Corrective Action Plans

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Corrective Action: 1. Review and revise existing policies and procedures for the application of indirect rates with the appropriate oversight by the Finance/Accounting department across federal grants to ensure accuracy and compliance with relevant regulations. 2. Review the allowable indirect rate ...
Corrective Action: 1. Review and revise existing policies and procedures for the application of indirect rates with the appropriate oversight by the Finance/Accounting department across federal grants to ensure accuracy and compliance with relevant regulations. 2. Review the allowable indirect rate methodologies to ensure the method used is based upon an equitable distribution across federal and non-federal programs. 3. Provide training to relevant staff on the revised policies, procedures to ensure the proper application of the indirect rate and calculation of indirect costs.
View Audit 364224 Questioned Costs: $1
Authority personnel responsible for resolution: Amy Bidwell Corrective Action Response: This finding relates to federal award draws requested by the previous administration. The requests were made prior to a grant amendment being finalized which would have made current expenditures eligible. Manag...
Authority personnel responsible for resolution: Amy Bidwell Corrective Action Response: This finding relates to federal award draws requested by the previous administration. The requests were made prior to a grant amendment being finalized which would have made current expenditures eligible. Management agrees with this finding and is following Uniform Guidance requirements to ensure that all eligible expenditures and incurred and eligible prior to requesting remimbursement from federal funds. Completed date: 10/01/2024
View Audit 364214 Questioned Costs: $1
Federal Agency Name: Department of Homeland Security Pass-Through Entity: State of Iowa Department of Homeland Security and Emergency Management Assistance Listing Number: 97.039 Program Name: Hazard Mitigation Grant Program Finding Summary: In two of two draw requests tested, we noted that the Coo...
Federal Agency Name: Department of Homeland Security Pass-Through Entity: State of Iowa Department of Homeland Security and Emergency Management Assistance Listing Number: 97.039 Program Name: Hazard Mitigation Grant Program Finding Summary: In two of two draw requests tested, we noted that the Cooperative did not have formal documentation to support the review of the draw prior to submission for reimbursement. Corrective Action Plan: The Cooperative will prepare an internal request for funds, which will include the amount being requested along with supporting documentation justifying the request. This request will be reviewed and signed by both the Accountant III preparing the documentation and the Vice President of Finance & Administration. Once approved, the request will be submitted to the appropriate authority for further processing. Responsible Individual(s): Faith Warden, VP, Finance & Administration and Sam Moore, Accountant III Anticipated Completion Date: July 2025
Finding #2024-003 Section 202 Supportive Housing for the Elderly – (Capital Advance) – ALN 14.157: Recommendation: We recommend that management should deposit the required funds in the future into the residual receipts reserve account within the 60-day requirement. Action taken: Carpenter Apartmen...
Finding #2024-003 Section 202 Supportive Housing for the Elderly – (Capital Advance) – ALN 14.157: Recommendation: We recommend that management should deposit the required funds in the future into the residual receipts reserve account within the 60-day requirement. Action taken: Carpenter Apartments agrees with the auditor’s recommendations and will implement procedures to ensure timely and accurate deposits in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.
2024-007 Missing Supporting Documentation for Federal Reimbursement Claims Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. A process for retaining claims and supporting documentation has been implemented.
2024-007 Missing Supporting Documentation for Federal Reimbursement Claims Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. A process for retaining claims and supporting documentation has been implemented.
View Audit 364023 Questioned Costs: $1
Finding 573173 (2024-002)
Significant Deficiency 2024
Views of Responsible Officials: One out of the two drawdowns for the major program during 2024 was not supported with a P&L to substantiate the costs were expended against the program. This drawdown was initiated and executed by the previous CFO, Deborah Edwards, and the appropriate documentation wa...
Views of Responsible Officials: One out of the two drawdowns for the major program during 2024 was not supported with a P&L to substantiate the costs were expended against the program. This drawdown was initiated and executed by the previous CFO, Deborah Edwards, and the appropriate documentation was not available. In 2025, AcademyHealth initiated a new control under the direction of the Director of Grants and Contracts, Tamika King. On a monthly schedule, the Grants and Contracts Associate will prepare each payment request by reviewing timecard reports and reconciling costs to the Job Cost Transactions report. The Director of Grants and Contracts will subsequently review and log the prepared request. The log will be reviewed with the CFO and Senior Accounting Manager during the weekly cash flow meetings.
2024-001 - (Noncompliance) Uniform Guidance Written Policies/Procedures Federal Program: Assistance Listing #16.812 Second Change Act Reentry Initiative, Passed Through Pennsylvania Commission on Crime and Delinquency, Pass-Through Entity Identifying Number: 36758 Condition/Context: While the Organi...
2024-001 - (Noncompliance) Uniform Guidance Written Policies/Procedures Federal Program: Assistance Listing #16.812 Second Change Act Reentry Initiative, Passed Through Pennsylvania Commission on Crime and Delinquency, Pass-Through Entity Identifying Number: 36758 Condition/Context: While the Organization has informal policies and procedures surrounding the administration of its federal programs, these policies and procedures have not been formally documented to ensure compliance with the areas of allowability of costs, cash management, procurement, travel, conflict of interest or subrecipient monitoring as required under the Uniform Guidance. Corrective Action Plan: To address this finding and strengthen our internal controls and compliance framework, CCAP will be implementing the following corrective actions: 1. Policy Development and Documentation: o We will be initiating a project to develop and formalize comprehensive written policies and procedures in the following required areas:  Allowability of Costs (2 CFR §200.403–§200.405)  Cash Management (2 CFR §200.305)  Procurement Standards (2 CFR §200.317–§200.326)  Travel Costs (2 CFR §200.474)  Conflict of Interest (2 CFR §200.112)  Subrecipient Monitoring (2 CFR §200.331–§200.333) o These policies will reference relevant Uniform Guidance sections and incorporate internal controls, approval processes, and documentation standards. 2. Internal Review and Approval: o Draft policies will be reviewed by senior leadership, legal counsel (if necessary), and the finance and grants teams to ensure alignment with regulatory requirements and operational realities. 3. Training and Dissemination: o Once finalized, all relevant staff (including program managers, finance personnel, and procurement staff) will receive training on the new policies. o Policies will be made available on CCAP’s intranet. 4. Ongoing Maintenance and Review: o A process will be established for annual review and update of these policies to incorporate regulatory changes and feedback from internal audits or grantor reviews.
The Financial Aid Office has added system controls that will assure that disbursements that are recorded on PeopleSoft is recorded on COD to assure that the Pell reporting requirements are executed in compliance with Federal statutes. The process consisted of creating automation that and reducing th...
The Financial Aid Office has added system controls that will assure that disbursements that are recorded on PeopleSoft is recorded on COD to assure that the Pell reporting requirements are executed in compliance with Federal statutes. The process consisted of creating automation that and reducing the manual intervention so that the issues preventing the Pell disbursement from being recorded on COD is reduced. We are adding automation for processing: FABATCH, ATB automation, and Citizenship automation.
Review of Claim Forms and Expenditure Reconciliation Recommendation: We recommend that there is an appropriate reviewer of each grant claim and monthly reconciliation. Action planned/taken in response to the finding: Management will evaluate their current processes and procedures during staffing tra...
Review of Claim Forms and Expenditure Reconciliation Recommendation: We recommend that there is an appropriate reviewer of each grant claim and monthly reconciliation. Action planned/taken in response to the finding: Management will evaluate their current processes and procedures during staffing transitions in fiscal year 2025 to ensure that proper review of claim forms and expenditure reconciliation. Names(s) of the contact person(s) responsible for corrective action: Paul Kunesh and Brian Johnson Planned completion date for corrective action: December 31, 2025
Item: 2024-003 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Arizona Department of Health Services Compliance Requirement: Reporting Criteria or Specific Requirement:...
Item: 2024-003 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Arizona Department of Health Services Compliance Requirement: Reporting Criteria or Specific Requirement: Per the grant agreements, award recipients are required to submit monthly reimbursement report within a set number of days after month end. Condition: Financial reimbursement reports were submitted after the required due date. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2025 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. The Organization will submit required reports timely going forward.
Item: 2024-001 Assistance Listing Number: 93.914 Programs: HIV Emergency Relief Project Grants Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Maricopa County Department of Public Health Services Compliance Requirement: Allowable Activities and Costs Criteria or...
Item: 2024-001 Assistance Listing Number: 93.914 Programs: HIV Emergency Relief Project Grants Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Maricopa County Department of Public Health Services Compliance Requirement: Allowable Activities and Costs Criteria or Specific Requirement: In accordance with 2 CFR 200.405 - Allocable Costs - (d) If a cost benefits two or more projects or activities in proportions that can be determined without undue effort or cost, the cost must be allocated to the projects based on the proportional benefit. Condition: Costs charged to the federal program were based on an allocation methodology that was not properly updated for the current period. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2025 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. The Organization will update allocations timely going forward.
View Audit 363873 Questioned Costs: $1
Finding 572993 (2024-002)
Significant Deficiency 2024
Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the approval of federal fund drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with...
Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the approval of federal fund drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have reviewed all our internal controls to ensure all approvals are documented. The procedure has been updated to include preparing the draw documentation, entering the accounts receivable invoice into the accounting system, which now requires an approval for all accounts receivable invoices. Once the accounts receivable invoices are approved in the accounting system then a draw down can be requested in the payment management system. This new process to ensure the documented approval of federal fund drawdown's was implemented mid-year 2024, after the three selections in this finding were completed.
AUDIT FINDINGS 2024-001: In one of 25 selections for testwork over period of performance, expenditures related to contract labor were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) that were outside of the project period. Further, the review performed over expenditure...
AUDIT FINDINGS 2024-001: In one of 25 selections for testwork over period of performance, expenditures related to contract labor were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) that were outside of the project period. Further, the review performed over expenditures was not completed appropriately to identify this error, this is an instance of the District’s internal control not operating as designed. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: Assess process and controls for improvements to identify expenditures incurred outside of the designated project period. Anticipated Completion Date: August 2025 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2024-001.
View Audit 363843 Questioned Costs: $1
We accept this finding as per 2 CFR 200.303, a formal documented review and approval process over the indirect cost calculations and online reimbursement requests was not reviewed or approved by someone other than the preparer prior to submittal to the grant agency. We have taken steps to correct t...
We accept this finding as per 2 CFR 200.303, a formal documented review and approval process over the indirect cost calculations and online reimbursement requests was not reviewed or approved by someone other than the preparer prior to submittal to the grant agency. We have taken steps to correct the issue as of June 1, 2025. The Accounting Manager will send the monthly indirect cost allocation report to the Executive Director to review and approve prior to beginning any month-end billing process so if corrections are needed, they can be made prior to reimbursement requests being sent to the grant agency. We have also implemented a new month-end process as of June 1, 2025, for the Accounting Manager to provide a detailed GL report to each Program Manager to review and approve program expenses for the given month prior to any billing requests being submitted to the grant agency.
The Housing Authority takes the recommendation from the audit regarding CFP. All CFPs after 2021 have been designated 25% to operating. CFP 21 was changed with permission from the Portfolio Manager at the time and the annual plan included this money to go to operating. All future designations in ...
The Housing Authority takes the recommendation from the audit regarding CFP. All CFPs after 2021 have been designated 25% to operating. CFP 21 was changed with permission from the Portfolio Manager at the time and the annual plan included this money to go to operating. All future designations in EPIC will show the amount to go to operating. However, the HA is not currently able to access CFP 21 in EPIC to edit it – it is locked.
Action Taken: Management agrees with the finding noted above. Management will also note that as a repeated finding we do not so much offer a corrective action plan as we do a summarization of steps already taken to close this finding for fiscal 2025. A new and highly qualified Chief Financial Office...
Action Taken: Management agrees with the finding noted above. Management will also note that as a repeated finding we do not so much offer a corrective action plan as we do a summarization of steps already taken to close this finding for fiscal 2025. A new and highly qualified Chief Financial Officer with over 30 years of public housing experience was hired by the agency in April of 2024. The CFO has fully staffed the department with competent and qualified individuals including a new and fully qualified Controller and Director of Finance. All individuals hired have received targeted training from both internal and external sources. In June 2024 the new financial management team implemented a policy/procedure for the records requirement and payment timeframes for all capital fund draw downs. This policy requires the hand signing of eLOCCS forms and reconciliation of individual draws at the time of drawdown. During fiscal 2025 the entire Finance staff was trained extensively on all matters related to HUD accounting. Specific training was directed to the Capital Fund program, its eligibility standards, accounting processes, and drawdown procedures. This training was conducted by a nationally recognized HUD-specific trainer. The Authority has hired a qualified, experienced internal auditor. The internal auditor has completed a 100% testing sample on capital fund draws made in fiscal 2025. His observations were rectified, and the policy revised where needed. The sampling assured that supporting documentation was sufficient for audit, that it matched the amounts drawn, and that invoices were paid within HUD dictate s timeframes. Management feels that with this policy and enhanced testing in place the finding will not be repeated in 2025. Management expects closure of this finding, under the direction of the Chief Financial Officer, for the Fiscal 2025 audit.
View Audit 363741 Questioned Costs: $1
Finding 2024-02 – Material Weakness in Internal Control over Compliance with Allowable Costs and Reporting Management agrees that due to turnover in staff during 2023 and 2024, there were gaps in communication leading to the cost allocation formulas and leadsheet account reconciliations not being up...
Finding 2024-02 – Material Weakness in Internal Control over Compliance with Allowable Costs and Reporting Management agrees that due to turnover in staff during 2023 and 2024, there were gaps in communication leading to the cost allocation formulas and leadsheet account reconciliations not being updated on a continuing basis as reimbursement requests were being to the California Department of Social Services. Management believes that all key accounting positions have since been filled by qualified personnel. A formal close process and reconciliation of all balance sheet accounts and indirect cost allocations each month will ensure reimbursement requests are complete and accurate. Process documentation is also being prepared to help personnel in the accounting department follow proper control procedures. Action: Develop and document process for drawdown calculation and year end reconciliation to accounting records. Due Date: 10/1/25 Staff: Carrie Castillo, Executive Director
Revew and Update: Accounting and Personnel Policies and Procedures and update to follow OMB's Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards (UG).
Revew and Update: Accounting and Personnel Policies and Procedures and update to follow OMB's Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards (UG).
We agree with the auditor’s comments and the following action will be taken to improve this situation. Second Harvest staff are currently developing an appropriate cost allocation plan which will address direct costs and indirect costs including salary, fringe benefits, and non-salary costs. Throug...
We agree with the auditor’s comments and the following action will be taken to improve this situation. Second Harvest staff are currently developing an appropriate cost allocation plan which will address direct costs and indirect costs including salary, fringe benefits, and non-salary costs. Through this process a spreadsheet will be developed to better distribute costs appropriately across all federal programs operated by Second Harvest and efforts supported through additional funding sources. This corrective action will be implemented by October 1, 2025.
Continuum of Care -Assistance Listing No. 14.267 Recommendation: We recommend that management implement a policy that both the preparer and reviewer {two separate individuals) of the drawdown requests document each of their sign offs upon completion of their process, including review of the matchin...
Continuum of Care -Assistance Listing No. 14.267 Recommendation: We recommend that management implement a policy that both the preparer and reviewer {two separate individuals) of the drawdown requests document each of their sign offs upon completion of their process, including review of the matching requirement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The preparer of the reimbursement and match documentation will be a different person than the person who draws down funds from the ELOCCS system. The preparer will sign and date the reimbursement packet that is presented to the finance staff for review prior to draw down. A separate person will approve the reimbursement packet and will draw down funds from the ELOCCS system. Name{s) of the contact person{s) responsible for corrective action: Laura Caldwell, President & CEO Planned completion date for corrective action plan: July 15, 2025
Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of reporting. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document in wri...
Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of reporting. 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.
FEDERAL AWARDS—CORRECTIVE ACTION PLAN REFERENCE # 2024-001 Federal Transit Cluster - ALN Number: 20.507; 20.525; and 20.526 Contract Number: C40261TECHINSP; C33941EFA-MTAB; C40265TECH-MTAB; U3NY-2023-101-02 and U9NY-2018-059-01 Significant Deficiency-Non-Compliance Agen...
FEDERAL AWARDS—CORRECTIVE ACTION PLAN REFERENCE # 2024-001 Federal Transit Cluster - ALN Number: 20.507; 20.525; and 20.526 Contract Number: C40261TECHINSP; C33941EFA-MTAB; C40265TECH-MTAB; U3NY-2023-101-02 and U9NY-2018-059-01 Significant Deficiency-Non-Compliance Agency: U.S. Department of Transportation Criteria: Activities Allowed/Allowable Costs/Cost Principles including Indirect Costs––Direct - As stated in Uniform Grant Guidance - §200 Requirements for Allowable Costs: a. Costs did not consist of improper payments, including (1) payments that should not have been made or that were made in incorrect amounts (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements; (2) payments that do not account for credit for applicable discounts; (3) duplicate payments; (4) payments that were made to an ineligible party or for an ineligible good or service; and (5) payments for goods or services not received (except for such payments where authorized by law). Condition/Context: The MTA has Activities Allowed/Allowable Costs/Cost Principles including Indirect Costs procedures in place. MTA has corporate policies and procedures regarding Activities Allowed/Allowable Costs. We tested the Federal Transit Cluster’s Allowable Costs compliance. Based on our review of sixty samples related to Personnel Services and Other than Personnel Services for this cluster, we noted that four samples related to an MTA Bus Company personnel’s hourly rate were charged at higher rate. We noted that the rate per personnel file and employee payroll register differs from the actual rate used by the agency to charge labor costs. The agency calculated labor cost using the annual earnings that is divided by 52 weeks because there are 52 weeks a year, but MTA payroll department used 52.1428 weeks based upon 365/7 days a week, which created variances in labor costs billed and actual recorded labor costs. For Contract # - U3NY-2023-101-02 and U9NY-2018-059-01 – We noted two instances of sixty samples reviewed where the agency used 2023 approved overhead rate of 98.18% instead of the 2024 approved overhead rate of 98.98%. Recommendation: We recommend that MTA ensure that all personnel are reviewed and should be charged at the correct hourly rates as required by §200 CFR Subpart E – Allowable Costs. We also recommend that approved indirect rate applied to direct costs. Corrective Action Plan: MTA Bus will work with the project team to implement the correct rate and calculate the variance. MTA Bus will return the credit to the FTA as needed. Going forward, MTA Bus will review the employee wage rates from the official data sources to ensure that the correct rates are applied. SIR Finance will ensure that the overhead rates on the labor sheets are reflecting the correct percentage by adding a "verification measure" to a checklist while performing internal audits and approvals of the invoices prior to submission. Additionally, SIR-Finance will adjust the formatting within the invoice spreadsheets for easier visibility to a potential error in the calculated overhead percentage. Action Date: MTABUS – 1ST QUARTER 2026 SIRTOA - Effective Immediately - on July 2025 Invoices Final Implementation Date: MTABUS – 2ND QUARTER 2026 SIRTOA – July 2025 Name And Phone Number of Person Responsible For Implementation: MTABUS Marixsa Rivera Assistant Budget Chief • Project Development 718-927-8056 SIRTOA Marissa Rand Assistant Director, Finance & Timekeeping - SIR 347-694-6448
View Audit 363411 Questioned Costs: $1
Finding 2024-003 See response to finding 2024-002.
Finding 2024-003 See response to finding 2024-002.
View Audit 363328 Questioned Costs: $1
OICA has instituted a new policy and procedure whereby all grant-related expenditures shall be reviewed by both the Finance Team and the Grant Administration team to ensure that spend is both appropriate and in line with budgeted expectations. Included in this new policy is the requirement that req...
OICA has instituted a new policy and procedure whereby all grant-related expenditures shall be reviewed by both the Finance Team and the Grant Administration team to ensure that spend is both appropriate and in line with budgeted expectations. Included in this new policy is the requirement that requests for funds under the grant be accompanied by evidence that there is a prior disbursement or existing obligation.
See response to finding 2024-001.
See response to finding 2024-001.
View Audit 363177 Questioned Costs: $1
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