Corrective Action Plans

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Finding 2021-002- Material Weakness and Material Noncompliance over Reporting Contact Person: Andrew Wenning Managements Response: We have determined that certain expenses reported through the Department of Health and Human Services PRF reporting portal for period 1 did not reconcile to the underlyi...
Finding 2021-002- Material Weakness and Material Noncompliance over Reporting Contact Person: Andrew Wenning Managements Response: We have determined that certain expenses reported through the Department of Health and Human Services PRF reporting portal for period 1 did not reconcile to the underlying expense details by nature and/or function, and therefore did not comply with PRF reporting requirements. We have implemented a monitoring control over PRF reporting to ensure that expenses submitted through the PRF portal are properly classified by nature and/or function, and that such amounts reconcile to the underlying details and accounting records. Completion Date: April 5, 2024
Allowable costs related to the program are expenses or losses that were not reimbursed from other sources or that other sources were not obligated to reimburse. The Hospital did not reduce COVID-19 related costs claimed under the PRF program for cost-based reimbursements received from the Medicare p...
Allowable costs related to the program are expenses or losses that were not reimbursed from other sources or that other sources were not obligated to reimburse. The Hospital did not reduce COVID-19 related costs claimed under the PRF program for cost-based reimbursements received from the Medicare program for the COVID-19 related expense. The Hospital will ensure the costs included in all subsequent Provider Relief Fund reporting is reduced for amounts reimbursed by other sources.
View Audit 302715 Questioned Costs: $1
2021–006 Allowable Costs Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00233 – 20 Award Period: January 1, 2021 through December 31, 20...
2021–006 Allowable Costs Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00233 – 20 Award Period: January 1, 2021 through December 31, 2021 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria or specific requirement: According to § 75.302 Financial management and standards for financial management systems of 45 CFR Part 75, the non-federal entity’s financial management systems, including records documenting compliance with federal statutes, regulations, and the terms and conditions of the federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions. Further, the financial management system of each non-federal entity must provide accurate, current, and complete disclosure of the financial results of each federal award or program in accordance with the reporting requirements. According to § 75.303 Internal controls of 45 CFR Part 75, the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: Documentation supporting allowable costs was not maintained by the Family Practice. Questioned costs: Unknown Context: During our testing of expenditures we noted two instances where payroll expenditures charged to the grant were not supported the by the employee’s approved wage rate. Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records required to support wage calculations are properly maintained in the files of the Family Practice. Cause: Management oversight. The Family Practice lacked established internal controls and procedures over financial grant management to ensure supporting records and documentation are properly maintained in the files of the Family Practice. Effect: Inability to support compliance with the grant and a potential loss of federal funding. Recommendation: We recommend the Family Practice design controls and procedures to ensure documentation is properly maintained in the files of the Family Practice. Views of responsible officials: There is no disagreement with the audit finding.
2021-003 Material Weakness - Allowable and Unallowable Activities and Allowable Costs Recommendation: We recommend the Family Practice design controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Pract...
2021-003 Material Weakness - Allowable and Unallowable Activities and Allowable Costs Recommendation: We recommend the Family Practice design controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Practice. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Family Practice designed controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Practice. The CEO and CFO roles have been separated into two distinct positions. Separating the roles has significantly strengthened internal controls. Furthermore, a controller has been hired to prepare the reports and maintain appropriate and complete supporting documentation, which will then be reviewed by the CFO and CEO before submission. Name(s) of the contact person(s) responsible for corrective action: Amanda Blodgett, CEO Planned completion date for corrective action plan: December 31, 2024
We agree with the auditors' comments, and the following action will be taken to improve the situation. We have adjusted the Organization’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accounting personnel will ensure t...
We agree with the auditors' comments, and the following action will be taken to improve the situation. We have adjusted the Organization’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accounting personnel will ensure the Organization’s General Ledger specifically details the month of rent and utility allowance being provided so eligible costs are clearly delineated. Someone other than the preparer will perform a review of each drawdown request to ensure that costs are not being drawn down prior to the operating start date of each individual grant. This issue was discussed with HUD in March 2024 at which time procedural changes were implemented. Effective March 2024 the preparer is required to include the month of rent and utility allowance being provided in the General Ledger detail. A review of the General Ledger detail supporting each draw request will be performed by someone other than the preparer to ensure that costs are not being drawn down prior to the operating start date of each individual grant.
View Audit 302371 Questioned Costs: $1
We agree with the auditors' comments, and the following action will be taken to improve the situation. As of the date of this report, we are adjusting the Organization’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. The...
We agree with the auditors' comments, and the following action will be taken to improve the situation. As of the date of this report, we are adjusting the Organization’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. The purpose of this change is to request drawdowns that agree with actual expenses incurred during the draw period requested. Due to late completion of the 2020 audit, recommendations cited in the audit report were not implemented in 2021. During 2022, the practice of tracking grant utilization on a monthly basis was instituted for all grant awards. Documentation of allocation methodologies for shared expenses (i.e., office rent, general office supplies, telephone/internet costs, copiers, payroll processing) had begun. After the 2020 audit report date, all grant draws were supported by the expense detail reflected in the general ledger as prepared by a Sr. Accountant and reviewed and approved by the Chief Financial Officer. Further, monthly reconciliations of grant draw requests and posted revenues, receivables, and expenses will be performed for each grant. The services of an external consultant were utilized to assess the finance department’s staffing levels. This resulted in the onboarding of three (3) new Sr. Accountants and a Chief Financial Officer by early 2022. This provides adequate staffing to perform a review of the federal grant expenditures on a timely basis.
View Audit 302371 Questioned Costs: $1
Finding 2021-003 a. Comments on the Finding and Each Recommendation: Management agrees with both the finding and recommendations. b. Action(s) Taken or Planned on the Finding The management overseeing the process has been completely replaced to ensure a fresh perspective and unwavering dedication to...
Finding 2021-003 a. Comments on the Finding and Each Recommendation: Management agrees with both the finding and recommendations. b. Action(s) Taken or Planned on the Finding The management overseeing the process has been completely replaced to ensure a fresh perspective and unwavering dedication to implementing robust internal controls. To address the shortcomings identified in Finding 2021-003, the Authority commits to a targeted action plan aimed at ensuring timely compliance with reporting requirements. Central to our approach is the engagement of a fee accountant, recognized for expertise in HUD reporting and public housing financial management. This specialist will be tasked with overseeing and streamlining our reporting processes. By leveraging this expertise, we aim to quickly rectify past reporting lapses and ensure future submissions are timely and compliant with HUD requirements. The new fee accountant will conduct a comprehensive review of our current reporting mechanisms, identify bottlenecks, and implement best practices tailored to our operations. This decisive action, centered around the expertise of the newly appointed fee accountant, demonstrates our commitment to enhancing our financial management practices and aligning with HUD's reporting expectations. Through these measures, we anticipate not only meeting HUD's deadlines but also setting a new standard for operational excellence within our Authority.
2021-001 – Internal Controls over Allowable Costs Individual Responsible for Corrective Action Plan: J. Neal Bolton, Director of Revenue Management & Budget Shemaine Rose, Controller Anticipated Completion Date: Completed Management notes that all expenses charged to the federal program were revi...
2021-001 – Internal Controls over Allowable Costs Individual Responsible for Corrective Action Plan: J. Neal Bolton, Director of Revenue Management & Budget Shemaine Rose, Controller Anticipated Completion Date: Completed Management notes that all expenses charged to the federal program were reviewed by the Vice President of Human Resources and the Finance Team, with guidance obtained from independent consultants, however, the documentation of the review was not retained. Management also notes that all expenses were deemed to be appropriately charged to the federal program. In order to ensure documentation is retained evidencing approval of costs, the Authority will require physical sign off on all invoices or electronic approval of all costs charged to the federal program.
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
1. All related administrative and program operational costs have been appropriately classified and documented in QuickBooks beginning in 2022. 2. Monthly review of administrative and program operational costs is performed by management and grant awarders.
1. All related administrative and program operational costs have been appropriately classified and documented in QuickBooks beginning in 2022. 2. Monthly review of administrative and program operational costs is performed by management and grant awarders.
View Audit 301528 Questioned Costs: $1
1. Processes related to the program stating roles of each individual involved in the process were documented and implemented in September 2022. 2. Regular risk assessment and monitoring functions are performed by management and grant awarders.
1. Processes related to the program stating roles of each individual involved in the process were documented and implemented in September 2022. 2. Regular risk assessment and monitoring functions are performed by management and grant awarders.
A grant allocation workbook is prepared monthly by External Bookkeeper and reviewed/approved by Executive Director before allocations are entered in accounting software. The method used has been based on the percentage of time each employee works on the individual programs as determined by managemen...
A grant allocation workbook is prepared monthly by External Bookkeeper and reviewed/approved by Executive Director before allocations are entered in accounting software. The method used has been based on the percentage of time each employee works on the individual programs as determined by management. Both hourly and salaried employees use the percentage method. This method is determined based on the programs being performed for the month. A time study is now being performed on the first week of every quarter for all employees to determine the accuracy of the percentages used in the grant allocation workbook. Responsiblity: External Bookkeeper, PurserBKS, is responsible for preparing monthly Grant Allocation Worksheet for review and approval by Executive Director. Once this is approved then PurserBKS prepares the grant billing documents for Executive Director's review and approval. Responsibility: Marial Ball, Executive Director, reviews and approves all grant billing and submits billing documents to funders. Completion Date: Ongoing
A grant allocation workbook is prepared monthly by External Bookkeeper and reviewed/approved by Executive Director before allocations are entered in accounting software. The method used has been based on the percentage of time each employee works on the individual programs as determined by managemen...
A grant allocation workbook is prepared monthly by External Bookkeeper and reviewed/approved by Executive Director before allocations are entered in accounting software. The method used has been based on the percentage of time each employee works on the individual programs as determined by management. Both hourly and salaried employees use the percentage method. This method is determined based on the programs being performed for the month. A time study is now being performed on the first week of every quarter for all employees to determine the accuracy of the percentages used in the grant allocation workbook. Responsiblity: External Bookkeeper, PurserBKS, is responsible for preparing monthly Grant Allocation Worksheet for review and approval by Executive Director. Once this is approved then PurserBKS prepares the grant billing documents for Executive Director's review and approval. Responsibility: Marial Ball, Executive Director, reviews and approves all grant billing and submits billing documents to funders. Completion Date: Ongoing
Tracking of Eligible Expenditures and Lost Revenues Finding 2021‐006 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: The Authority did not hav...
Tracking of Eligible Expenditures and Lost Revenues Finding 2021‐006 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI‐19 Provider Relief Fund and American Rescue Plan (ARP) 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: The Authority’s management company is reviewing compliance with all laws and regulations and ensuring conditions are met. Responsible Individual: Priacilla Leatherman, VP of Finance Anticipated Completion Date: August 2022
Finding 387369 (2021-007)
Significant Deficiency 2021
Audit Finding Reference: 2021-007 Lack of Documentation to Support Distribution of Wages Management’s View and Planned Corrective Action: After review we have also determined that this documentation was lacking. Since 2021 many changes have occurred. A Time and Effort policy and procedure has been e...
Audit Finding Reference: 2021-007 Lack of Documentation to Support Distribution of Wages Management’s View and Planned Corrective Action: After review we have also determined that this documentation was lacking. Since 2021 many changes have occurred. A Time and Effort policy and procedure has been established, documented and implemented. Federally funded stipends are no longer processed until the Time and Effort Log of hours have been received. Once we have received the form(s), which we now attach to the position in our accounting system we then process in payroll. This procedure is also located in our Federal Funds Handbook. A communication will be sent to Grant Manager’s reminding them of the Time & Effort policy and procedures. Name of Contact Person and Completion Date: Name 1 Amber Wheeler Name 2 Danielle Rossetti Anticipated Completion Date : Procedure has changed a reminder will be communicated by March 30th.
View Audit 299544 Questioned Costs: $1
Management Response and Corrective Action Plan: City’s Response: The City concurs with the finding. Staff responsible for this control during FY 2021 are no longer employed by the City. Corrective Action Plan: CDBG staff worked with program auditors to resolve the issues. Finance Staff and related C...
Management Response and Corrective Action Plan: City’s Response: The City concurs with the finding. Staff responsible for this control during FY 2021 are no longer employed by the City. Corrective Action Plan: CDBG staff worked with program auditors to resolve the issues. Finance Staff and related CDBG staff have been trained to ensure there is not duplication of expenditures in multiple programs. In addition, the City has hired third-party consultants to provide guidance and oversight. Planned Implementation Date: started in Q4 of FY 2023 Responsible Person: Finance Staff and CDBG Staff
View Audit 298952 Questioned Costs: $1
Management continues to evaluate the current controls related to reporting to ensure amounts are appropriately stated. Under a revised calculation, utilizing detailed listings of expenses and updated lost revenue calculations, we have adequate expenses and lost revenues to support funding reported ...
Management continues to evaluate the current controls related to reporting to ensure amounts are appropriately stated. Under a revised calculation, utilizing detailed listings of expenses and updated lost revenue calculations, we have adequate expenses and lost revenues to support funding reported for Periods 1 and 2.
Management continues to evaluate the current controls related to reporting to ensure amounts are appropriately stated. Though the decrease was significant, we have adequate expenses and lost revenues to support funding reported for Periods 1 and 2.
Management continues to evaluate the current controls related to reporting to ensure amounts are appropriately stated. Though the decrease was significant, we have adequate expenses and lost revenues to support funding reported for Periods 1 and 2.
2021-009 – Allocations of Salaries of Other Costs; In February 2024, J.E. Ryan & Associates determined the allocation methodology most appropriate for our Agency is to use square footage. Where appropriate and possible, employees will be directly charged to their funding source (project code). Quart...
2021-009 – Allocations of Salaries of Other Costs; In February 2024, J.E. Ryan & Associates determined the allocation methodology most appropriate for our Agency is to use square footage. Where appropriate and possible, employees will be directly charged to their funding source (project code). Quarterly time studies will be implemented as of April 2024 for employees who work across multiple programs and provide direct care. For employees working in Maintenance, Food Services, Human Resources, Finance, and IT, square footage allocation will be utilized. During the upcoming fiscal year, the Controller will review, on a monthly or quarterly basis, the incurred expenses compared to the UAC approved budget.
Finding 2021-008 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy to ensure reported amounts agreed with under...
Finding 2021-008 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy to ensure reported amounts agreed with underlying supporting documentation. In addition the underlying supporting documentation contained errors. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process to a ensure the report agrees with the under lying supporting documentation. Anticipated Completion Date: Ongoing
Finding 2021-007 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were bei...
Finding 2021-007 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were being reduced by Medicare's reimbursement or claimed on other grants. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process to ensure amounts claimed for this program are reduced by amounts reimbursed or obligated by another source and include a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission Anticipated Completion Date: Ongoing
Finding 2021-006 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA# 93.498 Finding Summary: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were...
Finding 2021-006 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA# 93.498 Finding Summary: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were being in the proper period. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. Anticipated Completion Date: Ongoing
Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues ...
Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues was reviewed and approved. Accordingly, the errors in the lost revenue calculation spreadsheet were not identified by management. In addition, the Hospital did not have an internal control process in place to ensure a review and approval of the Period 1 Report was performed by someone other than the preparer of the report. Responsible Individuals: Scott Callender Corrective Action Plan : The Hospital will implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. Anticipated Completion Date: Ongoing
Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of allowable costs. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document ...
Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of allowable costs. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document in writing, the process and review it with department leaders. Additionally, staff members working in areas concerning this process will be trained to ensure process adherence.
Description of Finding: The allocation of payroll costs to programs are done manually instead of done based on entity-wide timesheets Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: The ERP system...
Description of Finding: The allocation of payroll costs to programs are done manually instead of done based on entity-wide timesheets Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: The ERP system will include electronic timesheets for daily charging to specific grants, as well as more visibility into the proper separation of direct, indirect, and unallowable costs per the CFR. An indirect cost pool allocation structure will be designed and implemented to properly allocate the allowable indirect costs to each work effort. Detailed paper timesheets will be provided in the interim for all employees to ensure compliance with the requirements and provide proper support for all grant costs. Monthly reviews by the Project Directors/Managers plus Accounting will be performed to identify any potential cost charging issues and corrective action(s) required. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Susan Wright, Controller, 256-689-7055, swright@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: March 2024 for detailed paper timesheets, December 2024 for ERP system
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