Corrective Action Plans

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Findings and Recommendations: Finding Type: Material Noncompliance with Laws and Regulations. Condition: The Academy?s NSFSA?s fund balance exceeded the allowable three months? average expenditures at June 30, 2022. The Academy had approximately 4.61 months of expenditures as fund balance at June ...
Findings and Recommendations: Finding Type: Material Noncompliance with Laws and Regulations. Condition: The Academy?s NSFSA?s fund balance exceeded the allowable three months? average expenditures at June 30, 2022. The Academy had approximately 4.61 months of expenditures as fund balance at June 30, 2022. Recommendation: The Academy should submit a spend down plan and obtain Michigan Department of Education?s prior approval to improve the food quality or take other action to improve the program in accordance with 7 CFR 210.19(a)(2). Corrective Action Plan: The Academy is aware of the finding and has implemented procedures in order to prevent further noncompliance in the future. The Academy is working towards completion of the spend down plan currently in place which was previously approved by Michigan Department of Education. Responsible Department: Business department and Food Service department. Responsible Person: Frank Patterson (Business Manager) in conjunction with the Food Service Director and the Superintendent. Planned Completion Date (TBD or Date): Spend-down plan currently implemented and expected completion prior to June 30, 2023.
CORRECTIVE ACTION PLAN ? Not-for-profit Entity Project Legal Name: RMC Tooele Property, LLC HUD Project No.: 105-43073 Audit Firm: WSRP, LLC Period covered by the audit: Year Ended December 31, 2022 Corrective Action Plan prepared by: Name: LaMar Bangerter Position: CFO of Supporting Entity Telephon...
CORRECTIVE ACTION PLAN ? Not-for-profit Entity Project Legal Name: RMC Tooele Property, LLC HUD Project No.: 105-43073 Audit Firm: WSRP, LLC Period covered by the audit: Year Ended December 31, 2022 Corrective Action Plan prepared by: Name: LaMar Bangerter Position: CFO of Supporting Entity Telephone Number: (801) 397-4051 1. Finding 2022-1 a. Current Findings on Schedule of Findings, Questioned Costs and Recommendations. During the year ended December 31, 2022, management distributed funds before surplus cash was demonstrated at the end of the annual and semi-annual fiscal periods. In accordance with HUD guidelines and requirements regarding the Section 232 Insured Mortgage, distributions may only be made after the end of any annual or semi-annual fiscal period, and when positive surplus cash is demonstrated. b. Actions Planned on the Finding. During the year, excess cash was distributed from the Project to pay for expenses incurred by the parent on behalf of the project as well as the Parent?s own operating expenses. Management has reviewed the loan requirements and will ensure that excess cash will not be pulled from the Project except as allowed under the Section 232 guidelines and at annual or semi-annual intervals. Additional training was provided to the cash manager and a new process was put in place to ensure transfers don't happen in this bank account.
View Audit 31440 Questioned Costs: $1
Finding 2022-002 - Timesheet Signatures Recommendation: Controls should be strengthened to ensure all timesheets are signed by the employee and the employee's supervisor. Background: This appears to be an oversight when obtaining timesheets from employees. Responsible Person: Ericka Downing Correcti...
Finding 2022-002 - Timesheet Signatures Recommendation: Controls should be strengthened to ensure all timesheets are signed by the employee and the employee's supervisor. Background: This appears to be an oversight when obtaining timesheets from employees. Responsible Person: Ericka Downing Corrective Action: The Organization agrees with this finding and will implement the following:? Develop/Design internal controls to provide reasonable assurance that services charged to Federal awards are in accordance with applicable cost principles. ? All timesheets must be reviewed by the employee and their direct supervisor before submission for payroll processing to ensure accuracy of activities and time recorded. ? No time sheet will be processed for payroll by the organization unless the time sheet is signed by the employee and employee?s supervisor. ? Re-train leadership on protocols to ensure accuracy of time worked and grant allowable activities are recorded on time sheets and that all parties sign the timesheet as verification of approval of said activities. Completion date: March 31, 2023
2022-003 U.S. Department of Homeland Security Staffing for Adequate Fire and Emergency Response Activities Allowed or Unallowed and Allowable Costs Reporting Deficiency in Internal Control over Compliance Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Pr...
2022-003 U.S. Department of Homeland Security Staffing for Adequate Fire and Emergency Response Activities Allowed or Unallowed and Allowable Costs Reporting Deficiency in Internal Control over Compliance Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires internal control procedures to be performed over expenditures. During the course of our engagement, we noted reimbursement requests and required reports were not reviewed prior to submission and the City did not have sufficient internal controls over the reporting process. CORRECTIVE ACTION PLAN (CAP): Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Planned in Response to Finding: Management is aware of the compliance issue and will implement the suggested procedures. Official Responsible for Ensuring CAP: Amy Hove, Finance Director, would be responsible for procedures. Planned Completion Date for CAP: Procedures will be implemented in the current fiscal year. Plan to Monitor Completion of CAP: The finance department will review internal control procedures. Sincerely, Amy Hove Finance Director
2022-001 U.S. Department of Homeland Security Staffing for Adequate Fire and Emergency Response Activities Allowed or Unallowed and Allowable Costs The Staffing for Adequate Fire and Emergency Response grant requires grantees to request reimbursement for payroll costs incurred during the applicable ...
2022-001 U.S. Department of Homeland Security Staffing for Adequate Fire and Emergency Response Activities Allowed or Unallowed and Allowable Costs The Staffing for Adequate Fire and Emergency Response grant requires grantees to request reimbursement for payroll costs incurred during the applicable grant period. During the course of our engagement, we noted the City requested grant reimbursement for a greater amount of payroll costs then what was actually incurred during applicable grant periods. CORRECTIVE ACTION PLAN (CAP): Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Planned in Response to Finding: Management is aware of the compliance issue and will implement the suggested procedures. Official Responsible for Ensuring CAP: Amy Hove, Finance Director, would be responsible for procedures. Planned Completion Date for CAP: Procedures will be implemented in the current fiscal year. Plan to Monitor Completion of CAP: The finance department will review reimbursement requests and ensure compliance. Sincerely, Amy Hove Finance Director
CORRECTIVE ACTION PLAN September 26, 2023 U.S. Department of Health and Human Services Harrison County Hospital respectively submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Blue & Co., LLC 2650 Eastpoi...
CORRECTIVE ACTION PLAN September 26, 2023 U.S. Department of Health and Human Services Harrison County Hospital respectively submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Blue & Co., LLC 2650 Eastpoint Pkwy., Suite 300 Louisville, Kentucky 40223 Audit period: Year ended December 31, 2022. The findings from the schedule of findings and questioned costs for the year ended December 31, 2022, are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. FINDINGS ? FEDERAL AWARD PROGRAM AUDITS 2022-001 Condition: When providers are identifying their expenses attributable to coronavirus, they must offset these expenses with any amounts received through other sources, such as direct patient billing, commercial insurance, and other funding received. PRF and/or ARP payments may be applied to remaining expenses or costs, after netting the other funds received or obligated to be received, which offsets those expenses. Management did not net the estimate of funds received through patient billing against expenses claimed. Action: Management will implement internal control procedures to ensure proper reporting of lost revenues, as is required under the reporting guidelines stipulated by HRSA, in future reporting periods. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Dr. Lisa Clunie, CEO, at (812) 738-3730. Sincerely, Dr. Lisa Clunie CEO
Finding No 2022-001 Name of Responsible Party Fred Gibbs FKGibbs Company, LLC PO Box 410312 Kansas City, MO 64141 Fred@fkgibbs.com M: 913.709.1811 Views of Responsible Official and Corrective Action Management will fund residual receipts within the required timeframe going forward. ...
Finding No 2022-001 Name of Responsible Party Fred Gibbs FKGibbs Company, LLC PO Box 410312 Kansas City, MO 64141 Fred@fkgibbs.com M: 913.709.1811 Views of Responsible Official and Corrective Action Management will fund residual receipts within the required timeframe going forward. Expected Date of Completion:
FREMONT SCHOOL DISTRICT NO. 79 44-063-1580-22 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS21 Year Ending June 30, 2022 Corrective Action Plan Finding No.: 2022- 001 Condition: The District did not review the general ledger and ISBE expe...
FREMONT SCHOOL DISTRICT NO. 79 44-063-1580-22 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS21 Year Ending June 30, 2022 Corrective Action Plan Finding No.: 2022- 001 Condition: The District did not review the general ledger and ISBE expenditure reports to ensure grant expenditures were posted and reported correctly. Plan: District has implemented procedures to determine grant expenditures were posted correctly in the general ledger as well as the ISBE expenditure reports. Anticipated Date of Completion: 10/31/2022 Name of Contact Person: Ivy Fleming Management Response: n/a
Reporting views of responsible officials and planned corrective actions Management will put in place controls and procedures to ensure principle, accrued interest, and interest expense on debt is properly accounted for and reported.
Reporting views of responsible officials and planned corrective actions Management will put in place controls and procedures to ensure principle, accrued interest, and interest expense on debt is properly accounted for and reported.
Finding 31635 (2022-005)
Significant Deficiency 2022
Finding 2022-005 Excess Cash - SFA Plan: The University will continue to use the enhanced excess cash identification process which was implemented in May 2022 Expected Implementation Date: May 2022
Finding 2022-005 Excess Cash - SFA Plan: The University will continue to use the enhanced excess cash identification process which was implemented in May 2022 Expected Implementation Date: May 2022
Finding 31634 (2022-008)
Significant Deficiency 2022
Finding 2022-008 Timing of Subrecipient Payments Plan: UIUC- The University of Illinois Urbana-Champaign continues to review and enhance its internal subrecipient payment processes to find ways to identify and prevent untimely subrecipient payments, and to reduce the potential for human error. The U...
Finding 2022-008 Timing of Subrecipient Payments Plan: UIUC- The University of Illinois Urbana-Champaign continues to review and enhance its internal subrecipient payment processes to find ways to identify and prevent untimely subrecipient payments, and to reduce the potential for human error. The University will implement additional internal measures to address inefficiencies related to the current multi-department review, approval, and payment process. UIC - The University of Illinois Chicago will communicate reminders and provide training, as necessary, to parties involved in the subrecipient payment process. The University will continue to monitor and refine procedures. Expected Implementation Date: April 2023
Finding Synopsis: District reported program expenditures did not match District accounting records resulting in overreported program expenditures of $7,971. Action Steps: District will begin utilizing accounting software functionality designed to aid in proper expenditure reimbursement request re...
Finding Synopsis: District reported program expenditures did not match District accounting records resulting in overreported program expenditures of $7,971. Action Steps: District will begin utilizing accounting software functionality designed to aid in proper expenditure reimbursement request reporting. Contact Person: Regina Johnson, Bookkeeper and Casie Bowman, Superintendent. Anticipated Completion Date: February 1, 2023.
View Audit 30475 Questioned Costs: $1
Condition: Quarterly expenditure reports for the projects expenditures were not timely filed for ARP ESSER - Homeless Children and Youth (1 of 2 quarters required). Plan: To avoid this reporting and internal control issue, the District should schedule the due dates of all expenditure reports in orde...
Condition: Quarterly expenditure reports for the projects expenditures were not timely filed for ARP ESSER - Homeless Children and Youth (1 of 2 quarters required). Plan: To avoid this reporting and internal control issue, the District should schedule the due dates of all expenditure reports in order to avoid late filings. Anticipated Date of Completion: June 30, 2023 Name of Contact Person: Lisa Schuenke, Assistant Superintendent of Finance and Human Resources Management Response: This District is aware of the issue and has determined that the majority of the problem occurs when a grant is first approved, and the first reporting period is missed or if a grant continues into subsequent project years. Management has found a dashboard within IWAS that has a listing of all grants by project year and dates that the grants and budgets are approved that will help determine when the first expenditure reports are due. Additionally, management will work on a process to ensure that expenditure reports are no longer missed or filed late.
Finding 31527 (2022-002)
Significant Deficiency 2022
Finding 2022-002: Control Finding?Significant Deficiency?Immunization Outreach?Reporting Contact Person? Adrienne Sturrup, Austin Public Health Director Management Response? Austin Public Health (APH) identified the reporting discrepancy in August 2022 and quickly implemented tighter controls to tra...
Finding 2022-002: Control Finding?Significant Deficiency?Immunization Outreach?Reporting Contact Person? Adrienne Sturrup, Austin Public Health Director Management Response? Austin Public Health (APH) identified the reporting discrepancy in August 2022 and quickly implemented tighter controls to track the timely submission of the Financial Status Reports (FSRs). The new process was fully implemented on 10/1/2022. APH experienced a large increase in grants from multiple sources related to COVID-19. APH also experienced a complete staff turnover and the addition of two accountant positions for grant billing. The new controls are as follows: APH has implemented a monthly checklist for all Accountants to utilize during monthly grant billings. This checklist contains all monthly responsibilities, including each grant requiring FSR, B-13, supplemental forms, invoices/voucher, and any other items required to be submitted to the grantor. This checklist is submitted to the Accounting Manager to review with each grant monthly billing. 1. Each FSR due date is now recorded on the cover sheet check list of each monthly billing. 2. The FSR is submitted to the Accounting Manager with the monthly billing. 3. The grant does not get approved unless requirements 1 and 2 are met. 4. The Accounting Manager then sends the FSR to the Grantor and the accountant to record.
Finding Number: 2022-1 Payment of invoices before 30 days of received. The project staff was oriented about the importance of make a payment 30 days after receive the invoice. The plan of correction empathizes in verify weekly the supplier?s invoices and establish a payment date not more than 30 day...
Finding Number: 2022-1 Payment of invoices before 30 days of received. The project staff was oriented about the importance of make a payment 30 days after receive the invoice. The plan of correction empathizes in verify weekly the supplier?s invoices and establish a payment date not more than 30 days of the invoice was received.
Finding 31455 (2022-002)
Significant Deficiency 2022
Criteria: The terms and conditions of the CARES Act Provider Relief Fund (PRF) distributions state that funds are to only be used to prevent, prepare for and respond to coronavirus, and that funds may only be used for healthcare related expenses or lost revenue that is attributable to the coronaviru...
Criteria: The terms and conditions of the CARES Act Provider Relief Fund (PRF) distributions state that funds are to only be used to prevent, prepare for and respond to coronavirus, and that funds may only be used for healthcare related expenses or lost revenue that is attributable to the coronavirus and represent actual costs. Condition: During the process of identifying expenses that were incurred to prevent, prepare for or respond to the coronavirus pandemic, management utilized projected expenses claimed for reimbursement. Planned Corrective Action: Management will enhance its internal controls over federal award compliance to ensure that only eligible costs are included in amounts expended. Contact Person: Summer Owen, CFO Anticipated Completion Date: December 31, 2023
Audit Recommendation (1): Federal Program: Assistance Listing No.: 10.559 Summer Food Service Program for Children Recommendation: In order to prevent future occurrences of this deficiency, we recommend that management ensure that good record keeping is kept at all buildings of the meals served. We...
Audit Recommendation (1): Federal Program: Assistance Listing No.: 10.559 Summer Food Service Program for Children Recommendation: In order to prevent future occurrences of this deficiency, we recommend that management ensure that good record keeping is kept at all buildings of the meals served. We also recommend the records are reviewed more efficiently each month for accuracy. Implementation Plan of Action(s): ? The District reverted back to using its school food management computer-based system for meal tracking using student ID numbers upon a full return from remote and hybrid learning models implemented in response to the COVID-19 pandemic. Note: This is a repeat finding from the previous year's audit. The testing for this item occurred prior to the full implementation of the previous CAP during the months of October, November, and December 2021. The previous CAP was implemented effective January 2022 - no issues of this nature were found thereafter. Implementation Date: January 17, 2022 Person(s) Responsible for Implementation: ? Holly Heady, School Food Service Director
Management has completed the required, corrective deposit to the residual receipts reserve of $1,704 in April 2023.
Management has completed the required, corrective deposit to the residual receipts reserve of $1,704 in April 2023.
Finding 31353 (2022-004)
Significant Deficiency 2022
2022-004 Condition: There was one Education Stabilization Fund construction project performed by a contractor. Grant expenditures for the project paid by the Education Stabilization Fund totaled $775,262. There was not a prevailing wage clause in the contract and certified payrolls were not receive...
2022-004 Condition: There was one Education Stabilization Fund construction project performed by a contractor. Grant expenditures for the project paid by the Education Stabilization Fund totaled $775,262. There was not a prevailing wage clause in the contract and certified payrolls were not received. Criteria: Wage rate requirements apply to the Education Stabilization Fund when laborers and mechanics employed by contractors or subcontractors work on construction contracts more than $2,000. Laborers must be paid wages not less than those established for the locality of the project (prevailing wage rates) by the Department of Labor (DOL). Nonfederal entities shall include in their contracts, subject to wage rate requirements, a provision that the contractor or subcontractor comply with those requirements and the DOL regulations. This includes a requirement for the contractor or subcontractor to submit to the District weekly payrolls and a statement of compliance (certified payrolls). Cause: The District was not aware that wage rate requirements applied to the construction project. Effect: A reimbursement request was made for expenditures that did not comply with wage rate requirements. Questioned Costs: $775,262 Auditor's Recommendation: Establish controls to comply with wage rate requirements related to the Education Stabilization Fund. Grantee Response: The District will comply with the wage rate requirements for the Education Stabilization Fund going forward. Contact Person: Mary Prielipp Anticipated Completion: June 30, 2023
View Audit 35542 Questioned Costs: $1
Excess Cash in the Food Service Fund Corrective Action Plan (CAP). 1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: The District has developed a plan that has been approved by the School Board. The plan inc...
Excess Cash in the Food Service Fund Corrective Action Plan (CAP). 1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: The District has developed a plan that has been approved by the School Board. The plan includes the purchase of food service equipment, increased quantity and quality of food purchases, and other allowable alternative uses of these excess funds. The District has made a significant investment in purchasing new food service equipment in recent years. The District will continue to work to spend down the Food Service Fund within the allowable uses. 3. Official Responsible for Ensuring CAP: Tom Anderson, Finance Director, is the official responsible for ensuring corrective action. 4. Planned Completion Date for CAP: Fiscal year end 2023. 5. Plan to Monitor Completion of CAP: The District will continue to review and monitor this Food Service fund going forward.
Finding 2022-004: Allowable Costs - Significant Deficiency in Internal Control over Allowable Costs/Cost principles Official's Response and Corrective Action Plan: Prior accounting staff was gone by December 2021. New financial staff was hired and in place in the 4th quarter of April 2022. We made...
Finding 2022-004: Allowable Costs - Significant Deficiency in Internal Control over Allowable Costs/Cost principles Official's Response and Corrective Action Plan: Prior accounting staff was gone by December 2021. New financial staff was hired and in place in the 4th quarter of April 2022. We made changes in the accounting department during the past year to improve the overall functionality. Since we tripled our amount of grants, it was necessary to increase the accounting staff to maintain them, as well as increase overall efficiencies. We now have a staff of 4 accountants, as well as a new CFO with nonprofit/grant experience. The late filling of vacant positions delayed some of our internal processes during their training. We added monthly meetings with internal staff to make sure we have a good communication flow and appropriate documentation for new and existing grants which are monitored monthly Anticipated Completion Date: June 30, 2023
View Audit 31455 Questioned Costs: $1
Finding 31259 (2022-001)
Significant Deficiency 2022
Finding Number: 2022-001 Planned Corrective Action: The correction of this issue has already been in place even prior to this audit. As I have research more on federal funding and ...
Finding Number: 2022-001 Planned Corrective Action: The correction of this issue has already been in place even prior to this audit. As I have research more on federal funding and the criteria for drawing funds and the time line of disbursing them. Vantage has not drawn funds in advance of spending them to date and will continue to follow that method. Anticipated Completion Date: Already in place Responsible Contact Person: Laura Peters, Treasurer/CFO
Finding 2022-003 ?Claims Payments Made Based on Incorrect Calculations of Amounts Reimbursed Status: Under completion. Planned Corrective Action: A review was made by the Foundation?s outside accounting firm engaged to process claims and the errors cited in Finding 2022-003 resulted in only one ...
Finding 2022-003 ?Claims Payments Made Based on Incorrect Calculations of Amounts Reimbursed Status: Under completion. Planned Corrective Action: A review was made by the Foundation?s outside accounting firm engaged to process claims and the errors cited in Finding 2022-003 resulted in only one overpayment to a nursing home. This was confined to a single nursing home that received more than that nursing home would have been entitled to receive under the adopted allocation regime. That nursing home was contacted and has promptly refunded the overage. The Foundation plans to redistribute this amount to other nursing facilities with unmet needs on a ratio and proportion basis. Person(s) Responsible: John Matson, Acting Executive Director Completion Date: October 31, 2023
View Audit 25745 Questioned Costs: $1
CORRECTIVE ACTION PLAN September 8, 2023 U.S. Department of Health and Human Services St. Claire Regional Medical Center, Inc. respectively submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Blue & Co., LLC 2650 East...
CORRECTIVE ACTION PLAN September 8, 2023 U.S. Department of Health and Human Services St. Claire Regional Medical Center, Inc. respectively submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Blue & Co., LLC 2650 Eastpoint Parkway, Suite 300 Louisville, Kentucky 40223 Audit Period: Year ended June 30, 2022 The findings from the Schedule of Findings and Questioned Costs for the year ended June 30, 2022, are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. FINDINGS ? FEDERAL AWARD PROGRAM AUDITS 2022-001 Condition: Untimely disbursement of federal grant funds received: When receiving federal grant funds for the HHS Rural Health Care Services Outreach, Rural Health Network Development, and Small Health Care Provider Quality Improvement Plan Program, the Hospital did not disburse federal grant funds received within 3 working days. Action: Management will implement internal control procedures by December 31, 2023 to ensure proper and timely disbursements of federal grant funds to ensure proper cash management of any future HHS Rural Health Care Services Outreach, Rural Health Network Development, and Small Health Care Provider Quality Improvement Plan Program funds. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Chris McClurg, CFO, at (606) 783-6587. Sincerely, Chris McClurg Chief Financial Officer
2022-003 U.S. Department of Justice Federal Financial Assistance Listing/Federal CFDA #16.575 Victims of Crime Act (VOCA) Cash Management Significant Deficiency in Internal Control over Compliance Finding Summary: The Organization's internal control policy relating to the review over the preparati...
2022-003 U.S. Department of Justice Federal Financial Assistance Listing/Federal CFDA #16.575 Victims of Crime Act (VOCA) Cash Management Significant Deficiency in Internal Control over Compliance Finding Summary: The Organization's internal control policy relating to the review over the preparation of cash draws of federal funds prior to submission was not consistently applied throughout the year. No reviews were noted surrounding the preparation and draws of federal funds prior to submission. Without proper implementation of internal controls over Organization's cash draws, errors could occur and result in the Organization drawing funds in inappropriate amounts or for unallowed costs. We recommend that a member of the Organization's staff who does not prepare the cash draw review the cash draw prior to submission and document that review on a more consistent basis. Status: The Finance Director reviews and approves the prepared cash draw materials prior to submission electronically via email on a consistent basis. Responsibility of: Andrea Lang, Director of Organization Advancement & Jennifer Babcock, Finance Director Estimated Completion Date: Completed. The Finance Director is now reviewing and approving prepared cash draw materials prior to submission.
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