Corrective Action Plans

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Finding Number: 2024-004 Failure to Identify Single Audit Requirement Views of Responsible Officials and Corrective Action: The Organization was not explicitly made aware of the Uniform Guidance requirements and mistakenly assumed that since this originated from the state, it was state funding. The ...
Finding Number: 2024-004 Failure to Identify Single Audit Requirement Views of Responsible Officials and Corrective Action: The Organization was not explicitly made aware of the Uniform Guidance requirements and mistakenly assumed that since this originated from the state, it was state funding. The Organization is aware of this situation and will create and implement a formal process to review federal and state expenditures incurred and evaluate whether there are state or federal compliance audit implications for all government grants upon signing the agreement. We will then proactively communicate this with our auditor so that plans can be made to perform the applicable compliance audit. We do not view this as an ongoing deficiency, and we deem our corrective action plan to be one that fully addresses this control deficiency. Name of Responsible Person: Mike Cohoon, Executive Director Projected Implementation Date: December, 2025
To ensure the audit is submitted in a timely manner, and on time, we will begin at the beginning of the year.
To ensure the audit is submitted in a timely manner, and on time, we will begin at the beginning of the year.
COUNTY OF WASHINGTON, NEW YORK Corrective Action Plan Year ended December 31, 2024 To Whom It May Concern: There were two finding reported for corrective action in Washington County's single audit for the year ended December 31, 2024. The findings and the County’s response are listed below: Finding ...
COUNTY OF WASHINGTON, NEW YORK Corrective Action Plan Year ended December 31, 2024 To Whom It May Concern: There were two finding reported for corrective action in Washington County's single audit for the year ended December 31, 2024. The findings and the County’s response are listed below: Finding 2024-002 Criteria - In accordance with Uniform Guidance, 2 CFR § 200.512(a)(1), non-federal entities that are required to have a Single Audit must submit the audit reporting package to the Federal Audit Clearinghouse (FAC) within the earlier of 30 calendar days after receiving the auditors’ reports, or nine months after the end of the fiscal year. The non-federal entity is responsible for submitting the reporting package, which includes the Data Collection Form (DCF) and the required audit reports. Condition - Management did not submit the reporting package including the DCF for the fiscal year ended December 31, 2024, to the FAC by the deadline of September 30, 2025. Cause - The auditee experienced delays in providing necessary information to the external auditors, which led to the late filing. Effect of Condition - Failure to submit the single audit on time is a violation of federal regulations and will result in the County not being a low-risk auditee for the next two audit periods. Recommendation - Management should implement internal controls and procedures to ensure the timely submission of future reporting packages and the DCFs to the FAC. This should include establishing a project timeline and assigning responsibilities of key tasks to County employees as necessary. Views of Responsible Officials and Planned Corrective Action - The County Treasurer and Board of Supervisors will develop and implement internal controls and procedures to ensure the timely submission of future reporting packages to the FAC. Management expects to have this developed in time for the audit of the year ended December 31, 2025.
Views of Responsible Officials: We agree with the auditor’s findings and recommendations. We are going to review, strengthen, and more closely supervise all of our accounting procedures including response time to the Development Team’s requests for reports. We are also engaging in discussions about ...
Views of Responsible Officials: We agree with the auditor’s findings and recommendations. We are going to review, strengthen, and more closely supervise all of our accounting procedures including response time to the Development Team’s requests for reports. We are also engaging in discussions about how and when the Development Team requests information for the needed reports. A Grant Manager has been hired and we hope that Grantseeker, our grant tracking program, can be utilized more effectively which include tracking reporting timelines.
Views of Responsible Officials: We agree with the auditor’s findings and recommendations. Intacct allows for the automatic allocation of salaries to grants directly which provides us with much better records. ADP Workforce now will put all the appropriate approvals in place, both employee and superv...
Views of Responsible Officials: We agree with the auditor’s findings and recommendations. Intacct allows for the automatic allocation of salaries to grants directly which provides us with much better records. ADP Workforce now will put all the appropriate approvals in place, both employee and supervisor. We are discussing the right method for project-specific timesheets, but think that biweekly forms for staff to fill out are the best route. Staff would check off grant-allowable activities that they engaged in and then note the hours allocated to those activities.
View Audit 372349 Questioned Costs: $1
Corrective Action Plan Finding: 2024-003-Lack of quality control and SEMAP-Eligibility and Special Tests Condition: The tenant files and waiting list were much improved over the prior year, for which numerous exceptions were noted. However, we did note the following: (a)-SEMAP was apparently not pre...
Corrective Action Plan Finding: 2024-003-Lack of quality control and SEMAP-Eligibility and Special Tests Condition: The tenant files and waiting list were much improved over the prior year, for which numerous exceptions were noted. However, we did note the following: (a)-SEMAP was apparently not prepared by prior management. SEMAP is required by HUD regulations. This is a documentation that quality control was performed, broken down into subsets. Even if SEMAP was not required by HUD, at least similar documented quality control should be done and available for third party review. Statement of Auditing Standard #115, which auditors must follow, states “absent or inadequate segregation of duties within a significant account or process” is defined by the Standard as at least a significant deficiency or material weakness. Either require an audit finding. (b)-It appears that quality control inspections were not done. (c)-It appears that the last utility allowance review was done in August 2023. Federal regulations require that utility allowances be done annually. At least when any one category changes more than 10% since the last review, the allowances must be revised. Corrective Action Planned: We will comply with the auditor’s recommendation. Person responsible for corrective action: Louie Alfaro, Executive Director Telephone: (915) 886-4650 Housing Authority of the Town of Anthony, Texas Fax: (915) 886-2296 1007 Franklin Anthony, TX 79821 Anticipated Completion Date: September 30, 2025
Finding 1162698 (2024-002)
Material Weakness 2024
Finding Number: 2024-002 Closing Process (Significant Deficiency) Planned Corrective Action: The auditors noted issues related to the timeliness of the financial statement close process, additional entries to finalize the trial balance, and a lack of segregation of duties which led to journal entrie...
Finding Number: 2024-002 Closing Process (Significant Deficiency) Planned Corrective Action: The auditors noted issues related to the timeliness of the financial statement close process, additional entries to finalize the trial balance, and a lack of segregation of duties which led to journal entries being prepared, reviewed and posted by the same person in the general ledger system. The issues noted were largely the result of significant turnover within the Finance Department, including the departure of the former head of the department without a proper transfer of institutional knowledge to remaining staff or incoming leadership. Since that time, oversight has improved considerably, and key processes have been reviewed, updated, and formally documented. While the current size of the Finance Team necessitates that the same individual generally enters and posts journal entries, we have implemented compensating controls that we believe are appropriate given the assessed levels of risk and materiality. These controls include role-specific responsibilities for journal entries and reconciliations. For example, with respect to cash activity, different team members handle cash receipts, disbursements, and inter-account transfers. Additionally monthly bank reconciliations are formally reviewed and signed off by Fiscal Department management. Management remains committed to strengthening internal controls, maintaining adequate segregation of duties to the extent practicable, and continuing to enhance the overall financial close and reporting process. Person Responsible: The Executive Director and Chief Financial Officer Completion Date: July 2024
Management Response We accept the recommendations and have acted as follows: Training: Provided mandatory Uniform Guidance and grant-compliance training for all program and finance staff. Post-Award Grant Management System: Implemented an integrated post-award grant management system that includes a...
Management Response We accept the recommendations and have acted as follows: Training: Provided mandatory Uniform Guidance and grant-compliance training for all program and finance staff. Post-Award Grant Management System: Implemented an integrated post-award grant management system that includes a built-in reporting calendar with automated deadline notifications to ensure timely and accurate submissions. Personnel: Grants Administrator started in March 2025, and a dedicated Grants Compliance Officer to oversee all federal program requirements, is actively being recruited by the end of 2025. These measures will ensure ongoing compliance with OMB Uniform Guidance. Estimated Completion Date January 1, 2026 Responsible Party Kathy De Palma, Grants Coordinator
Corrective Action Plan: The Organization will implement a formalized process for the review and approval of payroll transactions, including the allocation of payroll costs to grants. We will do this by adding the proper software tools in place within our financial accounting software. This process w...
Corrective Action Plan: The Organization will implement a formalized process for the review and approval of payroll transactions, including the allocation of payroll costs to grants. We will do this by adding the proper software tools in place within our financial accounting software. This process will also involve establishing clear guidelines outlining the steps for reviewing and approving payroll transactions to ensure accuracy and compliance with grant requirements and financial processes. Designated personnel, the finance manager, will be assigned the specific responsibility of preparing payroll and the CEO will review the payroll report and sign off prior to payroll execution. This will be in the system of documented processes to track and document these approvals as well as written within the policies and procedures handbook. Anticipated Completion Date: November 30, 2025
Finding 1162599 (2024-001)
Material Weakness 2024
AIDS United submits the following corrective action plan for the identified findings for the audit period January 1, 2024 through December 31, 2024: Finding 2024-001 Material Adjusting Journal Entries and Late Filing of Data Collection form Corrective Action: Action 1: Implement a Formal Month-End a...
AIDS United submits the following corrective action plan for the identified findings for the audit period January 1, 2024 through December 31, 2024: Finding 2024-001 Material Adjusting Journal Entries and Late Filing of Data Collection form Corrective Action: Action 1: Implement a Formal Month-End and Year-End Close Process • Develop a plan with the Executive to onboard additional accounting support at both the staff and senior accountant levels. • Require all reconciliations to be completed within 15 business days of month-end. Responsible Party: Controller Completion: Date12/31/2025 Status: Planned Action 2: Strengthen Review Controls Over Journal Entries • Implement system-based controls where available in Intacct. Responsible Party: Controller Completion Date: 12/31/2025 Action 3: Improve Financial Statement Preparation Procedures • Develop a documented process for drafting, reviewing, and finalizing financial statements prior to sending them to external auditors. • Incorporate a pre-audit internal review meeting to validate account balances and disclosures. Responsible Party: Controller Completion Date: March 2026 Action 4: Ensure Timely Federal Audit Clearinghouse Submission • Start audit process earlier in 2026 no later than end of Q1 Responsible Party: Controller Completion Date: Next audit cycle
Insufficient Grant Monitoring The County will work to improve grant documentation and will consider implementing a review process to ensure the grant records agree to the grant reports that are filed.
Insufficient Grant Monitoring The County will work to improve grant documentation and will consider implementing a review process to ensure the grant records agree to the grant reports that are filed.
Insufficient Understanding of Federal Compliance Requirements The County will work to improve their understanding of federal compliance requirements for each grant award and documentation of procedures implemented to ensure compliance.
Insufficient Understanding of Federal Compliance Requirements The County will work to improve their understanding of federal compliance requirements for each grant award and documentation of procedures implemented to ensure compliance.
Condition and Context: The County does not have a complete set of written cash management policies and procedures required by the Uniform Guidance. The lack of written procedures did not result in any material noncompliance, fraud or abuse with respect to the major program. Recommendation: Managemen...
Condition and Context: The County does not have a complete set of written cash management policies and procedures required by the Uniform Guidance. The lack of written procedures did not result in any material noncompliance, fraud or abuse with respect to the major program. Recommendation: Management should determine the scope of written policies needed for compliance with all federal programs and develop policies and procedures to comply with the Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and recommendation. The County’s existing policies are currently under review by management and staff to determine what updates/changes are necessary in order to meet the Uniform Guidance requirements. Once any updates/changes are drafted, the policy will be presented to the Governing Body for review and approval.
Finding Number: 2024-003 Finding Name: Data Collection Form Late Submission Finding Synopsis: The organization did not submit the December 31, 2024 data collection form and reporting package to the Federal Audit Clearinghouse in a timely matter. Action Steps: The late submission was due to switching...
Finding Number: 2024-003 Finding Name: Data Collection Form Late Submission Finding Synopsis: The organization did not submit the December 31, 2024 data collection form and reporting package to the Federal Audit Clearinghouse in a timely matter. Action Steps: The late submission was due to switching audit service providers. Systems and procedures are already in place to ensure timely completion of audit and submission of the audit package to the Federal Audit Clearinghouse. Management is now aware that when switching audit firms. we will have to allocate more time for the new firm to get familiar with the agency. Contact Person(s): William Chatman, Executive Director/CEO, 815-963-6236 Claudia Seijas, Director of Finance, 815-963-6236 Anticipated Completion Date: Continues
Condition: Suspension and debarment compliance was not verified for four covered transactions. Corrective Action Planned: The Town will implement procedures to include a suspension and debarment certification in all federal contracts that are considered covered transactions to ensure that the contra...
Condition: Suspension and debarment compliance was not verified for four covered transactions. Corrective Action Planned: The Town will implement procedures to include a suspension and debarment certification in all federal contracts that are considered covered transactions to ensure that the contractors are eligible to receive federal funds and not excluded or disqualified from doing business. Anticipated Completion Date: March 31, 2026 Contact: Bryan Sawyer, Town Administrator
Compliance with Allowable Activities Planned Corrective Action: Heartland Alliance Health has partnered with an outside revenue cycle management firm to strengthen documentation oversight, billing accuracy, and compliance monitoring. Together with internal Revenue Cycle staff, the external firm now ...
Compliance with Allowable Activities Planned Corrective Action: Heartland Alliance Health has partnered with an outside revenue cycle management firm to strengthen documentation oversight, billing accuracy, and compliance monitoring. Together with internal Revenue Cycle staff, the external firm now generates and reviews weekly documentation and billing completeness reports to identify and resolve missing or incomplete encounter records. Clinic managers and providers receive weekly follow-ups to ensure that documentation is corrected promptly and that all billed services are properly supported. Person Responsible for Corrective Action Plan: Steve Knox, Controller Anticipated Date of Completion: Resolved
Internal Controls Over Rent Reasonableness - Significant Deficiency Condition: The Organization did not have a documented procedure supporting how rent reasonableness is documented and maintained in the tenant files to provide documentation of compliance with the criteria. Corrective Action Plan: CH...
Internal Controls Over Rent Reasonableness - Significant Deficiency Condition: The Organization did not have a documented procedure supporting how rent reasonableness is documented and maintained in the tenant files to provide documentation of compliance with the criteria. Corrective Action Plan: CHP will be updating internal controls to include evidence of appropriate reviews and approvals of rent reasonableness.
Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award P...
Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025 Description: Timely Completion of the 24-month Eligibility Screening Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: Management should continue to implement procedures to ensure completion of the eligibility screening prior to the end of the 24-month eligibility period including steps to ensure the eligibility date aligns with the supporting documentation. View of responsible officials: Management concurs with the finding and will continue to implement further procedures to ensure that timely documentation is received with regard to eligibility. Corrective Action Planned: Inova will comply with VDH's 24-month eligibility rule, ensuring that services are not provided to RWHAP clients who miss their reassessment. To prevent gaps in service, Inova will continue to maintain monthly expiring eligibility tracking sheet to ensure clients will receive reminders 30–45 days before their eligibility period ends. CAR reviews will continue periodically throughout the 24 month timeframe. Inova will transition to HRSA’s CareWare system for eligibility management and tracking. Inova will continue 100% internal monthly eligibility audits and peer reviews, as well as implement a 10% chart review by a team member outside of the Juniper Program. Clients who do not submit the required reassessment documents will be removed from the program. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2025.
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Execu...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2025.
View Audit 372175 Questioned Costs: $1
Mrs. Clark (the County Clerk) didn’t realize she hadn’t included the number of monies in the SEFA report from ARPA monies. The correction was made when auditors were here.
Mrs. Clark (the County Clerk) didn’t realize she hadn’t included the number of monies in the SEFA report from ARPA monies. The correction was made when auditors were here.
Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Repeat Finding No Action Taken The health center will share one location to maintain all UDS files and ensure that the worksheet/and data...
Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Repeat Finding No Action Taken The health center will share one location to maintain all UDS files and ensure that the worksheet/and data that is prepared is locked so only the owner can make changes.
Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that timesheets are reviewed and approved by the appropriate supervisor and ensure that they agree to the payroll register. Repeat Finding Yes Action Taken The staff accountant does th...
Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that timesheets are reviewed and approved by the appropriate supervisor and ensure that they agree to the payroll register. Repeat Finding Yes Action Taken The staff accountant does the payroll. We save a backup timecard report each payroll that we are paying from the approved by the employee's supervisor. We also have an internal worksheet that we use to document any changes that are made. Once the accountant is done with her review the controller will do the second review before we finish processing the payroll enforcing internal controls that are in place and being followed.
Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learnin...
Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learning and development. The Slide Fee Coordinator will run a daily report to audit the slide fees entered the previous day to ensure accuracy.
Finding 2024.006 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken In response to the audit finding, I will develop and implement a formal internal control system...
Finding 2024.006 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken In response to the audit finding, I will develop and implement a formal internal control system to ensure that all Uniform Data System (UDS) related calculations are accurately documented and consistently maintained.
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