Closeout that was submitted to FEMA. After the closeout, the CNMI understands that the remaining funds will need to return the overdrawn amount. The final closeout document was received from FEMA on June 13, 2024.
View Audit 317760 Questioned Costs: $1
Finding No.: 2021-031 AL Program: 21.027 - Coronavirus State and Local Fiscal Recovery Funds Area: Allowable Costs/Cost Principles Questioned Costs: $1,035,442 Contact Person(s): Thomasa DLG. Naraja, Sr. Financial Analyst, SOF Corrective Action Plan: The Department of Finance agrees with t...
Finding No.: 2021-031 AL Program: 21.027 - Coronavirus State and Local Fiscal Recovery Funds Area: Allowable Costs/Cost Principles Questioned Costs: $1,035,442 Contact Person(s): Thomasa DLG. Naraja, Sr. Financial Analyst, SOF Corrective Action Plan: The Department of Finance agrees with this finding. To address the findings identified, the Department of Finance (DOF) will conduct a thorough review of policies and procedures related to allowable costs/cost principles. We will review the $1,035,442 in questioned costs to identify specific deficiencies in documentation and expand our sample to ensure all instances of insufficient documentation are captured. The DOF will review current policies and procedures governing allowable costs/cost principles. This review aims to identify any gaps or ambiguities that may have contributed to the audit findings. The DOF is committed to updating these policies and procedures promptly to clarify requirements for documenting costs and strengthen controls over compliance. Proposed Completion Date: Ongoing
View Audit 317760 Questioned Costs: $1
Finding No.: 2021-026 AL Program: 21.019 - Coronavirus Relief Fund Area: Allowable Costs/Cost Principles Questioned Costs: $20,341,913 Contact Person(s): Ryan Camacho, Sr. Financial Analyst / Pam Marigmen, Sr. Financial Analyst, SOF Office Corrective Action Plan: The Department of Finance ...
Finding No.: 2021-026 AL Program: 21.019 - Coronavirus Relief Fund Area: Allowable Costs/Cost Principles Questioned Costs: $20,341,913 Contact Person(s): Ryan Camacho, Sr. Financial Analyst / Pam Marigmen, Sr. Financial Analyst, SOF Office Corrective Action Plan: The Department of Finance agrees with this finding under ALN# 21.019. We have completed our review and proposed adjustments to accurately reflect expenditures in compliance with grant policies and requirements. Moving forward, we have implemented policies and procedures to ensure that all documentation is uploaded to the new financial system, and proper review and documentation are included to verify the allowability of expenditures within grant policies and requirements. Proposed Completion Date: Completed
View Audit 317760 Questioned Costs: $1
Finding No.: 2021-017 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Allowable Costs/Cost Principles Questioned Costs: $402,941 Contact Person(s): Jazmin Camacho, Sr. Financial Analyst, OMB Corrective Action Plan: Condition 1 & 2: The OMB disagrees...
Finding No.: 2021-017 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Allowable Costs/Cost Principles Questioned Costs: $402,941 Contact Person(s): Jazmin Camacho, Sr. Financial Analyst, OMB Corrective Action Plan: Condition 1 & 2: The OMB disagrees with this finding. Compact Impact grants often operate on a reimbursement basis.  This means that when the award is received, we request payment or a transfer of expenses to cover prior expenses that have already been incurred and paid.  Therefore, the memo that was processed for such request and other supporting documents can be provided.  Condition 3: We agree and acknowledge the concerns regarding CNMI’s enforcement of recordkeeping and monitoring controls over compliance with allowable costs and costs principles. We also recognize the issues related to monitoring cumulative expenditures and approved funding limits. We are taking immediate steps to address these shortcomings and will implement corrective actions to ensure compliance and proper monitoring going forward. We appreciate your patience and understanding as we work to rectify these issues. Proposed Completion Date: Ongoing
View Audit 317760 Questioned Costs: $1
Finding No.: 2021-012 AL Program: 10.539 - CNMI Nutrition Assistance Area: Allowable Costs/Cost Principles Questioned Costs: $1,620 Contact Person(s): Margaret Aldan, NAP Administrator Corrective Action Plan: Condition 1: The CNMI-NAP disagrees with this finding. The following employee is ...
Finding No.: 2021-012 AL Program: 10.539 - CNMI Nutrition Assistance Area: Allowable Costs/Cost Principles Questioned Costs: $1,620 Contact Person(s): Margaret Aldan, NAP Administrator Corrective Action Plan: Condition 1: The CNMI-NAP disagrees with this finding. The following employee is not a NAP employee. When work is performed for NAP, the hours spent will be compensated but in a Journal Entry procedure. This is a fund transfer from one account to another under the MOA. Conditions 2 and 3: CNMI-NAP disagrees with the finding. The attached NOPAs and other payroll documents indicated the correct pay rate specified to the employees. Please refer to the supporting documents provided to clear this finding. Proposed Completion Date: Ongoing
View Audit 317760 Questioned Costs: $1
FINDING 2021-002 – Lack of Written Policies for Federal Grants (Repeated from Prior Year Findings 20-003, 19-004, 18-003, and 17-002) CONDITION: As of April 2021, Regional Office developed, but did not implement written procedures concerning cash management, the determination of allowability ...
FINDING 2021-002 – Lack of Written Policies for Federal Grants (Repeated from Prior Year Findings 20-003, 19-004, 18-003, and 17-002) CONDITION: As of April 2021, Regional Office developed, but did not implement written procedures concerning cash management, the determination of allowability of costs in accordance with Subpart E – Cost Principles of the Uniform Guidance and the terms and conditions of the federal award. For the period of July 2020 through March 2021 the Regional Office utilized informal procedures in which each purchase made or cost allocated to the IDEA – Improvement Grant - Part D was reviewed for allowability by an individual with knowledge of the budget, allowable costs and activities, and the cash management requirements. The allowability determinations were based on the amounts included in the budgets for the IDEA – Improvement Grant - Part D approved by, and the grant periods set by, the Illinois State Board of Education. PLAN: The Regional Office has developed written policies and procedures related to the Uniform Guidance. ANTICIPATED DATE OF COMPLETION: Fiscal Year 2021 CONTACT PERSON: Mr. Chris Tennyson, Regional Superintendent for Lee, Ogle, and Whiteside Counties.
Corrective action: Management understands the due date for single audit reporting package submission to the Federal Audit Clearinghouse and filed the 2021 single audit reporting package in August 2024.
Corrective action: Management understands the due date for single audit reporting package submission to the Federal Audit Clearinghouse and filed the 2021 single audit reporting package in August 2024.
Management acknowledges the findings and has implemented a corrective action plan to enhance compliance with Federal awards. This plan includes developing Standard Operating Procedures (SOPs) for grant management activities, identifying and documenting existing internal controls, and maintaining con...
Management acknowledges the findings and has implemented a corrective action plan to enhance compliance with Federal awards. This plan includes developing Standard Operating Procedures (SOPs) for grant management activities, identifying and documenting existing internal controls, and maintaining constant communication with stakeholders to prevent material noncompliance. Additionally, PREPA will provide training to staff on the new SOPs and establish a monitoring mechanism to continuously assess and improve the effectiveness of these controls. The corrective action plan, supervised by Mr. Ezequiel Nieves from the PREPA Disaster Funding Management Office, is expected to be completed by July 2025. Management is committed to addressing deficiencies, ensuring that processes and controls are robust and effective, and that Federal awards are managed transparently and in full compliance with all regulatory requirements. Effective June 1, 2021, the Authority transitioned the management and operation of its transmission and distribution network as well as certain back- office functions, including billing, collections and accounting, to a third party. The third-party operator is reviewing operating procedures and controls within its responsibilities to make the necessary improvements. Management will work to address these findings with the assistance of the third-party operators, where applicable. Also, effective July 1, 2023, the Authority transitioned the management and operation of its generation assets as well as certain back- office functions to a third party. The thirdparty operator is reviewing operating procedures and controls within its responsibilities to make the necessary improvements. In addition, the Authority will also be implementing and monitoring corrective actions taken by the new generation segment operator. Contact Name Responsible for Corrective Action Plan - Ezequiel Nieves Estimated Completion Date - July 2025
2 CFR Part 200.303(a) states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the federal award in compliance with federal statutes, regulations, and terms and conditions of the federal awar...
2 CFR Part 200.303(a) states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the federal award in compliance with federal statutes, regulations, and terms and conditions of the federal award. Section 200.507 of the Uniform Guidance states that the program-specific audit shall be completed, and reporting required submitted within the earlier of 30 calendar days after receipt of the auditors’ report, or nine months after the end of the audit, unless a longer period is specified in a program-specific audit guide. During 2023, we have strengthened internal controls related to review of the quarterly lost revenue calculations and reporting in the PRF reporting portal. Going forward, we will complete our audits and submit the required reports by the deadlines. We have taken appropriate steps to identify all other assistance received by quarter during the period of availability on the PRF report going forward.
FINDINGS - FEDERAL AWARDS Finding Number: 2021005 Finding Type: Significant Deficiency Condition: Program income was not used by DCCCMH to meet their matching requirements. DCCCMH reported allowable net program costs in excess of actual net allowable program costs of $15,569 and $3,446 for grants...
FINDINGS - FEDERAL AWARDS Finding Number: 2021005 Finding Type: Significant Deficiency Condition: Program income was not used by DCCCMH to meet their matching requirements. DCCCMH reported allowable net program costs in excess of actual net allowable program costs of $15,569 and $3,446 for grants M10071L5F011912 and Ml0439L5F011903, respectively. Management Response: Management acknowledges that program income generated from specific programs is to be used to cover net allowable program costs or to meet matching requirements. DCCCMH will implement measures to track program income for grant programs and will use program income to offset allowable program costs when preparing financial status reports. A final review of the use of program income will be performed by the Finance team before the annual audit commences. These measures will be incorporated into the updates to the financial policies and procedures for grant programs.
View Audit 315464 Questioned Costs: $1
Corrective action has been immediately implemented in response to the auditors' recommendation. As financial reporting is still in process of getting to current, the City anticipates findings to be reduced in future fiscal years.
Corrective action has been immediately implemented in response to the auditors' recommendation. As financial reporting is still in process of getting to current, the City anticipates findings to be reduced in future fiscal years.
View Audit 315185 Questioned Costs: $1
Finding 478312 (2021-006)
Significant Deficiency 2021
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City has other eligible costs that were not claimed for this grant that can be used to offset the questioned cost. Procedures are already in place to enhance payrate ...
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City has other eligible costs that were not claimed for this grant that can be used to offset the questioned cost. Procedures are already in place to enhance payrate calculations in the future. Planned Implementation Date: Implemented as of April 2024 Responsible Person(s): City Controller
View Audit 314981 Questioned Costs: $1
Finding 478311 (2021-008)
Significant Deficiency 2021
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The general accounting policy will be updated for the accountant to check the payroll register to accrue retroactive pay changes to the correct period. The payroll policy...
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The general accounting policy will be updated for the accountant to check the payroll register to accrue retroactive pay changes to the correct period. The payroll policy will also be updated to require that timecards be updated with supervisor signature if changes are made to change allocation to another fund. Planned Implementation Date: June 30, 2024 Responsible Person(s): City Controller
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The payroll policy will be updated to require that timecards be updated with supervisor signature if changes are made to change allocation to another fund. Planned Implem...
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The payroll policy will be updated to require that timecards be updated with supervisor signature if changes are made to change allocation to another fund. Planned Implementation Date: June 30, 2024 Responsible Person(s): City Controller
Finding 478307 (2021-003)
Significant Deficiency 2021
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The general accounting policy will be updated for the accountant to check the payroll register to accrue retroactive pay changes to the correct period. Planned Implementa...
Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The general accounting policy will be updated for the accountant to check the payroll register to accrue retroactive pay changes to the correct period. Planned Implementation Date: June 30, 2024 Responsible Person(s): City Controller
Finding 406040 (2021-003)
Significant Deficiency 2021
Finding No. 2021-003 – Reporting - Late filing of data collection form and reporting package Corrective Action Plan Commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be the designated officer in charge of concluding all necessary procedures, including the audit of financial sta...
Finding No. 2021-003 – Reporting - Late filing of data collection form and reporting package Corrective Action Plan Commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be the designated officer in charge of concluding all necessary procedures, including the audit of financial statements and single audit, for the Hospital to file its reporting package within it´s due date, as required by the CFR. Also, Mr. Julio Colón, Chief Financial Officer, will be the designated officer in charge of supervising and monitoring compliance with timely submittance each year. Name (s) of the Contact Person (s) Responsible for Corrective Action Mr. Julio Colón, Chief Financial Officer Anticipated Completion Date December 2024
Finding 406039 (2021-002)
Significant Deficiency 2021
Finding No. 2021-002 - Reporting Corrective Action Plan On July 29, 2022, all pending reports were submitted to AAFAF. Also, commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be de designated officer in charge of submitting the report by its due date and Mr. Julio Colón, Chief ...
Finding No. 2021-002 - Reporting Corrective Action Plan On July 29, 2022, all pending reports were submitted to AAFAF. Also, commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be de designated officer in charge of submitting the report by its due date and Mr. Julio Colón, Chief Financial Officer, will be de designated officer in charge of supervising and monitoring compliance with timely submittance each month. Name (s) of the Contact Person (s) Responsible for Corrective Action Julio Colón, Chief Financial Officer Anticipated Completion Date Completed on July 29, 2022
County Judge/Executive’s Response: The Fiscal Court has contracted with Compass to ensure are compliant.
County Judge/Executive’s Response: The Fiscal Court has contracted with Compass to ensure are compliant.
County Judge/Executive’s Response: The Fiscal Court has contracted with Compass to ensure that expenses for Federal Reimbursement are eligible for reimbursement.
County Judge/Executive’s Response: The Fiscal Court has contracted with Compass to ensure that expenses for Federal Reimbursement are eligible for reimbursement.
View Audit 311338 Questioned Costs: $1
The CFO and accounting team at Iroquois Memorial Hospital and Resident Home worked with its financial statement auditors and the HRSA audit support desk for Provider Relief Funds to identify a plan to update its documentation as well as update its internal records to reflect allowable costs under th...
The CFO and accounting team at Iroquois Memorial Hospital and Resident Home worked with its financial statement auditors and the HRSA audit support desk for Provider Relief Funds to identify a plan to update its documentation as well as update its internal records to reflect allowable costs under the program. One of the updates included utilization of additional lost revenue to cover nonallowable expenses under the first phases of reporting for Provider Relief Funds due to elimination of some expenses and reduction for Medicare cost reimbursement against expenses. Management developed a more detailed expense log and review those against current terms and conditions prior to any future portal submissions and took into account the use of additional lost revenue. The worksheets were mocked up internally as if these were submitted in the portal in Phase I reporting so that in the future for the next phases of reporting, these lost revenues are not utilized toward future Provider Relief Funding. One additional control being added for this reporting is that the CEO and CFO will be also completing a detailed review of the spreadsheets for entry into the portal and comparing this to the Compliance Supplement which governs the use of the Provider Relief Funds as to allowable costs as well as the Frequently Asked Questions (FAQs) available on HRSAs website. This may impact future reports, so management will ensure to take these updates into account on any future provider relief funds are they are released or future grant receipts if the Organization receives new grants in the future.
Compliance Finding 2021‐007 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority did not have internal controls established over the federa...
Compliance Finding 2021‐007 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority did not have internal controls established over the federal award to ensure the federal award has been managed in compliance with federal, states, regulations and conditions of the federal award. Corrective Action Plan: We will modify internal control policies to ensure there is an understanding of reporting requirements to ensure that reports are accurate and amounts are not inadvertently claimed that are considered unallowable. Responsible Individual: Doran Hammett, Chief Financial Officer Anticipated Completion Date: June 2024
2021-006—Allowable Costs Corrective Action: FCCH Management shall conduct training of human resource and accounting personnel to ensure they understand the requirement for allowable costs under 2 CFR Part 225 and shall follow the principles in 2 CFR Part 200, Subpart E. Current policies and procedu...
2021-006—Allowable Costs Corrective Action: FCCH Management shall conduct training of human resource and accounting personnel to ensure they understand the requirement for allowable costs under 2 CFR Part 225 and shall follow the principles in 2 CFR Part 200, Subpart E. Current policies and procedures shall be reviewed to ensure adequacy of measures to ensure compliance. FCCH leadership shall also be trained in the elements of allowable cost principles. Person Responsible: Shawna Gonzales, Chief Financial Officer and Abigail Jackson, Human Resources Director Completion Date: December 31, 2024
View Audit 310507 Questioned Costs: $1
Recommendation: The Auditor recommends that the Entity implement controls for documenting and retaining information on expenditures charged to federal awards to follow the requirements over 2 CFR Section 200.430(g)(i) and in addition the Entity is properly paying employees at the approved pay rate. ...
Recommendation: The Auditor recommends that the Entity implement controls for documenting and retaining information on expenditures charged to federal awards to follow the requirements over 2 CFR Section 200.430(g)(i) and in addition the Entity is properly paying employees at the approved pay rate. Action Taken: 1. Policy Revision and Development: o Develop or revise existing policies to clearly define the processes for documenting and retaining expenditure information related to federal awards. These policies should explicitly follow the requirements over 2 CFR Section 200.430(g)(i), ensuring that all expenditures are properly documented and justified as per federal award conditions. Specifically, approval of differential rates will be added to those policies. o Ensure that the policy includes guidelines for regularly reviewing employee pay rates against approved rates for compliance with federal award conditions. 2. Training and Awareness Programs: o Implement comprehensive training programs for all staff involved in charging costs to federal awards. This training should cover the importance of compliance with federal regulations, specifically focusing on the documentation and retention of expenditure information and adherence to approved pay rates. o Schedule regular refresher training sessions to ensure ongoing compliance and awareness. 3. Enhanced Monitoring and Audit Trails: o Introduce monitoring mechanisms to regularly review expenditures charged to federal awards for compliance with documented policies and federal requirements. o Develop an audit trail system that allows for the easy retrieval of documentation supporting expenditures and payroll compliance. This system should enable auditors to trace the documentation back to the federal award and the approved budget items. 4. Internal Control Improvements: o Review and strengthen internal controls related to the processing of expenditures and payroll to ensure that all transactions are authorized, recorded accurately, and in compliance with federal award requirements. o Implement segregation of duties where possible, to reduce the risk of errors or fraud in the charging of costs to federal awards. 5. Regular Compliance Reviews and Updates: o Conduct periodic internal reviews to assess compliance with federal award requirements and the effectiveness of the implemented corrective actions. o Ensure that any changes in federal regulations or award-specific requirements are promptly incorporated into the hospital's policies and training programs. 6. Documentation and Communication: o Maintain comprehensive records of all actions taken to address the audit findings, including policy revisions, training sessions, and internal review outcomes. Specifically, records for those these expenditures will remain onsite and not sent to long-term storage if the employee or vendor no longer has a relationship with the facilities. o Communicate regularly with federal awarding agencies to update them on the corrective actions taken and to seek guidance on compliance matters as needed. Implementation Timeline and Responsibility Assignment: • Management positions including the CEO, CFO and CNO for the 2021 fiscal year are no longer employed by Terry Memorial Hospital District. Administration employed in 2023 acknowledges these deficiencies and accepts responsibility for developing, applying and maintaining this corrective action plan going forward. • Assign specific responsibilities to designated staff members or departments for each component of the corrective action plan. • Set clear deadlines for the completion of each action item, with an initial goal to address all significant deficiencies within one to three months from the date of the audit report. Monitoring and Reporting: • Establish a mechanism for ongoing monitoring of the effectiveness of the corrective action plan, with periodic reports to senior management and the board of directors. Feedback Loop: • Create a feedback loop with employees and management to continuously improve internal controls and compliance processes based on practical experiences and challenges encountered during implementation. Responsible Person: Whitney Wilson, CFO
View Audit 310010 Questioned Costs: $1
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