Corrective Action Plans

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FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: The School Corporation stated that 100% of Free/Reduced lunch applications were reviewed during the audit period. However, testing of controls indicated that 100% of Free/Reduced lunch applications were not b...
FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: The School Corporation stated that 100% of Free/Reduced lunch applications were reviewed during the audit period. However, testing of controls indicated that 100% of Free/Reduced lunch applications were not being reviewed by an individual other than the individual making the initial determination. As a result, three of forty sampled students received the incorrect eligibility status in the system software when compared to supporting documentation (Direct Certifications and/or income-based applications). Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Currently all income based applications for free/reduced lunch status are processed by Pam Frost and then reviewed by the Business Manager. Beginning in the 2024-2025 school year Direct Certification students will also be reviewed by the Business Manager. Anticipated Completion Date: August 31, 2024
FINDING 2023-003 Finding Subject: Child Nutrition Cluster – Activities Allowed or Unallowed Summary of Finding: The School Corporation did not have internal controls in place over payroll disbursements charged to the food service program. Payroll disbursements were paid without evidence that the det...
FINDING 2023-003 Finding Subject: Child Nutrition Cluster – Activities Allowed or Unallowed Summary of Finding: The School Corporation did not have internal controls in place over payroll disbursements charged to the food service program. Payroll disbursements were paid without evidence that the detailed report of payroll disbursements was reviewed and approved by another person not involved in the original payroll process. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Currently the Business Manager and Food Service Director hold a monthly financial meeting to review the status of finances for the Food Service. A review of the payroll distribution reports for the previous month will be added to the agenda of this meeting. Anticipated Completion Date: March 31, 2024
Recommendation: We recommend that internal controls be strengthened and processes implemented to ensure all draw down requests are reviewed and approved to ensure costs were accurately reported and paid before requesting reimbursement. Grantee Response and Corrective Action Plan 2023-001: We concur...
Recommendation: We recommend that internal controls be strengthened and processes implemented to ensure all draw down requests are reviewed and approved to ensure costs were accurately reported and paid before requesting reimbursement. Grantee Response and Corrective Action Plan 2023-001: We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. Previously draw down documentation was uploaded to a shared folder, in which the CEO and Fiscal Manager had access. In 2024, we implemented additional procedures to document review of drawdowns and supporting documentation. Additionally, documentation includes attaining the CEO signature on draw down documentation before the draw down is made. Responsible Parties: Jemea Dorsey, CEO Date Corrected: April 30, 2024
Plan of Action: A New Cash Management Procedure was implemented on 5/5/24. We have also developed a tracking system in Microsoft Forms for the Project Director or Authorizing Officer to request and approve funds.
Plan of Action: A New Cash Management Procedure was implemented on 5/5/24. We have also developed a tracking system in Microsoft Forms for the Project Director or Authorizing Officer to request and approve funds.
View Audit 356257 Questioned Costs: $1
Finding 560112 (2023-004)
Significant Deficiency 2023
We will reconcile all of 2024 accounts to ensure accuracy. Expenditure and reimbursement of all federal funds will be recorded timely and accurately.
We will reconcile all of 2024 accounts to ensure accuracy. Expenditure and reimbursement of all federal funds will be recorded timely and accurately.
Finding 560003 (2023-002)
Significant Deficiency 2023
Finding Reference Number: 2023-002 Description of Finding: The security deposits, residual receipts, and replacement reserve were not properly established in separate bank accounts, and the required monthly deposits to the replacement reserve were not made. Statement of Concurrence or Nonconcurrence...
Finding Reference Number: 2023-002 Description of Finding: The security deposits, residual receipts, and replacement reserve were not properly established in separate bank accounts, and the required monthly deposits to the replacement reserve were not made. Statement of Concurrence or Nonconcurrence: Management agrees with this finding. Corrective Action: Management has set up separate bank accounts and continues to make the required deposits. Name of Contact Person: Kimalee Williams, CEO - Faith Asset Management, LLC, (860) 528-5000, kimalee@faithassetmgt.com Projected Completion Date: December 15, 2024
COVID-1 9 Coronavirus State and Local Fiscal Recovery Funds — Assistance Listing No. 21 .027 Recommendation: We recommend the District design controls to ensure an adequate review process over the invoices recorded and presented on the schedule of expenditures of federal awards to determine complian...
COVID-1 9 Coronavirus State and Local Fiscal Recovery Funds — Assistance Listing No. 21 .027 Recommendation: We recommend the District design controls to ensure an adequate review process over the invoices recorded and presented on the schedule of expenditures of federal awards to determine compliance with the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District’s policies will be updated and approved if needed to conform to federal guidance. Name(s) of the contact person(s) responsible for corrective action: Ron McEachern, General Manager or Delia Stoor, Accounting Manger Planned completion date for corrective action plan: September 30, 2024
Name of Contact Person: Veronica Williams, Interim Executive DirectorCorrective Action:KHMA’s Board has approved new written policies and procedures and are in place now.Appropriate staff have begun taking proper safeguards for Capital Fund Program management to ensure proper accountability. This in...
Name of Contact Person: Veronica Williams, Interim Executive DirectorCorrective Action:KHMA’s Board has approved new written policies and procedures and are in place now.Appropriate staff have begun taking proper safeguards for Capital Fund Program management to ensure proper accountability. This includes the oversight of processing payments of CFP expenditures, which includes the following procedures for: 1) payment of invoices; 2) requisition of funds; 3) monitoring; and 4) reporting of CFP funds.payment of InvoicesAll CFP invoices will be reviewed and clearly marked as approved and documented to show that the source of funds for payment are CFP grant funds by the Executive Director prior to payment. The Executive Director will specify the general ledger code, including the BLI account to be used for payment processing on the invoice before providing the invoice to the accounts payable clerk.Under no circumstances will a payment be made if KMHA has not drawdown and received the respective CFP funds.With the exception of funds associated with BLI 1406 “Operations”, PHAs have three (3) business days to issue and mail the check once the CFP funds are received.The Executive Director/accounts payable clerk will specify the BLI account and CFP grant year on the check voucher prior to sending the check voucher to the fee accountant for financial statement processing.Requisition of FundsFor each drawdown, the Executive Director will print the associated eLOCCS Voucher Payment form from the eLOCCS system.The Executive Director will document the check number(s) and vendor(s) associated with each CFP draw (i.e., the eLOCCS Voucher Payment form). In addition, each individual draw shall be numbered for reference purposes.A copy of each draw shall be submitted to the fee accountant to ensure proper reporting of the grant drawdown.With the exception of funds associated with BLI 1406 “Operations”, in no case shall a draw be made without the proper approved invoices.MonitoringThe fee accountant's monthly financial statements will include a CFP report for each grant which will be reviewed by the Executive Director for proper coding and accuracy.Folder has been created to track all required information in the management of a CFP grant to include correspondence to and from HUD, expenses, grant reimbursements, budgets, closeout documentation and EPIC management.Proposed Completion Date: Immediately
Finding 559163 (2023-003)
Significant Deficiency 2023
Management agrees with the finding and has developed and implemented the appropriate policies and procedures effective September 2024.
Management agrees with the finding and has developed and implemented the appropriate policies and procedures effective September 2024.
In alignment with this audit finding, Illuminate Colorado has implemented processes to improve working capital and address cash flow challenges, including:  improved invoicing procedures to ensure timely submission of invoices to minimize time elapsed between submission of invoices to funders and r...
In alignment with this audit finding, Illuminate Colorado has implemented processes to improve working capital and address cash flow challenges, including:  improved invoicing procedures to ensure timely submission of invoices to minimize time elapsed between submission of invoices to funders and reimbursement of those invoices, and  seeking increased working capital via a larger line of credit or other source (foundation, corporate, or individual donations) In addition, Illuminate Colorado is in process of developing a Standard Operating Procedure to ensure consistent identification of vendors utilized for direct Federal assistance programs in order to prioritize payment of those vendors with federal drawdown receipts. Standard Operating Procedure will include:  Process to identify vendors paid with federal funds  Process to monitor invoice timelines of vendors paid with federal funds  Process to prioritize payments of vendors paid with federal funds following federal drawdowns  Process for internal review of payment timelines
Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: ...
Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: Management was unable to reproduce a detailed listing of expenses incurred that agreed to the amounts submitted under the federal award for reimbursement. Planned Corrective Action: Management agrees with the finding and will review its policies and procedures to ensure that a detailed listing of expenses submitted for reimbursement is maintained. Planned Completion Date: Ongoing Person Responsible: Mary Young, Director of Operations
2023‐009 Reporting Annual Project and Expenditures Report (Material Weakness): The City did complete the Project and Expenditures Report but just not timely as a result of staff turnover during the actual fiscal year. Since taking office in fiscal year 2024, the current Finance Director has prioriti...
2023‐009 Reporting Annual Project and Expenditures Report (Material Weakness): The City did complete the Project and Expenditures Report but just not timely as a result of staff turnover during the actual fiscal year. Since taking office in fiscal year 2024, the current Finance Director has prioritized compliance with federal reporting requirements. As of fiscal year 2025, all required project and expenditures reporting has been completed and submitted in accordance with U.S. Department of Treasury guidelines. To prevent future occurrences, the Finance Department has implemented internal controls ensuring multiple staff members are responsible for federal reporting. Specifically, both the Finance Director and the Financial Analyst now share the responsibility and authority to complete and submit these annual reports. This new process ensures continuity in reporting, even in the event of staff turnover, and strengthens the City’s commitment to compliance with federal funding requirements. In addition, The City’s Procurement officer now maintains responsibility for grants from award to reversion date. A tracking file is maintained for all active grants at the point it is awarded, expended, and reimbursement received to ensure this process is properly managed. Additionally, the Finance Director oversees this responsibility so there are now multiple controls to ensure timely completion.
Management recognizes its compliance requirements for maintaining and implementing sound controls over financial reporting and the potential non-compliance impacts of a lack of such control environment. Leadership is currently considering options for adequate oversight and review. Until such time th...
Management recognizes its compliance requirements for maintaining and implementing sound controls over financial reporting and the potential non-compliance impacts of a lack of such control environment. Leadership is currently considering options for adequate oversight and review. Until such time that adequate staffing for review is in place, a member of management or their designee will review claims.
1. Enhance Document Retention Procedures: *We will update our document retention policy to clearly define retention periods for payroll-related records, ensuring compliance with legal and regulatory requirements. This will include retaining all necessary documentation such as payroll reports, tax fi...
1. Enhance Document Retention Procedures: *We will update our document retention policy to clearly define retention periods for payroll-related records, ensuring compliance with legal and regulatory requirements. This will include retaining all necessary documentation such as payroll reports, tax filings, and third-party payroll contracts. *A secure, organized system will be implemented for storing payroll-related documents, whether physical or digital. This will include utilizing secure cloud storage or an enterprise document management system with restricted access controls. *We will conduct a quarterly review to ensure that documents are being retained for the appropriate time frame and securely disposed of when no longer required. 2. Implement Stronger Controls During Payroll Provider Transitions: *We will formalize and document the process for changing third-party payroll providers. This process will include detailed steps for due diligence, transition planning, data transfer procedures, and ensuring continuous payroll processing during the transition period. *A project team will be assigned for every payroll provider change to ensure proper planning, including backup and contingency plans, data verification, and communication with both internal and external stakeholders. *A comprehensive review of the transition will be conducted after each change, including a reconciliation of payroll records to ensure that all data is accurately transferred, and all systems are functioning properly. 3. Vendor Oversight and Service Level Agreements (SLAs): *We will ensure that future contracts with third-party payroll providers include clear Service Level Agreements (SLAs) outlining the provider's responsibilities in terms of document retention, data security, and transition procedures. This will ensure that providers maintain the necessary standards and practices for managing payroll-related documents.
View Audit 353876 Questioned Costs: $1
Condition: During the audit it was noted that, in most of the instances, employee timecards were missing. Plan: The Club will review their monitoring procedures to ensure consistent retention of employee timecards. Anticipated Date of Completion: As soon as possible – before FY25 year end Name of Co...
Condition: During the audit it was noted that, in most of the instances, employee timecards were missing. Plan: The Club will review their monitoring procedures to ensure consistent retention of employee timecards. Anticipated Date of Completion: As soon as possible – before FY25 year end Name of Contact Person: Germain Castellanos, CEO Management Response: Since the audit, we have reviewed our monitoring procedures to ensure consistent approval of employees timecards.
Condition: During the audit it was noted that there were twenty-three individuals who did not have documentation of the correct wage that was used on the grant expenditure report. The Club also does not keep any copies of the invoices to back up which expenses are allocated to the grant. Plan: The C...
Condition: During the audit it was noted that there were twenty-three individuals who did not have documentation of the correct wage that was used on the grant expenditure report. The Club also does not keep any copies of the invoices to back up which expenses are allocated to the grant. Plan: The Club plans to review the issue with its current procedures and revise them as necessary to provide better controls over grant expenditures. Anticipated Date of Completion: As soon as possible – before FY25 year end Name of Contact Person: Germain Castellanos, CEO Management Response: Since the audit, we have started to keep the documentation for each salary increase and review in the employee’s personnel files and the supplies that have been purchased.
Condition: During the audit it was noted that instances of wages submitted for reimbursement for two Club employees were more than gross wages that should have been assigned to the grant based on the amount of the paycheck and the percentage allocation. Plan: The Club plans to review the issue with ...
Condition: During the audit it was noted that instances of wages submitted for reimbursement for two Club employees were more than gross wages that should have been assigned to the grant based on the amount of the paycheck and the percentage allocation. Plan: The Club plans to review the issue with its current procedures and revise them as necessary to provide better controls over grant expenditures. Anticipated Date of Completion: As soon as possible – before FY25 year end Name of Contact Person: Germain Castellanos, CEO Management Response: Since the audit, we have evaluated our procedures related to grant reimbursement requests review and we are working on improving our current procedures.
View Audit 353845 Questioned Costs: $1
Finding 555148 (2023-005)
Significant Deficiency 2023
Views of Responsible Officials: SAMU management has ordered that all SAMU staff that corresponds with grantor personnel has to document such correspondence via emails or other means the afreed procedures including those of delayed submission of drawdowns.
Views of Responsible Officials: SAMU management has ordered that all SAMU staff that corresponds with grantor personnel has to document such correspondence via emails or other means the afreed procedures including those of delayed submission of drawdowns.
Finding 555110 (2023-001)
Material Weakness 2023
Effective October 1, 2023, management implemented extensive accounting and documentation controls to ensure full accounting and reporting compliance on direct costs incurred for all federal grants and expenditures. These controls are reviewed and monitored for compliance by management on a periodic ...
Effective October 1, 2023, management implemented extensive accounting and documentation controls to ensure full accounting and reporting compliance on direct costs incurred for all federal grants and expenditures. These controls are reviewed and monitored for compliance by management on a periodic basis during the year.
View Audit 353705 Questioned Costs: $1
Finding 554895 (2023-003)
Material Weakness 2023
Finding Number: 2023-003 Allowable Costs; Cash Management (Material Weakness) Programs: Unaccompanied Alien Children Program ALN#93.676 Contract#: 90ZU0323 & 90ZU0548 Contract Period: 07/01/22 - 06/30/23 Planned Corrective Action: The auditors noted that certain payroll expenses and other than ...
Finding Number: 2023-003 Allowable Costs; Cash Management (Material Weakness) Programs: Unaccompanied Alien Children Program ALN#93.676 Contract#: 90ZU0323 & 90ZU0548 Contract Period: 07/01/22 - 06/30/23 Planned Corrective Action: The auditors noted that certain payroll expenses and other than personnel service (OTPS) expenses are not being charged directly or allocated to the correct cost center in the accounting system monthly. Therefore, the amounts being drawn down during any given month may not be fully supported until the year-end when a reallocation of costs by function occurs. Beginning in FY 2025, personnel costs are being manually recorded to the correct cost centers in Serenic Navigator each month. A parallel review of employee setups in ADP, our payroll system, led to the reassignment of staff to appropriate cost centers as needed. Going forward, ADP cost center assignments will be reviewed monthly to reflect any departmental changes. These steps are expected to reduce manual adjustments, improve the accuracy of interim financials, and ensure more precise federal and program drawdowns. Additionally, OTPS expenses have been charged directly or allocated to the appropriate cost centers on a monthly basis since the start of FY 2025. Person Responsible: The Executive Director and Chief Financial Officer Completion Date: April 30, 2025
Federal Award Findings Finding 2023-001 Lack of Internal Controls Over Cash Management Name of Contact Person: Galen Gilbert, First Chief Corrective Action Plan: AVC staff were unable to complete a drawdown for the HUD grants due to a change in staff. AVC is working with HUD to resolve the matt...
Federal Award Findings Finding 2023-001 Lack of Internal Controls Over Cash Management Name of Contact Person: Galen Gilbert, First Chief Corrective Action Plan: AVC staff were unable to complete a drawdown for the HUD grants due to a change in staff. AVC is working with HUD to resolve the matter. AVC staff is currently drawing down all other funds in a timely matter. AVC has limited unrestricted cash. AVC is currently looking for opportunities to increase unrestricted cash, such as increasing prices for gas and electric. Proposed Completion Date: July 31, 2024
View Audit 353454 Questioned Costs: $1
Material Weakness in Compliance and Internal Control over Compliance Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence is retained by ICEDC as proof of oversight of expenditure of federal funds. Additionally, we recommend adding ...
Material Weakness in Compliance and Internal Control over Compliance Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence is retained by ICEDC as proof of oversight of expenditure of federal funds. Additionally, we recommend adding a review and approval process for the ED’s timesheets. There is no disagreement with the audit finding. Action taken in response to finding: ICEDC appreciates CLA’s recommendation to enhance processes concerning the retention of documentary evidence of approvals and importance of maintaining strong oversight of expenditures, especially when handling federal funds. ICEDC will place greater emphasis on obtaining and retaining documentation of approvals related to the expenditure of funds. This documentation will serve as proof of oversight, ensuring compliance with federal regulations and enhancing transparency in fund management. A formal review and approval process will be established for the Executive Director's (ED’s) timesheets. This process will involve periodic reviews by a designated authority and documentation will be retained to maintain a clear audit trail. Name(s) of the contact person(s) responsible for corrective action: Kristina Hines Planned completion date for corrective action plan: 8/31/2025
View Audit 353072 Questioned Costs: $1
Corrective Action: The Organization has plans to transition to a new digital software to electronically receive meal counts
Corrective Action: The Organization has plans to transition to a new digital software to electronically receive meal counts
Finding 554133 (2023-017)
Significant Deficiency 2023
Public Health’s Office of AIDS (OA) agrees with the finding and recommendation. OA introduced and fully implemented an internal Secondary Review (SR) process for all AIDS Drug Assistance Program (ADAP) applications in March 2018. This SR process enables ADAP staff to verify that contracted and certi...
Public Health’s Office of AIDS (OA) agrees with the finding and recommendation. OA introduced and fully implemented an internal Secondary Review (SR) process for all AIDS Drug Assistance Program (ADAP) applications in March 2018. This SR process enables ADAP staff to verify that contracted and certified enrollment workers across California are consistently adhering to eligibility and documentation requirements. However, due to staffing challenges caused by the redirection of staff during the state of emergency declared for the COVID-19 pandemic, ADAP faced significant workforce shortages from March 2020 through much of 2023. This caused a backlog in SR processing, which delayed tasks, including the review of this client’s application. The client’s eligibility lapsed after 130 days, before SR could be conducted. The Eligibility Operations Section (EOS) of ADAP which conducts SR, is now fully staffed and has successfully addressed the backlog. As of early 2024, SR processing has returned to normal operations and is current. Estimated Implementation Date: Already implemented as of April 2024 Contact: Joseph Lagrama, ADAP Branch Chief California Department of Public Health
DHCS implemented a process to impose payment withholds for significantly late cost reports, which addresses CSA’s recommendations. As of January 1, 2025, DHCS has issued 26 Notices of Delinquency to contracted counties of Short-Doyle funding (two notices for FY 2015-16, four notices for FY 2016-17, ...
DHCS implemented a process to impose payment withholds for significantly late cost reports, which addresses CSA’s recommendations. As of January 1, 2025, DHCS has issued 26 Notices of Delinquency to contracted counties of Short-Doyle funding (two notices for FY 2015-16, four notices for FY 2016-17, one notice for FY 2018-19, three notices for FY 2019-20, six notices for FY 2020-21, and ten notices for FY 2021-22). DHCS has received positive responses from some of the delinquent counties, stating the cost reports should be submitted shortly. If the counties do not submit their cost reports within 30 calendar days of the delinquency notice, DHCS will send a Notice of Intent to Impose Temporary Withhold of Funds with an option to meet and confer. If a county still has not submitted its cost report within 30 calendar days after Notice of Intent to Impose Temporary Withhold of Funds, the county will be put on Final Notice of Intent to Impose Temporary Withhold of Funds with an effective date of 30 days, at which time a withhold of funds will be processed. Estimated Implementation Date: January 1, 2025 Contact: California Department of Health Care Services • Primary – Ryan Whalen, Behavioral Health Interim Settlement, Section Chief, Audit & Investigations (A&I) Financial Review Outpatient and Behavioral Health Division (FROBHD) • Secondary – Lisa Alder, Behavioral Health Financial Review, Branch Chief, A&I FROBHD • Tertiary – Charles Anders, Behavioral Health Financing Branch, Chief, Local Governmental Financing Division (LGFD)
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