Corrective Action Plans

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Planned Corrective Action: Single Audit Report will be completed as soon as possible for Fiscal Year 2024, and Fiscal year 2025 will be completed in a timely manner. It is anticipated that Single Audits will no longer be required after Fiscal Year 2025. Planned Implementation Date of Correction Ac...
Planned Corrective Action: Single Audit Report will be completed as soon as possible for Fiscal Year 2024, and Fiscal year 2025 will be completed in a timely manner. It is anticipated that Single Audits will no longer be required after Fiscal Year 2025. Planned Implementation Date of Correction Action: 7/1/2025. Person Responsible for Correction Action: Jane Bizeur, Business Manager; Erin McFarland Stafford, Rowley and Associates
View of Responsible Official Currently, based on the capacity of the Organization’s staffing pool, the most efficient and effective means of review and reconciliation of cash disbursements and payroll is the Organization’s Board Chair and CEO reviewing the cash disbursements and payroll every two we...
View of Responsible Official Currently, based on the capacity of the Organization’s staffing pool, the most efficient and effective means of review and reconciliation of cash disbursements and payroll is the Organization’s Board Chair and CEO reviewing the cash disbursements and payroll every two weeks, prior to payments being made. The Organization’s bookkeeper forwards the Board Chair and CEO a listing of cash disbursements and payroll due with the suggested payments. The Board Chair and CEO each will ask questions and formally “approve” or “disapprove” each transaction, prior to any payments. Once reviewed, the CEO will contact the bookkeeper with the amounts to pay. Also, the Organization’s outsourced accountant will review and approve each monthly bank reconciliation and bank statement for all Organization accounts, as well as the monthly credit card statements. The outsourced accountant does not have the ability to access the monthly bank statements and make purchases. Going forward, the Organization’s Director of Communications will retain the Board Chair’s check stamp. The Director of Communication will only be allowed to use the Board Chair’s check stamp once the Board Chair and CEO approved payment.
Recommendation: Implement enhanced procedures for the systematic maintenance and retrieval of all financial records related to expenditures, including staff training on these protocols. Action Taken: Management agrees with the auditor’s finding and recommendation. The newly appointed Deputy Dire...
Recommendation: Implement enhanced procedures for the systematic maintenance and retrieval of all financial records related to expenditures, including staff training on these protocols. Action Taken: Management agrees with the auditor’s finding and recommendation. The newly appointed Deputy Director of Finance will oversee the implementation of these enhanced procedures.
U.S. Department of Health and Human Services Federal Assistance Listing Number 93.498 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Responsible Party: Brian Lutz, Vice President of Accounting Estimated Completion Date: December 2024 Issue Counseling Associates, Inc. (CAI) re...
U.S. Department of Health and Human Services Federal Assistance Listing Number 93.498 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Responsible Party: Brian Lutz, Vice President of Accounting Estimated Completion Date: December 2024 Issue Counseling Associates, Inc. (CAI) reported $375,083.37 in ‘Total Reportable Other PRF Expenses’ on its Phase 4 Provider Relief Fund (PRF) Report covering the period July 1, 2021-December 31, 2021. CAI’s intent was for the entire $992,263.30 in total reportable PRF payments to be applied to lost revenues. The $375,083.37 amount reported in the Other PRF Expenses section of the report represented allowable expenditures for funding received through the Arkansas Workforce Stabilization Incentive Program funded through Section 9817 of the America Rescue Plan Act. The reporting error was due to the misinterpretation of the form by both the preparer and approver that Total Reportable Other PRF Expenses was an accounting for the use of funds reported in the ‘Other Assistance Received’ section immediately preceding this section. Corrective Action This report was prepared by the Vice President of Accounting and reviewed and approved prior to submission by the Chief Financial Officer. The approval process is deemed to be adequate by management but failed in this case due to the preparer and approver committing the same misinterpretation and overlooking the accounting provided in the ‘Other PRF Summary’ section of the report. The preparer and approver will both apply a corrected understanding and perform a more thorough review of future PRF reports.
Finding 2023-001: Internal Control Over Financial Reporting Management’s Response Mid Michigan CAA has a long-standing history of exemplary stewardship of federal, state, and local funds. The significant delay in preparation and subsequent completion of the FY2023 audit is directly related to staf...
Finding 2023-001: Internal Control Over Financial Reporting Management’s Response Mid Michigan CAA has a long-standing history of exemplary stewardship of federal, state, and local funds. The significant delay in preparation and subsequent completion of the FY2023 audit is directly related to staffing issues within the agency’s finance department. To prevent recurrence of this issue, Mid Michigan CAA is implementing the following corrective actions: 1. Revised Internal Timeline: We have established an internal audit preparation calendar with clearly defined deadlines to ensure timely completion and submission of future audits. 2. Enhanced Oversight: The Finance Committee of the Board will now receive monthly updates on audit progress during the audit cycle to ensure accountability and timely resolution of any issues. 3. Staff Engagement: Key finance staff are provided with more context and information on the audit process so that they can be more engaged and able to assist in the data gathering process. Contact Person Responsible for Corrective Action: Mark Polega, Executive Director Anticipated Completion Date: February 2025 – September 2025
Condition: Certain underlying support related to the VOCA Victim Assistance Formula Grant did not agree to amounts charged to the grant. Supporting information and records indicated more funds were spent by the Organization than were charged to the grant. Planned Corrective Action: Management will ...
Condition: Certain underlying support related to the VOCA Victim Assistance Formula Grant did not agree to amounts charged to the grant. Supporting information and records indicated more funds were spent by the Organization than were charged to the grant. Planned Corrective Action: Management will review its processes, procedures and controls to ensure that reconciliation and review of grant reimbursement requests and supporting underlying documentation occurs in future periods. Planned Completion Date: Ongoing Person Responsible: Kim Reed, VP of Finance
As of 12/11/2024 OKVU updated the SSVF policy and procedure manual to ensure grant compliance with the VA-designated satisfaction survey and added a review requirement to the discharge file QC checklist. As of 12/11/2024 all case manager staff were provided training.
As of 12/11/2024 OKVU updated the SSVF policy and procedure manual to ensure grant compliance with the VA-designated satisfaction survey and added a review requirement to the discharge file QC checklist. As of 12/11/2024 all case manager staff were provided training.
N/A - The Healthy Start Program transitioned to another local non-profit October 31, 2023. The Council will no longer have direct control over their corrective action plan.
N/A - The Healthy Start Program transitioned to another local non-profit October 31, 2023. The Council will no longer have direct control over their corrective action plan.
Management agrees with the auditors' finding and will take action to implement controlling procedures over federal programs. Name(s) of Contact Person(s) Responsible for Corrective Action: Nhia Xiong, Accounting Specialist, Alex Sukalski, Chief Financial Officer
Management agrees with the auditors' finding and will take action to implement controlling procedures over federal programs. Name(s) of Contact Person(s) Responsible for Corrective Action: Nhia Xiong, Accounting Specialist, Alex Sukalski, Chief Financial Officer
FINDING 2023-004 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Mindy McGee Contact Phone Number and Email Address: 812-265-8300, mmcgee@madison-in.gov Views of Responsible Officials: We concur with the finding regardi...
FINDING 2023-004 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Mindy McGee Contact Phone Number and Email Address: 812-265-8300, mmcgee@madison-in.gov Views of Responsible Officials: We concur with the finding regarding errors in Coronavirus Fund reporting. Description of Corrective Action Plan: Historically, the city has not had a centralized position who would be responsible for grant compliance and reporting. Individual department heads were responsible for comp0lying with each awarded grant for their own area of responsibility. In spring of 2025, a new Project & Grant Manager position was created and filled by a qualified individual. The responsibilities of the position include data collection and analysis, project management, grant coordination, information management and compliance monitoring and reporting. Anticipated Completion Date: The new position referenced above has been filled and is in operation as of April 8th 2025.
Action to be taken – Future internal approval of all timesheets will include first approval by the immediate supervisor, reviewing total hours worked per week, grants billed, and total hours worked. There will be a second approval by an outside financial management firm when they process the payroll...
Action to be taken – Future internal approval of all timesheets will include first approval by the immediate supervisor, reviewing total hours worked per week, grants billed, and total hours worked. There will be a second approval by an outside financial management firm when they process the payroll to prevent errors in overpayments. Estimated completion date – In September 2024 the new executive director mandated her approval or that of the board treasurer for any expenses. We are in the process of onboarding with the new financial management company with the anticipated start date of October 1, 2025 (the beginning of 2026 fiscal year).With this addition to our process, payroll will be processed off site by a third party. Responsible person – Carla Filkins, Executive Director and Julie Rushing, Board Treasurer
View Audit 359118 Questioned Costs: $1
Action to be taken – Immediately upon discovering the 2023 audit had not been completed, the Organization reached out to Weinlander Fitzhugh to schedule completion of the audit. As soon as the September 30, 2023 audit is complete, we have engaged with a new audit firm to begin the September 30, 2024...
Action to be taken – Immediately upon discovering the 2023 audit had not been completed, the Organization reached out to Weinlander Fitzhugh to schedule completion of the audit. As soon as the September 30, 2023 audit is complete, we have engaged with a new audit firm to begin the September 30, 2024 audit immediately. The Data Collection Forms will be submitted to the Federal Audit Clearinghouse within 30 days of the completion of each audit. Estimated completion date – The outstanding September 30, 2023 and September 30, 2024 fiscal year end audits are anticipated to both be completed by August 31, 2025. The September 30, 2025 audit will be scheduled timely after completion of the fiscal year. Responsible person – Carla Filkins, Executive Director and Julie Rushing, Board Treasurer
Action to be taken – Internal controls have been adjusted to reflect double approval of all transactions by the direct supervisor and the executive director or treasurer. This will include coding of bills, approval of all transactions and the processing of transactions. All approved transactions wil...
Action to be taken – Internal controls have been adjusted to reflect double approval of all transactions by the direct supervisor and the executive director or treasurer. This will include coding of bills, approval of all transactions and the processing of transactions. All approved transactions will be handled by an offsite financial management service in the future. By eliminating the use of the credit card, this will significantly reduce the chance of not having proper supporting documentation in the future. Estimated completion date – In September 2024 the new executive director mandated her approval or that of the board treasurer for any expenses, including credit cards. In February 2025 we updated our internal controls and added an administrative assistant to provide an extra level of segregation of duties. We are in the process of onboarding with the new financial management company with the anticipated start date of October 1, 2025 (the beginning of 2026 fiscal year). Responsible person – Carla Filkins, Executive Director and Julie Rushing, Board Treasurer
Action to be taken – Since becoming aware of the discrepancies between the credit card statements and transactions recorded in Quickbooks, the Organization has been entering all charges, interest and fees into the accounting software to reflect true balances on the credit cards. Going forward, all e...
Action to be taken – Since becoming aware of the discrepancies between the credit card statements and transactions recorded in Quickbooks, the Organization has been entering all charges, interest and fees into the accounting software to reflect true balances on the credit cards. Going forward, all entries related to credit cards will be recorded by an outside financial management firm. The Organization has accepted a purchase agreement for the Organization's building at 118 S Mitchell Street. The outstanding balance of the credit cards owed will be paid from the proceeds of the sale. Since becoming aware of the credit card balances, the use of Organization credit cards has been significantly restricted by management. Going forward, all credit card charges, if there are any, are only approved by the discretion of the executive director and paid on the balance immediately. Estimated completion date – Credit card balances have been reviewed and are current in their posting to our accounting software through journal entries that have been recorded. All fees and interest have also been recorded. All open credit card balances will be paid off from the proceeds on the sale of our building. This is anticipated to be completed by June 2025. Responsible person – Carla Filkins, Executive Director and Julie Rushing, Board Treasurer
Action to be taken – The Organization has updated its internal controls to reflect incorporate segregation of duties over the disbursement process and payroll processing. For payroll the updated process includes one person approving timesheets, another person processing payroll, the executive direct...
Action to be taken – The Organization has updated its internal controls to reflect incorporate segregation of duties over the disbursement process and payroll processing. For payroll the updated process includes one person approving timesheets, another person processing payroll, the executive director and board treasurer approving payroll, and lastly include a final approval of payroll. For disbursements the director of operations will open the mail and code bills for expense accounts, the executive director will approve bills for payment, the director of operations will print checks, the executive director or board treasurer will sign checks, the community response coordinator will mail checks, and the board treasurer will review bank reconciliations completed by the director of operations. All reconciliations will be reviewed by the board treasurer. Payroll processing will be performed by an outside financial management firm moving forward. Estimated completion date – In September 2024 the new executive director mandated her approval or that of the board treasurer for any expenses, including credit cards. In February 2025 we updated our internal controls and added an administrative assistant to provide an extra level of segregation of duties. Responsible person – Carla Filkins, Executive Director and Julie Rushing, Board Treasurer
Action to be taken – The Organization has adjusted its internal controls to include a final approval of payroll and withholdings by the executive director and board treasurer. The newly contracted outside financial Organization will be responsible for the processing of all payroll withholdings. The ...
Action to be taken – The Organization has adjusted its internal controls to include a final approval of payroll and withholdings by the executive director and board treasurer. The newly contracted outside financial Organization will be responsible for the processing of all payroll withholdings. The executive director and the treasurer will have online access to the accounts for oversight. Estimated completion date – In October 2024 the Executive Director began reviewing payroll and payroll withholdings during each pay period. Responsible person – Carla Filkins, Executive Director and Julie Rushing, Board Treasurer
Action to be taken – In September 2024 when the new executive director joined the Organization, the Organization immediately began to pay and file the payroll withholding. The late tax payments were brought to the attention of the executive director by the auditing firm during the audit. The board o...
Action to be taken – In September 2024 when the new executive director joined the Organization, the Organization immediately began to pay and file the payroll withholding. The late tax payments were brought to the attention of the executive director by the auditing firm during the audit. The board of directors immediately contacted tax attorney Patti O’Dell. The tax attorney has been communicating with the IRS and the State of Michigan on behalf of the Organization. Patti O’Dell has since joined the Organization's board of directors. The new internal controls in place and the new arrangement of contracting with an outside financial management firm will improve oversight in the future. The Organization has accepted a purchase agreement for the Organization's building at 118 S Mitchell Street. The balance of the payroll taxes owed will be paid from the proceeds of the sale. Estimated completion date – The sale of the building and payment of the outstanding payroll tax balances are anticipated to be completed by June 2025. The Organization will pay the total amount owed along with interest and penalties as soon as the sale of the building closes. All 2024-2025 fiscal year payroll taxes are current in processing and payment. Responsible person – Carla Filkins, Executive Director and Julie Rushing, Board Treasurer
Corrective Action Plan: 1. Proper identification and segregation of restricted revenue: Created spreadsheet that tracks restricted revenue, expenses, and balance remaining for each fund or restriction. This helps with both internal and external reporting requirements. 2. Matching Expenditures to Res...
Corrective Action Plan: 1. Proper identification and segregation of restricted revenue: Created spreadsheet that tracks restricted revenue, expenses, and balance remaining for each fund or restriction. This helps with both internal and external reporting requirements. 2. Matching Expenditures to Restrictions: As expenditures related to restricted funds are incurred (e.g., paying for program services or project costs), ensure these expenses are recorded against the same fund or tracking code used for the revenue. This ensures that all expenditures meet the requirements of the restriction and provides proper documentation for audit purposes. 3. Continuous monitoring and analysis to ensure accurate recording in the general ledger: Restricted funding will be reviewed at monthly Development meetings to ensure that revenue and expenses are appropriately recorded and that the remaining balance matches the restrictions. 4. Regular reviews and reconciliation of restricted funds to ensure compliance with restrictions. 5. Clear reporting to stakeholders and proper disclosure in financial statements. Anticipated completion date: 1. Completed 2. Ongoing 3. Starting February 10, 2025 4. Ongoing 5. Ongoing
Corrective Action Plan: 1. Standardize financial reporting procedures: • Accountant and ED will meet bi-weekly to review revenue and expenses • Accountant will meet with Donor Operations Manager monthly to confirm fund development revenue and expenses are properly allocated to the correct GL code • ...
Corrective Action Plan: 1. Standardize financial reporting procedures: • Accountant and ED will meet bi-weekly to review revenue and expenses • Accountant will meet with Donor Operations Manager monthly to confirm fund development revenue and expenses are properly allocated to the correct GL code • Accountant will send monthly financials to ED first for review • Once approved, ED will send monthly financials to Finance Committee Chair and BOD President • Finance Committee Chair will send to full board • Any questions will be addressed to the Finance Committee Chair • Budget will be reviewed at monthly leadership meetings • Regularly assess and refine, as applicable, financial reporting and closing processes to improve efficiency and accuracy 2. Finance Committee • Effective 9/2023, the finance committee was re-instituted to review financials and to implement stronger financial safeguards for TBS • Monthly meetings are held where financial performance and reports are reviewed in depth • Any anticipated risks will be reviewed • Finance Committee prepares annual budget with input from ED and BOD President 3. Board reporting • BOD members will receive monthly financial packet from Finance Committee Chair for review • Any questions will be directed to the Finance Committee Chair • Each quarterly board meeting will include a budget review highlighting projections and actuals vs budgeted • First board meeting of year will include comprehensive review of previous year Anticipated completion date: 1. Ongoing 2. Ongoing 3. Ongoing
Corrective Action Plan: 1. Review and update credit card and expense policies making it clear that receipts and invoices are mandatory for all purchases. Share this updated policy with all staff. 2. At the end of each month, staff members who have credit cards will submit their receipts along with t...
Corrective Action Plan: 1. Review and update credit card and expense policies making it clear that receipts and invoices are mandatory for all purchases. Share this updated policy with all staff. 2. At the end of each month, staff members who have credit cards will submit their receipts along with their credit card statement to the Administrator. The Administrator will be responsible for reviewing and ensuring that all of the receipts are in hand. If any are missing, the Administrator will work with the staff member to get a copy. If no copy is available, the staff member will write a statement explaining they are missing a receipt and what it was for. Document will be signed by the staff member and the Executive Director. 3. We will conduct quarterly reviews of expense documentation to ensure consistent compliance with policies. This will be reviewed during our quarterly Quality Improvement Program (QIP) meeting. Anticipated Completion Date: 1. Within 30 days 2. Within 30 days 3. Quarterly starting on February 10
Management’s Response/Corrective Action Plan: Discrepancies noted above are due to the timing of transactions posting in the accounting system where period transactions are not posted until after the data is gathered for the report or even after the reporting period, but still has an effective dat...
Management’s Response/Corrective Action Plan: Discrepancies noted above are due to the timing of transactions posting in the accounting system where period transactions are not posted until after the data is gathered for the report or even after the reporting period, but still has an effective date within the period, so it is not picked up when reports are filed. They are corrected in the following quarterly report. For TRUCK/LFVNT, the amounts were correct but just not in the period reported, and were corrected in subsequent reports. We can try to have another person duplicate the calculation of amounts for the reporting, which will depend on staffing level and time of year. The reporting site is also difficult and in order to be able to file on time, we really need to start mid-month to make sure it’s working and allow time for contacting the helpdesk to resolve any technical issues.
Management’s Response/Corrective Action Plan: The School Department has had turnover in positions that have had oversight and direct involvement in this process. In some cases, the established process was followed as constructed; however, in others, gaps in coverage are clearly exposed. The School D...
Management’s Response/Corrective Action Plan: The School Department has had turnover in positions that have had oversight and direct involvement in this process. In some cases, the established process was followed as constructed; however, in others, gaps in coverage are clearly exposed. The School Department agrees that the management of important documents has been inconsistent. In the future, the School Department will be assigning the management of these documents to positions where turnover is less likely to occur and a more consistent process is maintained.
Management’s Response/Corrective Action Plan: The School Department has had turnover in positions that have had oversight and direct involvement in this process. In some cases, the established process was followed as constructed; however, in others, gaps in coverage are clearly exposed. The School D...
Management’s Response/Corrective Action Plan: The School Department has had turnover in positions that have had oversight and direct involvement in this process. In some cases, the established process was followed as constructed; however, in others, gaps in coverage are clearly exposed. The School Department agrees that the management of important documents has been inconsistent. In the future, the School Department will be assigning the management of these documents to positions where turnover is less likely to occur and a more consistent process is maintained.
Finding 2023-003 Material Weakness in Internal Control Over Special Tests and Provisions Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human S...
Finding 2023-003 Material Weakness in Internal Control Over Special Tests and Provisions Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services, Health Resources and Services Administration Passthrough Agency N/A Award Number/Year 2023 Criteria FFHC is responsible for keeping adequate supporting documentation of the calculation of patient service fees for those patients who qualify for discounted fees based on family size and household income. FFHC is also required to apply discounted fees accurately based on an approved sliding fee scale that meets federal compliance requirements. Views of Responsible Officials and Planned Corrective Actions Friend Family Health Center Inc. and Affiliates (Organization) will implement the following corrective actions for the fiscal year ending June 30, 2023, to remediate the finding and address the cause of the finding. The Organization will implement the following corrective actions for fiscal year 2023 to remediate the finding and address the cause of the finding. • The Chief Financial Officer (CFO) will be responsible for the implementation of the corrective action plan and will oversee all related finance activities. • FFHC will enforce its current policy and related internal control procedures to ensure that supporting documentation of family size and household income is maintained for all patients that receive discounted patient service fees in relation to the Health Centers Program and Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program. • FFHC will enforce its current policy and related internal control procedures to ensure that discounted patient service fees are properly calculated and charged based on the applicable approved sliding fee scale. The target date for full implementation of these corrective actions is December 30, 2025. The person responsible for the planned resources will be Raheel Shahzad, Chief Financial Officer (847) 957-6244. Our address is 340 E. 51st St., Chicago, IL 60615.
Auditor's Recommendation: The Auditor recommends the Organization implement controls for documenting and retaining information to indicate the Organization follows the requirements over 2 CFR section 200.430(i), and that all time charged to the grant are reviewed for approval. Management’s Response:...
Auditor's Recommendation: The Auditor recommends the Organization implement controls for documenting and retaining information to indicate the Organization follows the requirements over 2 CFR section 200.430(i), and that all time charged to the grant are reviewed for approval. Management’s Response: In fiscal year 2024, LIFE Inc. implemented the following: • Reviewed, updated and established policies/procedures that aligned with the compliance of 2 CFR, 200.430(i). • Implemented a newly customized timekeeping system that enabled accurate recording of time spent on grant-related activities and that ensured capabilities for supervisory review and approval. • Conducted training sessions for all staff on updated policies regarding timekeeping procedures, the new online timekeeping portal and adherence to federal regulations. • Scheduled internal audits and reviews at least once a fiscal quarter to ensure that the new timekeeping system was being used correctly and that all time charged to grants was appropriate and compliant with LIFE Inc.’s policies/procedures and federal regulations. Due date of completion: August 31, 2024 Responsible Officer: Executive Director, Michelle Crain
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