Corrective Action Plans

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SAOP shall establish a procedure to securely store payment support, ensuring all transactions are supported by proper documentation.
SAOP shall establish a procedure to securely store payment support, ensuring all transactions are supported by proper documentation.
SAOP shall implement a policy to secure approvals for charges related to the federal program.
SAOP shall implement a policy to secure approvals for charges related to the federal program.
Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.
Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.
Corrective Action Plan: The Utility Commission General Manager or Communications System Supervisor will review the quarterly progress reports prepared by someone else. Section II of the Project Status Report instructions states “Answer each question to the best of your ability.” The work orders do n...
Corrective Action Plan: The Utility Commission General Manager or Communications System Supervisor will review the quarterly progress reports prepared by someone else. Section II of the Project Status Report instructions states “Answer each question to the best of your ability.” The work orders do not include all costs related to labor benefits and taxes, and also the electronics and customer premise equipment associated with the projects. These costs are calculated and added in when the project is completed and is being closed out. Estimating these items for the quarterly Project Status Report is providing the project costs spent through the respective quarter to the best of our ability due to the limitations of the work order reporting process. Planned Completion Date for the Corrective Action: On-going Contact Persons Responsible for the Corrective Action Plan: The following Reedsburg Utility staff members are responsible for items outlined above in the Corrective Action Plan: • Brett Schuppner, Reedsburg Utility General Manager • Ken Las, Communications System Supervisor
2023-006 Internal Controls and Compliance over Special Tests and Provisions – Reasonable Rental Rates (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that ...
2023-006 Internal Controls and Compliance over Special Tests and Provisions – Reasonable Rental Rates (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to special tests and provisions – reasonable rental rates are consistently implemented including maintaining documentation of the verification of rental reasonableness in the program participant's file. Corrective Action: In response to the findings from the 2023 audit regarding the annual requirement for rent reasonableness, we developed the following action plan to ensure compliance with HUD regulations: 1. Annual Schedule: We established that annual rent reasonableness assessments for Temenos TCDC would be conducted each January, as required by HUD. This included comprehensive assessments for all scatter site properties. 2. Staff Reminders: A systematic reminder protocol was implemented for all staff involved in the rent reasonableness process. This included: 1. Calendar alerts 2. Email notifications 3. Regular team meetings to discuss timelines and responsibilities 3. Monitoring and Compliance: The Executive Director (ED) and Director of Operations closely monitored the compliance process to ensure assessments were completed accurately and on time. By implementing this action plan, Temenos TCDC aimed to address the 2023 audit findings effectively and ensure compliance with HUD's annual rent reasonableness requirements, including assessments for all TCDC site properties. Responsible Parties: Sandra Robicheaux – ED Ramona Edwards – Property Manager Wanda Williams – Case Manager Damita Gardner – Case Manager Terence Gomes – Case Manager Date to be Corrected: Implemented in January of 2025
2023-005 Compliance and Internal Controls over Program Income (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to program income are c...
2023-005 Compliance and Internal Controls over Program Income (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to program income are consistently implemented. In addition, documentation should be included in each participant's files to support income calculations and the participant's share of rent payable to the program. Corrective Action: We would like to clarify our approach to income documentation within client files: 1. Income Documentation: While not all clients have income, we will ensure that clients without income provide a zero-income affidavit (also known as a non-income affidavit) to document their status. 2. Stabilized Case Management: Our current case managers have been with Temenos CDC (TCDC) for over a year, providing stability and experience in verifying client income. 3. Policy and Procedure Updates: Recent updates to our policies and procedures have introduced standardized forms that clearly differentiate between households with income and those without. 1. Households with income will include the mandatory TCDC income calculation sheet. 2. Households without income will be required to submit the zero-income affidavit. 4. File Checklists: We have created file checklists to ensure uniformity across all client files, enhancing our documentation process. 5. Annual Audits: All client files will be audited by a supervisor at least once a year to ensure compliance with our policies. 6. HMIS Training: Case managers are required to complete mandatory HMIS training, which supports effective compliance in file management and income verification. These measures are designed to strengthen our documentation practices and ensure compliance with audit requirements. Responsible Parties: Sandra Robicheaux – ED Ramona Edwards – Property Manager Wanda Williams – Case Manager Damita Gardner – Case Manager Terence Gomes – Case Manager Date to be Corrected: Mandatory Training Implemented 01/2025 Updated Document Requirements 11/2025
Internal Control over Major Federal Program Compliance Program: Education Stabilization Fund (CFDA 84.425) Condition: Lack of policies and procedures for verifying and monitoring Wage Rate Requirements. Material Weakness Corrective Action Plan: The District will adopt policies to require prevailing ...
Internal Control over Major Federal Program Compliance Program: Education Stabilization Fund (CFDA 84.425) Condition: Lack of policies and procedures for verifying and monitoring Wage Rate Requirements. Material Weakness Corrective Action Plan: The District will adopt policies to require prevailing wage payments for contractor employees working an federally funded projects. The District will adopt policies and implement procedures requiring contractors on federally funded projects provide certified payroll reports to the District to ensure compliance with Wage Rate Requirements. The District will implement verification procedures to ensure contractor compliance with prevailing wage payments to employees. Planned Completion Date: March 20, 2024 Responsible Contact Perosn: Kathalee Cole, Superintendent (417) 273-4274
We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting. Management agrees with the finding. After correcting the calculation of expenses to include reimbursement from other sources, the Hospital still has sufficient lost revenues and expenses ...
We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting. Management agrees with the finding. After correcting the calculation of expenses to include reimbursement from other sources, the Hospital still has sufficient lost revenues and expenses to cover the amount of provider relief funding received. Management will perform a detailed analysis of the reporting requirements in accordance with the final guidelines set by HRSA for future reporting periods. As deemed necessary, the Hospital will modify policies and procedures over federal grant reporting The CFO, Hong Wade, will be responsible to ensure this is accomplished. The corrective action plan will be implemented by December 31, 2025.
Management will review Uniform Guidance 2 CFR sections 200.318 through 200.327 to ensure the Organization’s procurement policy fully incorporates all federal compliance requirements. Management will develop and implement a formal, written procurement policy.
Management will review Uniform Guidance 2 CFR sections 200.318 through 200.327 to ensure the Organization’s procurement policy fully incorporates all federal compliance requirements. Management will develop and implement a formal, written procurement policy.
Finding 2023-002 – Financial Reporting of Federal Expenditures Condition: Internal controls over financial reporting lacked oversight and thorough review of federal expenditures being included within the SEFA during fiscal year 2023. In conjunction with our FY2023 single audit, please see the City’s...
Finding 2023-002 – Financial Reporting of Federal Expenditures Condition: Internal controls over financial reporting lacked oversight and thorough review of federal expenditures being included within the SEFA during fiscal year 2023. In conjunction with our FY2023 single audit, please see the City’s corrective action plan below: We have reviewed current procedures regarding SEFA preparation and have implemented necessary changes to ensure accuracy. We have also established procedures to ensure a timely reconciliation of federal revenues and expenses.
Finding 2023-003 – Filing with the State Auditor and Federal Audit Clearinghouse Condition: The City did not submit its audit report to the State Auditor prior to the deadline of six months after the end of the fiscal year ending June 30, 2023. Additionally, the City did not submit its audit report ...
Finding 2023-003 – Filing with the State Auditor and Federal Audit Clearinghouse Condition: The City did not submit its audit report to the State Auditor prior to the deadline of six months after the end of the fiscal year ending June 30, 2023. Additionally, the City did not submit its audit report to the FAC within nine months from year ending June 30, 2023. In conjunction with our FY2023 single audit, please see the City’s corrective action plan below: Management recognizes the need to submit its single audit reports to the State Auditor and FAC in accordance with the required deadlines in order to remain compliant with the requirements. Management has made Professional Services changes to ensure timely audit compliance moving forward.
The City will work to ensure all reports for grant funding are completed.
The City will work to ensure all reports for grant funding are completed.
2023-4 –Activities Allowed Contact Person: Kaitlin M. Rosselli, Business Manager Recommendation: We recommend that the District strengthen internal controls over payroll charged to Federal awards by ensuring required approvals are obtained and review processes occur. Additionally, the District shoul...
2023-4 –Activities Allowed Contact Person: Kaitlin M. Rosselli, Business Manager Recommendation: We recommend that the District strengthen internal controls over payroll charged to Federal awards by ensuring required approvals are obtained and review processes occur. Additionally, the District should review their record retention policy to ensure sufficient supporting documentation is retained to demonstrate compliance with Federal requirements. Action: The District will ensure that all payroll timecards are approved and signed by the appropriate supervisor before being processed for payment. The payroll clerk will not process the timecard unless it is signed and approved. Additionally, we will review the District’s record retention policy to ensure sufficient supporting documentation is retained to demonstrate compliance with Federal requirements. The District will thoroughly review timecards to avoid clerical errors in the future. Date for Completion: These steps have already been put into place and will continue to be built upon.
2023-3 –Equipment and Real Property Management Contact Person: Kaitlin M. Rosselli, Business Manager Recommendation: We recommend that the District implement procedures to ensure prior written approval is obtained for applicable equipment purchases funded by federal grants and that fixed asset recor...
2023-3 –Equipment and Real Property Management Contact Person: Kaitlin M. Rosselli, Business Manager Recommendation: We recommend that the District implement procedures to ensure prior written approval is obtained for applicable equipment purchases funded by federal grants and that fixed asset records include all required information in accordance with Uniform Guidance. The District should also provide appropriate training to personnel involved in grant purchasing and asset management to ensure ongoing compliance. Action: ARP-ESSER III was the first time the District purchased equipment over the $5,000 threshold with federal funding, so processes and procedures for doing so were not in place at the time of the purchases. In the future, the District will implement procedures to ensure written approval is obtained for applicable equipment purchases funded by federal grants prior to purchasing. We will also provide appropriate training to personnel involved in grant purchasing and asset management to ensure ongoing compliance. Date for Completion: These steps have already been put into place and will continue to be built upon.
The City will design and implement controls to ensure that federal awards are expended only for allowable activities.
The City will design and implement controls to ensure that federal awards are expended only for allowable activities.
Response to finding 2023-003 – Lack of Documented Approval for Payroll Transactions Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-003. Due to the organizational pause at the...
Response to finding 2023-003 – Lack of Documented Approval for Payroll Transactions Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-003. Due to the organizational pause at the end of 2024 and the transition period throughout 2025, the Organization discontinued its prior payroll system when staff were laid off and shifted remaining personnel to contractor status. During this period, approval and payment of contractor invoices were processed through Ramp, with documentation maintained but not within a formalized payroll approval workflow. As CSforALL prepares for the 2026 rebuilding phase, management has re-established a structured payroll approval and documentation process aligned with audit recommendations. Corrective Action taken in 2025: Beginning in August 2025, the Organization transitioned to ADP, a trusted payroll service integrated with QuickBooks, in anticipation of restoring full payroll operations in 2026. Since implementation, payroll reporting and documentation have been maintained accurately each month by the Operations Manager and the Accountant, with formal approval granted by the Advisory Consultant. All invoices, payments, and payroll records are shared and stored bi-weekly as payroll is executed, establishing a consistent and documented approval trail. Corrective Action Planned for 2026: Beginning in January 2026, CSforALL will apply standardized supervisory approval procedures within ADP for all payroll transactions. Management will implement periodic monitoring of payroll records, ensure consistent use of the approved timekeeping and approval system, and maintain documentation of all supervisory approvals to ensure compliance with established internal controls throughout the 2026 operating year and beyond.
Finding 2023-003 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June ...
Finding 2023-003 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June 2025 and have been trained and have fully implemented Sanford Health procedures by September 2025, such that the Sanford Health system of controls now extend to MCHS. Specifically with these changes, grants management and accounting duties have also transitioned to the MCHS grant team which extends Sanford Health’s systems of control to MCHS to ensure accurate and timely completion of the Schedule. Completion Date: September 30, 2025.
Finding 2023-002 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and docum...
Finding 2023-002 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and documented approval of employee reimbursed expenditures charged to externally sponsored programs. It can be noted that, subsequent to sample testing, the one transaction in question was reviewed by Management and deemed an allowable cost.Completion Date: December 31, 2024
Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information f...
Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information for each individual employee tested. One for the test order and a second for the test result. Each row was counted and costed as two separate employee tests and therefore a portion of the cost for employee COVID tests was accidentally doubled and overstated in the portal for Period 5. However, although these expenses were overstated by $49,000, the grant was not overcharged as these questioned costs would be fully replaceable by an allowable amount of unused eligible lost revenues of approximately $109,516,000. Management will implement a procedure that requires a second level review of expenditures reported to ensure accuracy of reimbursement claimed for federal- and state-funded expenditures.Completion Date: September 30, 2024
PUC concurs with the auditor's recommendation. PUC will access its' needs for additional personnel and resources. October 2025, Daisy Nanpei, CFO
PUC concurs with the auditor's recommendation. PUC will access its' needs for additional personnel and resources. October 2025, Daisy Nanpei, CFO
Finding 1167725 (2023-010)
Material Weakness 2023
We agree with the recommendations offered for the relevant programs and will establish and implement policies that provide for documentary evidence of review of applicable reports by qualified individuals to ensure the timely submission of required reports to applicable federal agencies that can be ...
We agree with the recommendations offered for the relevant programs and will establish and implement policies that provide for documentary evidence of review of applicable reports by qualified individuals to ensure the timely submission of required reports to applicable federal agencies that can be easily reconciled to the underlying accounting records.
Finding type: Significant deficiency.
Finding type: Significant deficiency.
Federal award: 93.912, Rural Health Care Services Outreach.
Federal award: 93.912, Rural Health Care Services Outreach.
Passthrough organization: Not applicable.
Passthrough organization: Not applicable.
Condition: Lack of approval on bank reconciliations and journal entries.
Condition: Lack of approval on bank reconciliations and journal entries.
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