Corrective Action Plans

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Effective January 2025, Catalyst CT, Inc. transferred all accounting and finance functions in-house after terminating a contract with a third-party accounting firm. The in-house transition process was completed in phases, commencing in October 2023 with the hiring of a VP of Finance (CFO equivalent)...
Effective January 2025, Catalyst CT, Inc. transferred all accounting and finance functions in-house after terminating a contract with a third-party accounting firm. The in-house transition process was completed in phases, commencing in October 2023 with the hiring of a VP of Finance (CFO equivalent) who reviewed the in-place accounting/finance model. Based on the review, an in-house Controller was hired in March 2024, and a Staff Accountant was hired in December 2024. Transitioning of financial report preparation in-house began in the March 31, 2024 reporting period with a goal of having all reporting transferred in-house by year-end. As a result of this transition, reporting is handled by a central group of finance/accounting associates with consistent processes as well as improved internal notifications, including a Grant Cover Sheet, a Grant Cover Sheet Budgets spreadsheet and regular spend rate meetings with relevant senior program directors. Regarding this particular finding, until the end of year 2024, many past reports were a few days to a few weeks overdue because monthly/quarterly books weren’t typically closed by the third-party accountants until at least the third week of the following month. This is not atypical, a monthly closing date within 15 days is usually an exception rather than a rule. Furthermore, most of our grantors were not flummoxed by this. Those who had issues with reporting past the 15th would usually communicate this to us and we would arrange to provide estimated figures by the 15th. Given the nature of our grants, the newly formed in-house accounting group, as of January 1, 2025 has expedited the closing process to occur before the 15th of each month, allowing Catalyst CT, Inc. to meet reporting deadlines with that deadline to be more easily met.
Management Response/Corrective Action Plan: Management agrees with the recommendation and acknowledges the importance of implementing stronger internal controls to ensure that all wage rates charged are properly documented and approved. The District is currently reviewing its written policies and pr...
Management Response/Corrective Action Plan: Management agrees with the recommendation and acknowledges the importance of implementing stronger internal controls to ensure that all wage rates charged are properly documented and approved. The District is currently reviewing its written policies and procedures to strengthen its internal controls. These updates will be communicated to the staff involved. Targeted training will be provided to reinforce federal compliance requirements, the importance of accurate documentation, and the roles and responsibilities in the review and approval process.
Management’s response/corrective action plan: Management will implement a formal, documented process for annually verifying the status of all active vendors and contractors. This process will include checking the federal System for Award Management (SAM.gov) to confirm that entities are not suspende...
Management’s response/corrective action plan: Management will implement a formal, documented process for annually verifying the status of all active vendors and contractors. This process will include checking the federal System for Award Management (SAM.gov) to confirm that entities are not suspended or debarred from receiving federal funds. The results of these checks will be documented and retained in each vendor’s file. For new vendors, the verification will occur prior to contract execution or payment. For existing vendors, the verification will be conducted at least annually and prior to the renewal or continuation of any federally funded work. Management will assign responsibility to a designated individual or department to oversee ongoing compliance with the vendor verification process.
Management’s Response/Corrective Action Plan: Management has communicated directly with all staff responsible for student recordkeeping and cohort tracking at the high school level. The District procedural form for documenting student removals will be required in all cases. This form will serve as t...
Management’s Response/Corrective Action Plan: Management has communicated directly with all staff responsible for student recordkeeping and cohort tracking at the high school level. The District procedural form for documenting student removals will be required in all cases. This form will serve as the official record and must be completed, signed, and retained in accordance with district policy and audit requirements. No student will be removed from the cohort without completed and verifiable documentation.
2024-005 – Reporting Contact Person Terry Hanson Corrective Action Plan Management recognizes the delayed submission of the 2024 audit to the Federal Audit Clearinghouse. To prevent recurrence, management is developing a compliance calendar and assigning responsibility for federal filing deadlines t...
2024-005 – Reporting Contact Person Terry Hanson Corrective Action Plan Management recognizes the delayed submission of the 2024 audit to the Federal Audit Clearinghouse. To prevent recurrence, management is developing a compliance calendar and assigning responsibility for federal filing deadlines to the Director of Finance. Regular progress reviews will ensure all audit deliverables are completed and submitted within the required ninemonth period. This corrective measure will improve accountability and ensure timely compliance with federal reporting standards. Planned Completion Date for CAP Immediately
Finding Number: 2024-004 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Janelle White – Controller Health and Wellness Service Team Melody Santana-Marty – Controller Community Services and Supports Corrective Action Pla...
Finding Number: 2024-004 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Janelle White – Controller Health and Wellness Service Team Melody Santana-Marty – Controller Community Services and Supports Corrective Action Planned: Internal quality controls specific to the Medicaid program, will be reviewed and updated. Department-wide communication to staff regarding the importance of complete and adequate supporting documentation in the case file prior to case approval has been implemented and will continue on an ongoing basis. This communication will include guidance on how to determine whether documentation is sufficient, along with examples of acceptable support. At a minimum, required documentation will include: • Documentation verifying citizenship. • Examples of properly completed applications. • Reconciliation of the income verification in MAXIS and the documentation in the case file. • Reconciliation of the asset verification in MAXIS and the documentation in the case file. The Quality Assurance review process and Corrective Action Plan have been documented and communicated to provide guidance for new staff, serve as refresher training for existing staff, and ensure that appropriate actions are consistently followed. This documentation will be reviewed and revised as necessary to maintain compliance and consistency across the department. Supervisory review has been implemented for new hires. When issues are identified with current staff, enhanced review strategies and procedures will be applied to ensure required documentation is properly reviewed prior to case approval. Supervisors will conduct periodic reviews of case files to ensure that all required documentation is on file. If errors are identified and overpayments occur, the Department will follow established protocols of the Minnesota Department of Human Services regarding the identification, reporting, and recovery of overpayments. Anticipated Completion Date: 06/10/2026
Finding Number: 2024-003 Finding Title: Eligibility and Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Janelle White – Controller Health and Wellness Service Team Melody Santana-Marty – Controller Commun...
Finding Number: 2024-003 Finding Title: Eligibility and Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Janelle White – Controller Health and Wellness Service Team Melody Santana-Marty – Controller Community Services and Supports Corrective Action Planned: Internal quality control review checklists, specific to each program area, will be reviewed and updated, and additional controls will be developed to ensure that required documentation is obtained and maintained. Department-wide communication to staff regarding the importance of complete and adequate supporting documentation in the case file prior to case approval has been implemented and will continue on an ongoing basis. This communication will include guidance on how to determine whether supporting documentation is sufficient, along with examples of acceptable documentation. At a minimum, required documentation will include: • Documentation verifying client eligibility for the key eligibility-determining factors. • Evidence of the verification process recorded in MAXIS. • Documentation confirming that child support files have been reviewed and updated for non-cooperation, as applicable. Supervisors will conduct periodic reviews of case files to ensure that all required documentation is on file. Anticipated Completion Date: June 30, 2026
FINDING 2024-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Pamela J. Beck Flora Clerk-Treasurer Contact Phone Number and Email Address: 574-967-4844 clerktreasurer@townofflora.org Views of Responsible O...
FINDING 2024-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Pamela J. Beck Flora Clerk-Treasurer Contact Phone Number and Email Address: 574-967-4844 clerktreasurer@townofflora.org Views of Responsible Officials: Option 1: “We concur with the finding.” . Description of Corrective Action Plan: Follow internal controls to obtain a second internal signature for Federal reports. Anticipated Completion Date: 12-1-2025
CORRECTIVE ACTION PLAN The City of Agawam, Massachusetts respectfully submits the following corrective action plan for the year ended June 30. 2024. Audit period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. The ...
CORRECTIVE ACTION PLAN The City of Agawam, Massachusetts respectfully submits the following corrective action plan for the year ended June 30. 2024. Audit period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Audit Finding Reference: 2024-002 Reporting to the Federal Government – Significant Deficiency Views of responsible officials: The City agrees with the recommendation to implement procedures to ensure that the eligible expenditures reported on the Project and Expenditure (P&E) report include all eligible costs in the reporting period. The City will implement the proper segregation of duties by including an independent review of the P&E report prior to submitting the report. Planned Implementation Date of Corrective Action: The City plans to implement recommendations for the next P&E report filing. Official Responsible for Implementing Corrective Action: Cheryl St. John Town Auditor
Corrective Action: The duties will be separated as much as possible and alternative controls will continue to be used to compensate for lack of separation. The governing board has become more involved in providing some of these controls. Proposed Completion Date: The Board is remaining involved by p...
Corrective Action: The duties will be separated as much as possible and alternative controls will continue to be used to compensate for lack of separation. The governing board has become more involved in providing some of these controls. Proposed Completion Date: The Board is remaining involved by providing authorization and monitoring controls on a regular and timely basis.
Finding 2024-003 Federal Agency Name: U.S. Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants, Community Facilities Loans and Grants Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not sufficiently f...
Finding 2024-003 Federal Agency Name: U.S. Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants, Community Facilities Loans and Grants Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not sufficiently fund their reserve account. As of December 31, 2024, the Hospital should have USDA debt reserves at least equal to $459,326. Responsible Individuals: Doug B. Lewis, Chief Financial Officer Corrective Action Plan: Management will review the reserve account requirements and ensure appropriate contributions are made during the fiscal year.
2024-003 – Significant Deficiency in Internal Control over Compliance and Other Matters – Special Tests and Provisions Name of Contact Person: Mariya Lovishchuk, Development Director Corrective Action: This was a clerical error issue. Davis Bacon Wages were paid throughout the entire project and cer...
2024-003 – Significant Deficiency in Internal Control over Compliance and Other Matters – Special Tests and Provisions Name of Contact Person: Mariya Lovishchuk, Development Director Corrective Action: This was a clerical error issue. Davis Bacon Wages were paid throughout the entire project and certified payroll was provided. However, the original construction contract did not include the correct prevailing wage language. Prevailing wages requirement was discussed and agreed upon prior to issuance of contract, but wrong language was inserted by mistake. Upon discovery of the wrong language, contract amendment was immediately issued to rectify. Proposed Completion Date: Already complete
Management will research and clean up the old outstanding items, create a new general ledger account and reconcile all accounts on a monthly basis.
Management will research and clean up the old outstanding items, create a new general ledger account and reconcile all accounts on a monthly basis.
Management will evaluate the cost benefit of making cash to accrual adjusting entries on an annual basis.
Management will evaluate the cost benefit of making cash to accrual adjusting entries on an annual basis.
Management is aware of the finding and has concluded that it is not economically feasible to correct this finding. Management will rely on oversight by the Mayor and City Council to monitor this condition.
Management is aware of the finding and has concluded that it is not economically feasible to correct this finding. Management will rely on oversight by the Mayor and City Council to monitor this condition.
For now, the City accepts the degree of risk associated with this condition and thoroughly reviews a draft of the financial statements, footnote disclosures, and supplementary information prior to issuance. Management will engage the audit firm to prepare drafts of its annual financial statements an...
For now, the City accepts the degree of risk associated with this condition and thoroughly reviews a draft of the financial statements, footnote disclosures, and supplementary information prior to issuance. Management will engage the audit firm to prepare drafts of its annual financial statements and related footnote disclosures in accordance with the regulatory basis of accounting.
The Town has implemented a process whereas the Town Manager and Board of Trustees review all federal or state grant agreements to verify whether the grant agreement outlines a CFDA number in determining whether the funds are related to federal awards.
The Town has implemented a process whereas the Town Manager and Board of Trustees review all federal or state grant agreements to verify whether the grant agreement outlines a CFDA number in determining whether the funds are related to federal awards.
Corrective Action Plan: The Hospital is currently working on a plan to file all audit reports for the subsequent fiscal year ended September 30, 2025, before their required reporting due date of June 30, 2026.
Corrective Action Plan: The Hospital is currently working on a plan to file all audit reports for the subsequent fiscal year ended September 30, 2025, before their required reporting due date of June 30, 2026.
Finding: The Organization did not have adequate and effective controls over compliance in place as it relates to activities allowed or unallowed and allowable costs. We noted Instances where payroll and non-payroll related expenditures did not have documentation of review. Corrective Response: Manag...
Finding: The Organization did not have adequate and effective controls over compliance in place as it relates to activities allowed or unallowed and allowable costs. We noted Instances where payroll and non-payroll related expenditures did not have documentation of review. Corrective Response: Management is committed to strengthening how we track and allocate hours to grant-funded projects to ensure full compliance with 2 CFR 200.430. Going forward, the organization will implement a time study approach to support the allocation of personnel costs to federal grants. Employees working across multiple funding sources will participate in periodic time studies designed to reasonably estimate the distribution of their time based on actual activities performed. The results of these time studies will be used as the basis for allocating payroll costs to the appropriate grants, and will be supported by documentation and supervisory review. We will also implement consistent tools and processes to ensure allocations are applied systematically across all funding sources. On a monthly basis, the finance team will review and reconcile payroll allocations to ensure they align with the established methodology. In addition, we will provide training and ongoing oversight to reinforce compliance and prevent similar Issues In the future.
Finding 2024-02 Internal Control Over Compliance: Written Compliance Policies and Procedures. Management concurs with the finding. In June 2025, IHS completed revising its Fiscal Policy Manual to incorporate key Uniform Grant Guidance compliance requirements
Finding 2024-02 Internal Control Over Compliance: Written Compliance Policies and Procedures. Management concurs with the finding. In June 2025, IHS completed revising its Fiscal Policy Manual to incorporate key Uniform Grant Guidance compliance requirements
Finding 2024-01 Internal Control Over Financial Reporting: Revenue Recognition. Management concurs with the finding. Innovative Health Solutions (IHS) began full implementation of GAAP reporting in FY2024/25. The Fiscal Policy Manual was updated during FY2024/25 to incorporate GAAP revenue recogniti...
Finding 2024-01 Internal Control Over Financial Reporting: Revenue Recognition. Management concurs with the finding. Innovative Health Solutions (IHS) began full implementation of GAAP reporting in FY2024/25. The Fiscal Policy Manual was updated during FY2024/25 to incorporate GAAP revenue recognition criteria for various revenue streams. IHS will continue to review and refine its accounting policies and procedures as it transitions some of its financial reporting and audit support functions to a new outside CPA firm specializing in nonprofit services beginning July 1, 2025.
Finding reference: 2024-010 - 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Special Tests and Provisions Recommendation: All elements required for the sliding fee discount should be properly maintained in Allscripts. Employees should be properly trained on t...
Finding reference: 2024-010 - 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Special Tests and Provisions Recommendation: All elements required for the sliding fee discount should be properly maintained in Allscripts. Employees should be properly trained on the software, and a user manual should be created related to patient intake so patient records are consistent and documented appropriately. Action taken: All elements required for the sliding fee discount are being properly maintained. All employees have been properly trained in software.
Indirect cost proposal. MSCIL acknowledges the need to maintain compliance wi th fed eral reporting requirements and has taken steps to ensure timely submission going forward. Management will complete and submit the indirect cost proposal immediately upon finalization of the audited financial statem...
Indirect cost proposal. MSCIL acknowledges the need to maintain compliance wi th fed eral reporting requirements and has taken steps to ensure timely submission going forward. Management will complete and submit the indirect cost proposal immediately upon finalization of the audited financial statements. Responsibility for preparing future proposals will be assigned to a designated staff member, with oversight from the President/CEO to ensure deadlines are met. MSCIL is also refining its reporting schedule and review procedures to support timely and accurate filings in future years. The Fyffe Jones Group will assist with filing needs as necessary to support compliance and ensure accuracy of submissions. These steps will help e nsure tha t indirect cost proposals are submitted timely in accordance with federal requirements.
United States Environmental Protection Agency Capitalization Grants for Clean Water Revolving Funds ALN: 66.458 Condition: The Village has not updated its existing policies and written procedures to conform to Uniform Guidance requirements. Planned Corrective Action: The Village’s Treasurer will wor...
United States Environmental Protection Agency Capitalization Grants for Clean Water Revolving Funds ALN: 66.458 Condition: The Village has not updated its existing policies and written procedures to conform to Uniform Guidance requirements. Planned Corrective Action: The Village’s Treasurer will work on updating all policies and procedures relating to the U.S. Office of Management and Budget Uniform Guidance to ensure the Village policies are in compliance with these guidelines. Responsible Contact Person: Linda M. Morrisey Village Treasurer Village of Ocean Beach Bay & Cottage Walks, P.O. Box 457 Ocean Beach, NY 11770 Anticipation completion date: March 31, 2026
Criteria Uniform Guidance requires management to provide reasonable assurance that federal awards are expended only for allowable activities, that the cost of goods and services charged to federal awards are allowable and in accordance with the specific cost principles, and to ensure expenditures we...
Criteria Uniform Guidance requires management to provide reasonable assurance that federal awards are expended only for allowable activities, that the cost of goods and services charged to federal awards are allowable and in accordance with the specific cost principles, and to ensure expenditures were incurred and paid prior to requesting for reimbursement. Condition The Organization lacked controls over purchasing and payments to vendors. More specifically, there was no formal process for approving invoices before payment to vendors. There is inadequate segregation of duties among those who: (1) Initiate routine transactions and (2) Review, evaluate, or approve routine transactions. There is also a lack of documentation of reviews performed and closing and reconciliation procedures. Cause The board and management of the Organization did not have adequate financial expertise to exercise effective oversight or design and implement a control environment or control activities sufficient to carry out the objectives of the Organization during the fiscal year. Effect The Organization cannot ensure that its activities and costs charged to the federal award program were allowable during the audit period conducted. Recommendation We recommend the Organization design and implement written accounting policies and procedures to formally approve invoices before payment to vendors to ensure proper segregation of duties.
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