Corrective Action Plans

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Finding Number 2024-001 Contact Person(s): Dionne Gordon dgordon@pnri.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Although the findings consisted primarily of a small number of late payments that were either ...
Finding Number 2024-001 Contact Person(s): Dionne Gordon dgordon@pnri.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Although the findings consisted primarily of a small number of late payments that were either 1 day late or late as a result of a poorly timed holiday, we fully acknowledge the accuracy of the finding and have added an additional control to account for the impact of weekends and holidays on our AP payment runs. Corrective action planned: Internal control established in AP department to keep track of sub recipients’ request reimbursement to ensure payments are disbursed within 30 calendar days after receipt of request. Anticipated completion date: March 31st 2025
An action plan included training and working with the Treasurer to reconcile money market accounts and bank statements.
An action plan included training and working with the Treasurer to reconcile money market accounts and bank statements.
During the fiscal year 2024, the entity experienced staffing shortages. In addition, this was the first year the entity was required to have a single audit. This caused a delay in the 2024 single audit. As of now, staffing has stabilized and the entity does not foresee delays with future audits.
During the fiscal year 2024, the entity experienced staffing shortages. In addition, this was the first year the entity was required to have a single audit. This caused a delay in the 2024 single audit. As of now, staffing has stabilized and the entity does not foresee delays with future audits.
Management's Response and Corrective Action Plan: On July 8, 2024, NPI received a reimbursement from ASHA of $741,559 for invoices that NPI received from Nazareth Hospital prior to June 30, 2024. NPI submitted these invoices for reimbursement on June 29, 2024, and recorded the revenue and the receiv...
Management's Response and Corrective Action Plan: On July 8, 2024, NPI received a reimbursement from ASHA of $741,559 for invoices that NPI received from Nazareth Hospital prior to June 30, 2024. NPI submitted these invoices for reimbursement on June 29, 2024, and recorded the revenue and the receivable, but did not record the expense until the funds were remitted to Nazareth Hospital on July 9, 2024. NPI should have recorded the expense and accrued a liability on June 29, 2024, during the same period in which the revenue was recognized. We acknowledge our failure to properly match the grant expense to the grant revenue in the proper accounting period and affirm that our cash basis of accounting was not appropriate to account for this grant. We have implemented a process to reconcile all grant revenues and expenses at the end of each accounting period to ensure proper recording. Further, the Treasurer of the Organization will take a more active role in reviewing the accounting for grants.
Management's Response and Corrective Action Plan: In past experience with USAID reimbursement requests, payment was received 10-14 days after the request for reimbursement was submitted to the office of CFO.CMP Electronic Invoices (USAID). For example, on October 11, 2022, we submitted a request fo...
Management's Response and Corrective Action Plan: In past experience with USAID reimbursement requests, payment was received 10-14 days after the request for reimbursement was submitted to the office of CFO.CMP Electronic Invoices (USAID). For example, on October 11, 2022, we submitted a request for $308,942.22. Payment was received on October 28, 2022 – 17 days after the request for reimbursement. In the specific case of reimbursement received on September 15, 2023, NPI submitted the request for reimbursement on September 13. In this specific case reimbursement was received within only two days. We acknowledge our failure to remit grant funds to the Nazareth Hospital on a timely basis. For future grant reimbursement requests, we have implemented a plan to be more diligent in monitoring the receipt of grant reimbursements to ensure that we can immediately disburse them to the recipient.
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Numbers and Year: 2405MN5MAP and 2405MN5ADM, 2024 Pass-Through Agency: Minnesota Department of Human Ser...
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Numbers and Year: 2405MN5MAP and 2405MN5ADM, 2024 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2405MN5MAP and 2405MN5ADM Compliance Requirement Affected: Allowable Costs/Allowable Activities Award Period: Year-Ended December 31, 2024 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: It is recommended the Agency implement control procedures to ensure Income Maintenance Random Moment Study (IMRMS) and Social Services Time Study (SSTS) listings are accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Agency will review procedures and implement changes as needed to ensure going forward that the IMRMS and SSTS listings are accurate. Name of the contact person responsible for corrective action plan: Chera Sevcik, Human Services Executive Director Planned completion date for corrective action plan: December 31, 2025
Finding 565796 (2024-001)
Material Weakness 2024
Corrective Action Plan: The Airport and Director of Finance will implement internal controls to properly record capital assets and lease receivables on a timely basis prior to audit fieldwork.
Corrective Action Plan: The Airport and Director of Finance will implement internal controls to properly record capital assets and lease receivables on a timely basis prior to audit fieldwork.
2024-003 Twenty-First Century Community Learning Centers -Assistance Listing No. 84.287 Significant Deficiency in Internal Control Over Compliance and Noncompliance - Appropriate Internal Control Structure Related to Compliance Requirements A. Activities Allowed or Unallowed, B. Allowable Costs/Cost...
2024-003 Twenty-First Century Community Learning Centers -Assistance Listing No. 84.287 Significant Deficiency in Internal Control Over Compliance and Noncompliance - Appropriate Internal Control Structure Related to Compliance Requirements A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, and C. Cash Management Recommendation: The Auditor recommends the policies in accordance with §200.302 Financial Management paragraph (b) (6) and (b)(7) be written by the Organization, approved by the Board of Directors, and included in the permanent files of the Organization. Planned Corrective Action: We agree with the recommendation, and updated our policies in accordance with §200.302 Financial Management paragraph (b) (7) in December 2024 and will update our policies in accordance with (b) (6) by August 2025.
2024-002 Twenty-First Century Community Learning Centers - Assistance Listing No. 84.287 Significant Deficiency in Internal Control Over Compliance and Noncompliance - Appropriate Review of Expenditures Claimed B. Allowable Costs/Cost Principles Recommendation: The Auditors recommend that management...
2024-002 Twenty-First Century Community Learning Centers - Assistance Listing No. 84.287 Significant Deficiency in Internal Control Over Compliance and Noncompliance - Appropriate Review of Expenditures Claimed B. Allowable Costs/Cost Principles Recommendation: The Auditors recommend that management strengthen its review procedures over expense cutoff to ensure that expenditures are recognized on the SEFA in alignment with GMP. Additionally, training should be provided to accounting personnel on Uniform Guidance compliance and GMP requirements related to expense recognition. Planned Corrective Action: We agree with the recommendation and plan to have the corrective action implemented by August 2025.
View Audit 359460 Questioned Costs: $1
CORRECTIVE ACTION PLAN Year Ended June 30, 2024 Finding Number: 2024-001 Planned Corrective Action: Cleveland Play House has had difficulties with finding a long-term replacement for the Director of Finance roll and thus the position has experienced much turnover since June of 2023. During this time...
CORRECTIVE ACTION PLAN Year Ended June 30, 2024 Finding Number: 2024-001 Planned Corrective Action: Cleveland Play House has had difficulties with finding a long-term replacement for the Director of Finance roll and thus the position has experienced much turnover since June of 2023. During this time period, practices have been put in place for the reviewing of grant draws and the approval of time and effort logs. However, the turnover has led to inconsistency with the application of these practices. While the Director of Finance position remains temporarily staffed, there has been improvement in the following of industry best practice for the monitoring of time and effort and grant expenditures. Based on the reduction in questioned costs down from prior year findings and with the continued adherence to best practices for grant costs, Cleveland Play House continues to work towards a clean audit for the fiscal 2025 year ending June 30th, 2025. Anticipated Completion Date: June 30, 2025
View Audit 359414 Questioned Costs: $1
The finding from Section III – 2024-006 General Ledger System Condition: The District did not track the federal expenditures within the general ledger system, or if they were, the business office was unaware of the process and was not using the correct expenditures to claim as eligible expenditures...
The finding from Section III – 2024-006 General Ledger System Condition: The District did not track the federal expenditures within the general ledger system, or if they were, the business office was unaware of the process and was not using the correct expenditures to claim as eligible expenditures. Views of Responsible Officials and Planned Corrective Actions: Southern Fulton School District has hired a Certified Public Accountant (CPA) as the Chief Financial Officer (CFO) as of 4/1/2025 who will be responsible for ensuring that the general ledger system is utilized to track all federal expenditures.
Recommendation: We recommend that accounting staff verify that the federal meal payments received from CDSS are distributed to providers within five working days of receipt. Action Taken: Management agrees with the result of the finding above. As of May 27, 2025, policies and procedures in place wi...
Recommendation: We recommend that accounting staff verify that the federal meal payments received from CDSS are distributed to providers within five working days of receipt. Action Taken: Management agrees with the result of the finding above. As of May 27, 2025, policies and procedures in place will be followed by the Agency staff. The Agency has updated its policies and procedures to ensure timely disbursement of CACFP provider reimbursements. A backup person in the CACFP department will be emailed a copy of the date stamped checks notifying them that a reimbursement check has arrived from CDSS. Having two people in the department receive the notification will ensure that an email is not overlooked and the provider reimbursement is processed within the required timeframe.
Corrective Action Plan: The Accounts Receivable of $1.6 million for the Capital Fund Program was drawn down from eLOCCS on November 27th, 2024. Additionally, the new Executive Director has gained access to eLOCCS.
Corrective Action Plan: The Accounts Receivable of $1.6 million for the Capital Fund Program was drawn down from eLOCCS on November 27th, 2024. Additionally, the new Executive Director has gained access to eLOCCS.
Finding 565337 (2024-001)
Significant Deficiency 2024
To address the identified non-compliance with timely subrecipient payments, the Cook County State’s Attorney Office has implemented an internal invoice submission form designed to streamline and formalize the invoice processing workflow. This form is now utilized by all business managers and program ...
To address the identified non-compliance with timely subrecipient payments, the Cook County State’s Attorney Office has implemented an internal invoice submission form designed to streamline and formalize the invoice processing workflow. This form is now utilized by all business managers and program managers, who have been trained and granted functional access to ensure consistent and accurate usage. Additionally, a dedicated SharePoint site has been established to manage and monitor the invoice submission process. This platform allows for real-time tracking of invoice numbers, amounts, vendor names, and payment statuses, thereby enhancing transparency and accountability. These measures collectively aim to strengthen internal controls, improve communication among parties involved, and ensure compliance with federal cash management requirements moving forward. Party(ies) responsible for overseeing the corrective action plan for the grant programs: - Nader Abusumayah, Chief Accountant, nader.abusumayah2@cookcountysao.org, 312.603.1840 The department plans on completing the above corrective action on 6/1/2025.
Management will have the employee responsible for the review of the LIHEAP Agency Invoice Reports sign each weekly report as approved.
Management will have the employee responsible for the review of the LIHEAP Agency Invoice Reports sign each weekly report as approved.
Finding 565190 (2024-003)
Significant Deficiency 2024
Finding NO. 2024-003 Cash Management View of the University of Guam and Corrective Action Plan: The Financial Aid Office (FAO) will conduct both internal and external monthly reconciliations to ensure the accuracy of financial aid disbursements and compliance with federal regulations. Internally, ...
Finding NO. 2024-003 Cash Management View of the University of Guam and Corrective Action Plan: The Financial Aid Office (FAO) will conduct both internal and external monthly reconciliations to ensure the accuracy of financial aid disbursements and compliance with federal regulations. Internally, the FAO and the Business Office will reconcile actual disbursements and adjustments against drawdowns, drawdown adjustments, refunds of cash, and returns weekly or bi-weekly, following each transmittal to the Business Office. Any discrepancies will be documented and resolved promptly. Externally, the FAO will reconcile with the COD system by the 10th of each month, comparing all disbursements, adjustments, and refunds to the balances reported in COD. A copy of the completed monthly reconciliation will be forwarded to Accounts Receivable as official documentation. Name of Contact Person: Mark Duarte, Director, Financial Aid and Triton One Stop Office Proposed Completion date: Ongoing
To address the issue of meal counts not being properly taken and recorded at the point of service, SCO Family of Services is reinforcing internal controls in accordance with 7 CFR 210.8 to ensure the accuracy of meal counts prior to submitting monthly claims for reimbursement. Staff involved in meal...
To address the issue of meal counts not being properly taken and recorded at the point of service, SCO Family of Services is reinforcing internal controls in accordance with 7 CFR 210.8 to ensure the accuracy of meal counts prior to submitting monthly claims for reimbursement. Staff involved in meal service have received refresher training on proper point-of-service meal counting procedures, and supervisors will continue to conduct routine monitoring to verify compliance. These steps will help ensure that all meal counts are accurately recorded in real-time, supporting the integrity of reimbursement claims. To ensure accountability, the agency is currently in the process of recruting a full-time Food Service Director who will have oversight over the Child Nutrition Porgram and will be responsible for continued compliance, staff training, on-site reviews, and all documentation required by both state and federal regulations. While we will recruit to fill this poistion, an interim Food Service Director will be appointed. Our PQI department will continue to support and monitor activities as well. Proposed Implementation Date: Immediately
In Finding 2024-003, a condition was noted that during the year, the Organization failed to reconcile expenditures prior to drawing federal grant funds. Management recognizes the importance of the requirements to draw federal grant funds only after making qualifying expenditures. In response to Fi...
In Finding 2024-003, a condition was noted that during the year, the Organization failed to reconcile expenditures prior to drawing federal grant funds. Management recognizes the importance of the requirements to draw federal grant funds only after making qualifying expenditures. In response to Finding 2024-003, procedures will be established to reconcile all expenditures prior to making federal grant draws to ensure that advance draws of federal funds do not occur.
Federal Agency Name: Department of Health and Human Services Program Name: Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Federal Financial Assistance Listing #93.912 Compliance Requirement: Cash Management Finding Summary: ...
Federal Agency Name: Department of Health and Human Services Program Name: Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Federal Financial Assistance Listing #93.912 Compliance Requirement: Cash Management Finding Summary: The cash draw requests were done on a prospective basis despite the program requiring that cash draw requests must be for expenditures already incurred or that would be paid within three days. Responsible Individuals: Kayla Trent, Finance Director Corrective Action Plan: Management agrees with the finding and has reviewed the operating procedures of Robert C. Byrd Clinic. Furthermore, we have implemented procedures to understand program requirements related to cash draws. The Clinic began requesting funds only for expenditures already incurred or that would be paid within three days. Anticipated Completion Date: Ongoing
The cash draw findings were focused on tracking staff time and effort. The Museum implemented corrective action regarding the use of time sheets for federal award tracking immediately after the DOE grant performance period and exists for each time period in FY25. The Human Resources department has i...
The cash draw findings were focused on tracking staff time and effort. The Museum implemented corrective action regarding the use of time sheets for federal award tracking immediately after the DOE grant performance period and exists for each time period in FY25. The Human Resources department has incorporated the timesheets into employee training, onboarding, and the updated staff handbook. Already Completed. Kevin Cantfil, VP of Finance and Administration.
Drawdown requests that include reimbursement for time and attendance will include documented approval by one additional staff member. If programmatic staff prepare the drawdown, the VP of Finance and Administration will complete the final approval. If the VP of Finance and Administration prepares th...
Drawdown requests that include reimbursement for time and attendance will include documented approval by one additional staff member. If programmatic staff prepare the drawdown, the VP of Finance and Administration will complete the final approval. If the VP of Finance and Administration prepares the drawdown, a member of the Advancement department will complete the final approval. June 30, 2025. Kevin Cantfil, VP of Finance and Administration.
Item: 2024-001 Assistance Listing Number: 93.243 Program: Substance Abuse and Mental Health Services, Expanded Access to Homeless Services Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: n/a Contract Number: 5H79TI082775-02 Award Year: 9/30/2023 – 9/29/2024 Compl...
Item: 2024-001 Assistance Listing Number: 93.243 Program: Substance Abuse and Mental Health Services, Expanded Access to Homeless Services Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: n/a Contract Number: 5H79TI082775-02 Award Year: 9/30/2023 – 9/29/2024 Compliance Requirement: Cash Management, Reporting Criteria: Per 2 CFR 200.305, under the reimbursement method, expenditures must be incurred prior to the date of the reimbursement request. The Organization is also responsible for submitting an annual Federal Financial Report (“FFR” or SF-425) to the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Condition: The Organization erroneously included a duplicate request for reimbursement in a monthly reimbursement request report submitted to the granting agency and was overpaid by the amount of this duplicate request for reimbursement totaling $41,042. Additionally, the total expenditures reported in the FFR/SF-425 were misstated by $23,058. Name of Contact Person: Ramon Dominguez, CFO Phone Number: (480) 831-7566 x4909 Anticipated Completion Date: September 30, 2025 Views of Responsible Officials and Corrective Actions: The Organization will implement additional controls to ensure monthly requests for reimbursement and reviewed and approved prior to submission. Additionally, the annual FFR/SF-425 will be reviewed and reconciled to the monthly draws.
View Audit 358970 Questioned Costs: $1
CORRECTIVE ACTION PLAN Arizona Department of Education/U.S. Department of Education Sierra Vista Unified School District No. 68 respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 – June 30, 2024 The findings from the schedule of fin...
CORRECTIVE ACTION PLAN Arizona Department of Education/U.S. Department of Education Sierra Vista Unified School District No. 68 respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 – June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT 2024-003 REPORTING Program: Child Nutrition Cluster CFDA Number: 10.533, 10.555, 10.559 Federal Agency: U.S. Department of Agriculture Pass-Through Agency: Arizona Department of Education Grantor Number: ADE ED09-0001 Questioned Costs: $18.50 Type of Finding: Noncompliance, significant deficiency Compliance Requirement: L. Reporting Condition/Context: For two of 3 monthly submissions tested, meal counts did not agree between the District’s records and what was reported to ADE. There was a net of 3 meals over claimed by the District. Criteria: The District must follow Uniform Guidance and ensure that meal reimbursement claims are accurately reported and adequately supported. Action planned in response to finding: The District will establish a system of internal controls to ensure meal counts reported on ADE match with District records. Planned completion date for corrective action plan: For the period ending June 30, 2025. Name of the contact person responsible for corrective action: Janet Cline, Business Office Manager, Laurel McEwan, Business Manager.
View Audit 358925 Questioned Costs: $1
Management is aware of the duplicate expenditures that were reported under two federal grants and has put procedures in place to enhance internal controls, have a single review and validation group, and a log with invoice submission documentation for reference checks. The VP of Finance has also made...
Management is aware of the duplicate expenditures that were reported under two federal grants and has put procedures in place to enhance internal controls, have a single review and validation group, and a log with invoice submission documentation for reference checks. The VP of Finance has also made it clear to the senior leadership team that as part of this error was driven by two separate functions submitting data for this funding support, all communications internal and external reporting must run through the Finance department going forward. This will allow a central check function that will have historical data submissions with invoices and work order reference checks to ensure expenses are submitted one time only. Finance will be the control point going forward doing these validation checks.
Corrective Actions Taken Commons has taken the following actions to protect against such fraudulent incidents in the future: • Engaged a firm to assist with managing the incident; • Opened a new bank account; • Added account verification services with our banking partner, which will be utilized to v...
Corrective Actions Taken Commons has taken the following actions to protect against such fraudulent incidents in the future: • Engaged a firm to assist with managing the incident; • Opened a new bank account; • Added account verification services with our banking partner, which will be utilized to verify account updates; • Limited the amount of per vendor/subrecipient daily payments to our insurance limits, with verifications prior to releasing additional funds when the total payment exceeds the insurance limits; • Subrecipient payment receipt is verified by both the subrecipient and the Commons grants team; • Updated our policy and procedures to direct our subrecipients to request banking changes through our procurement system and not through email; and • Expanded implementation of our Kissflow procurement system across the organization, which includes new vendor process as well as a change of vendor information module. Vendor changes would be approved first by the program/department that works with the vendor prior to Finance approval. Completion Date With the exception of implementing the change of vendor information module in Kissflow, the above actions have all been completed by the date of this report. The projected completion date for Kissflow change of vendor information module is April 30, 2025. Responsible Party Dana Thomas, Chief Financial Officer Angela Allen, Vice President of Finance
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