Corrective Action Plans

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Corrective Action: Management agrees with the finding and has subsequently supported other eligible expenses that were not included in the original submission. These amounts exceeded the funding received. Anticipated Completion Date: November 15, 2024 Contact Person: Marco Giordano, Vice President ...
Corrective Action: Management agrees with the finding and has subsequently supported other eligible expenses that were not included in the original submission. These amounts exceeded the funding received. Anticipated Completion Date: November 15, 2024 Contact Person: Marco Giordano, Vice President and Chief Financial Officer
Management has acknowledged a breach in protocol and deposited the current year’s surplus cash on February 6, 2025.
Management has acknowledged a breach in protocol and deposited the current year’s surplus cash on February 6, 2025.
he Executive Director has implemented procedures for the procurement of an auditor to ensure the Financia Data Schedule is filed within nine months after the conclusion of the fiscal year. Name of Responsible Person: Tami Lucia, Executive Director Implementation date: April 2024
he Executive Director has implemented procedures for the procurement of an auditor to ensure the Financia Data Schedule is filed within nine months after the conclusion of the fiscal year. Name of Responsible Person: Tami Lucia, Executive Director Implementation date: April 2024
2023-003 Selection of the Waiting List RHA has put in place comprehensive new procedures and controls for all the staff members, including Clerks, Housing Assistants, Housing Coordinators and Project Managers, concerning the management of the waiting list process. As of September 2024m a new waitin...
2023-003 Selection of the Waiting List RHA has put in place comprehensive new procedures and controls for all the staff members, including Clerks, Housing Assistants, Housing Coordinators and Project Managers, concerning the management of the waiting list process. As of September 2024m a new waiting list will be generating following each new move-in, and the previous waiting list will be appropriately filed and preserved. Name of Responsible Person: Entire Admin Staff Implementation Date: September 2024
BRHC is in the process of hiring additional accounting staff to better ensure the month-end and year-end close processes are performed timely and will work with the audit firm to ensure that audit field work is scheduled with sufficient time to allow the audit report and data collection form to be f...
BRHC is in the process of hiring additional accounting staff to better ensure the month-end and year-end close processes are performed timely and will work with the audit firm to ensure that audit field work is scheduled with sufficient time to allow the audit report and data collection form to be filed in a timely manner in the future.
Management will maintain supporting schedules and prepare timely reconciliations to the general ledger on a monthly basis. Required adjustments will be communicated to the management of the accounting function and posted to the general ledger. Management will conduct a final review of the monthly ...
Management will maintain supporting schedules and prepare timely reconciliations to the general ledger on a monthly basis. Required adjustments will be communicated to the management of the accounting function and posted to the general ledger. Management will conduct a final review of the monthly financials prior to finalization, ensuring all requested correcting adjustments have been made and any unnatural balances have been investigated and corrected.
Finding 522350 (2023-001)
Significant Deficiency 2023
Rabble Mill has implemented an updated process for invoice approvals using a new bill pay software which includes an integrated internal approval feature. This feature ensures that all items and services purchased via invoice are approved by two individuals, one of whom is a Co-Executive Director, a...
Rabble Mill has implemented an updated process for invoice approvals using a new bill pay software which includes an integrated internal approval feature. This feature ensures that all items and services purchased via invoice are approved by two individuals, one of whom is a Co-Executive Director, and neither of whom is the purchaser, prior to payment. The new system addresses the breakdown in internal controls over allowable costs by facilitating clear and documented approval of purchases.
Finding 2023-004- Lack of Effective Controls Over Preparation of Schedule of Expenditures of Federal Awards Grantor: U.S. Department of the Treasury Assisstance Listing#: 21.027 Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Award Year: Fiscal year 2023 9/1/22-8/31/23 Award Number...
Finding 2023-004- Lack of Effective Controls Over Preparation of Schedule of Expenditures of Federal Awards Grantor: U.S. Department of the Treasury Assisstance Listing#: 21.027 Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Award Year: Fiscal year 2023 9/1/22-8/31/23 Award Number: Not Listed Management understands the importance of effective internal controls over the preparation of the Schedule of Expenditures of Federal Awards (SEFA). At the time of preparing the 2023 SEFA, $2 Million was improperly excluded causing the reported to be restated. Corrective Action Plan and Anticipated Completion Date: The total expenditures reported in error for the 2023 SEFA will be restated and the consolidated Financial and Compliance Report in Accordance with the Uniform Guidance will be re-sibmitted to the appropriate federal and state agencies. On a go forward basis, management's review will include a reconciliation of all grant expenses reported on the current SEFA to the grant awards listed on the State of Illinois Department of Public Health (IDPH) grant portal (EGrMS) to ensure all federal awards are reported.
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 represents that there was not sufficient documentation of controls. Operational and reporting improvements will be pursued to better document expenditure review on a go-forward basis.
Recommendation 1: Comment: We appreciate the recommendation and fully agree with the importance of having a clear documentation process for all deliveries. To address this, we will implement a policy that ensures all deliveries to the Organization and Units are properly documented. A designated empl...
Recommendation 1: Comment: We appreciate the recommendation and fully agree with the importance of having a clear documentation process for all deliveries. To address this, we will implement a policy that ensures all deliveries to the Organization and Units are properly documented. A designated employee responsible for receiving deliveries will be tasked with ensuring that all receipts and receiving reports are accurately matched with the corresponding invoices. This process will enhance our internal controls and improve the tracking and accountability of all deliveries. Recommendation 2: Comment: We will implement a policy requiring Unit Directors to submit daily "End of Day Reports" using a standardized template. This template will capture essential information, including activities conducted, materials distributed, and deliveries received. We will also establish a policy for maintaining and utilizing sign-in sheets at each Unit, outlining the required information such as the activity or event description, number of children involved, materials distributed, and the names of the Unit Director and Assistant Director. These sign-in sheets will be submitted to the appropriate parties promptly and saved in an online repository, organized by Unit and grant year. Additionally, supporting documentation will be collected and stored as part of the overall documentation process. We are committed to enforcing these policies to ensure timely submission and proper maintenance of all required documentation, further reinforcing our dedication to transparency, accountability, and effective use of grant funds.
View Audit 341463 Questioned Costs: $1
Recommendation: We recommend the City adopt procedures to ensure applicable reports are submitted timely and accurately. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Taken in Response to the Finding: The City will adopt procedures and work w...
Recommendation: We recommend the City adopt procedures to ensure applicable reports are submitted timely and accurately. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Taken in Response to the Finding: The City will adopt procedures and work with federal agencies to ensure accurate and timely reporting. Official Responsible for Corrective Action: Kristi Lillehaug, City Clerk/Treasurer. Planned Completion Date for Corrective Action Plan: December 31, 2024.
The Organization’s Accounting Department, under the direction of the Chief Executive Officer, Connie Franks, will ensure that there’s proactive communication, dedicated resource allocation, and regular status checks on the deadline. He should ensure everyone involved understands the deadlines and re...
The Organization’s Accounting Department, under the direction of the Chief Executive Officer, Connie Franks, will ensure that there’s proactive communication, dedicated resource allocation, and regular status checks on the deadline. He should ensure everyone involved understands the deadlines and responsibilities to avoid any delays. Completion of the referenced corrective action will be implemented by January 2025.
Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size.
Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size.
Management Response and Corrective Action Plan Finding 2023-003 – Reporting Program: Provider Relief Fund and American Rescue Plan Federal Agency: Health Resources and Services Administration Assistance Listing Number: 93.498 Responsible Individual: Katherine Bacher, VP of System Services Account...
Management Response and Corrective Action Plan Finding 2023-003 – Reporting Program: Provider Relief Fund and American Rescue Plan Federal Agency: Health Resources and Services Administration Assistance Listing Number: 93.498 Responsible Individual: Katherine Bacher, VP of System Services Accounting and Finance Contact Information: Katherine.bacher@bilh.org; 617-278-7059 Management agrees with the recommendation and moving forward, BILH will centralize the compilation of the SEFA, along with conducting periodic reconciliations of the schedule, the general ledger and supporting documentation. Management will also utilize its new accounting system to track all federal funding by requiring the appropriate worktags be utilized when recording such transactions, allowing for accurate reporting. Lastly, management will require at least two reviews of the SEFA. Corrective Action Plan: • Management will have training sessions with the Finance staff on the use of worktags when recording federal funding. • A new position has been created, Director of Technical Accounting, who will be responsible for compiling the SEFA and ensuring accuracy of the filing, with sign off by department managers who are submitting information • Director of Research Finance will review initial draft of SEFA for completeness and accuracy • VP of Revenue and Reimbursement will review the initial draft of SEFA for completeness and accuracy • VP of System Services Accounting and Finance will final review for completeness and accuracy Expected Completion Date: June 30, 2025 Status of Completion: In Process
Management will continue to rely on the audit firm to draft the financial statements and the related notes to the financial statements, and will review, approve, and accept responsibility for the annual financial statements prior to their issuance. Management will continue to increase internal abili...
Management will continue to rely on the audit firm to draft the financial statements and the related notes to the financial statements, and will review, approve, and accept responsibility for the annual financial statements prior to their issuance. Management will continue to increase internal abilities and advancement in order to monimize reliance on audit firm for financial statements.
The program tested requires a manual entry directly into the grantors system. Going forward the Organization will document the review and approval of the amounts submitted monthly to this system.
The program tested requires a manual entry directly into the grantors system. Going forward the Organization will document the review and approval of the amounts submitted monthly to this system.
Problem: Lake County Government did not file quarterly or annual reports as required by Coronavirus State and Local Fiscal Recovery Funds as per Department of Treasury. Actions Steps: All Coronavirus State and Local Fiscal Recovery Funds must be managed going forward as per the standardized grant fu...
Problem: Lake County Government did not file quarterly or annual reports as required by Coronavirus State and Local Fiscal Recovery Funds as per Department of Treasury. Actions Steps: All Coronavirus State and Local Fiscal Recovery Funds must be managed going forward as per the standardized grant funding policy in both process and procedure. Status: Granted funds awarded to Lake County Government are managed and controlled via the BOCC voted and approved Lake County Grant Policy. Dates: July 2024 to present Goal: To accurately and reliably manage and report on all funds granted awarded to Lake County Government.
Management accepts the finding and recommendation. During fiscal year 2023, the finance department hired additional personnel to assist with the completion of the year-end closing processes and procedures. We have discussed with employees the importance of timely submission of the City’s annual audi...
Management accepts the finding and recommendation. During fiscal year 2023, the finance department hired additional personnel to assist with the completion of the year-end closing processes and procedures. We have discussed with employees the importance of timely submission of the City’s annual audit package and data collection form to the federal audit clearinghouse on an ongoing basis.
Finding 521096 (2023-009)
Significant Deficiency 2023
Condition: Suspension and debarment compliance was not verified for two covered transactions. Corrective Action Planned: All Purchase Order requests that are associated with a federal government grant will all have an attached list showing the company is not on the debarment list. We will also u...
Condition: Suspension and debarment compliance was not verified for two covered transactions. Corrective Action Planned: All Purchase Order requests that are associated with a federal government grant will all have an attached list showing the company is not on the debarment list. We will also update our School Contract language to include specific wording where the Vendor acknowledges the law and forfeits the contract if they are on the debarment list after the contract has been signed. A statement will be added to the contracts that states the following: ‘The Contractor (or use the term in the contract that identifies the vendor instead of Contractor) certifies under the pains and penalties of perjury, that the Contractor is not currently debarred or suspended by the Federal government, or any of its agencies, entities or subdivisions, nor is the Contractor currently debarred or suspended by the Commonwealth Massachusetts or any of its agencies, entities or subdivisions.’ If there is a section in the contract where the vendor certifies to other conditions (i.e. state taxes paid), then this language could be included under that section as another certification requirement. A Google Drive has been created to upload all supporting documents on a yearly basis. Anticipated Completion Date: 2/17/2025 Contact: Noel Velez, Director of Finance and Fiona Maxwell, Procurement Director
Condition: The City did not reconcile its 2021 and 2022 revenue loss calculations with the final adjusted general ledger. Calendar year 2021 revenue was understated by $5,040,960 and calendar year 2022 revenue was understated by $1,455,486 in the 2021 and 2022 revenue loss calculations, respective...
Condition: The City did not reconcile its 2021 and 2022 revenue loss calculations with the final adjusted general ledger. Calendar year 2021 revenue was understated by $5,040,960 and calendar year 2022 revenue was understated by $1,455,486 in the 2021 and 2022 revenue loss calculations, respectively. Corrective Action Planned: Revenue reports for Calendar years 2020 - 2023 have been re-run and revenue loss calculations have been re-run by ARPA consultant for those years with results given to Auditors. Anticipated Completion Date: Complete Contact: Robert Dickinson, City Auditor
Finding 521085 (2023-007)
Significant Deficiency 2023
Condition: Suspension and debarment compliance was not verified for five covered transactions. Corrective Action Planned: All Purchase Order requests that are associated with a federal government grant will all have an attached list showing the company is not on the debarment list. We will also ...
Condition: Suspension and debarment compliance was not verified for five covered transactions. Corrective Action Planned: All Purchase Order requests that are associated with a federal government grant will all have an attached list showing the company is not on the debarment list. We will also update our School Contract language to include specific wording where the Vendor acknowledges the law and forfeits the contract if they are on the debarment list after the contract has been signed. A statement will be added to the contracts that states the following: ‘The Contractor (or use the term in the contract that identifies the vendor instead of Contractor) certifies under the pains and penalties of perjury, that the Contractor is not currently debarred or suspended by the Federal government, or any of its agencies, entities or subdivisions, nor is the Contractor currently debarred or suspended by the Commonwealth Massachusetts or any of its agencies, entities or subdivisions.’ If there is a section in the contract where the vendor certifies to other conditions (i.e. state taxes paid), then this language could be included under that section as another certification requirement. A Google Drive has been created to upload all supporting documents on a yearly basis. Anticipated Completion Date: 2/17/2025 Contact: Noel Velez, Director of Finance and Fiona Maxwell, Procurement Director
Condition: The Food Service Department did not perform its verification process by the date required by the state pass-through agency. Corrective Action Planned: No applications were submitted to be verified. The school district prompted caregivers on numerous occasions to return the forms witho...
Condition: The Food Service Department did not perform its verification process by the date required by the state pass-through agency. Corrective Action Planned: No applications were submitted to be verified. The school district prompted caregivers on numerous occasions to return the forms without receiving any. Anticipated Completion Date: 2/17/2025 Contact: Peter Cushing, Assistant Superintendent
Condition: Free or reduced meals applications could not be provided. The Food Service Department did not process free or reduced priced meals applications for the 2022-2023 school year. Corrective Action Planned: The School District has hired a qualified leader for the School Nutrition Program i...
Condition: Free or reduced meals applications could not be provided. The Food Service Department did not process free or reduced priced meals applications for the 2022-2023 school year. Corrective Action Planned: The School District has hired a qualified leader for the School Nutrition Program in order to comply with the requirements of this program. Additionally, the school district has enrolled all but the Brooks Elementary School as Community Eligibility Provision (CEP) sites and we are no longer required to collect these forms. At the Brooks School, these forms were sent to families from the Brooks School during the FY24 school year. Despite the efforts of the school and Food Services Director, no forms were returned to the school. Presently the forms are not required for the Brooks as the CEP eligibility requirements were reduced from 40% to 25% for determination. Anticipated Completion Date: 2/15/2025 Contact: Peter Cushing, Assistant Superintendent
Condition: Claims support could only be provided by the School for two months. For one month, support was in the form of spreadsheets with tray counts in lieu of a point-of-sale system. For the other month, the tray count spreadsheets were accompanied by reports from the point-of-sale system. Th...
Condition: Claims support could only be provided by the School for two months. For one month, support was in the form of spreadsheets with tray counts in lieu of a point-of-sale system. For the other month, the tray count spreadsheets were accompanied by reports from the point-of-sale system. The point-of-sale system reports provided did not agree to the amounts claimed for reimbursement. The tray counts did not indicate whether the meal provided was paid, free or reduced. The claims for reimbursement submitted by the School used allocation percentages derived from prior year claims when estimating amounts to be claimed as paid, free and reduced. The tray count spreadsheets for the other months could not be located by the School. Corrective Action Planned: In January 2023 DESE sent an auditor to review the Medford School Nutrition Program. Before this review, there was significantly limited oversight by the central office finance team. Almost no documents were prepared before the review as required by DESE. As a result of this audit a 58-item, 19-page Corrective Action Plan was issued to the district. A new district leader was assigned for departmental oversight. The district then had weekly meetings with DESE to address the corrective action plan, for this was the single largest CAP DESE has issued to any district of our size. Nearly $1.3 million in reimbursements were withheld from the district from approximately November 2022 through the end of the Fiscal Year. DESE issued the reimbursements with a nominal penalty during the summer of 2023. At the end of FY23, the district terminated the director of the program. We are now training several individuals in the MCPPO program for enhanced oversight. DESE forced an immediate return audit for FY24. This was an exceptional action as DESE has only rarely done this. The same reviewer attended and noted significant improvements as a result of district actions undertaken. As relates to this particular finding, the School Department has purchased and is consistently using a point of sale system for students to purchase their meals. The system is used to track all transactions. Anticipated Completion Date: 2/17/2025 Contact: Peter Cushing, Assistant Superintendent
View Audit 341024 Questioned Costs: $1
The Meadows Mental Health Policy Institute for Texas (the Institute) respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: 01/01/2023 – 12/31/2023 The findings from the Schedule of Findings and Questioned Costs identified in the December 05, 20...
The Meadows Mental Health Policy Institute for Texas (the Institute) respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: 01/01/2023 – 12/31/2023 The findings from the Schedule of Findings and Questioned Costs identified in the December 05, 2024, audit report are discussed below. Findings are numbered consistently with the numbers assigned in the schedule. Findings – Federal Awards Audit Significant Deficiency Federal Awards Program Audit Findings and Recommendations Finding 2023-001: Reporting – significant deficiency in internal control over compliance and compliance finding. All federal grants. Criteria: Grantees who are subject to single audit requirements are required to submit their Data Collection form to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditors’ report or 9 months after the audit period. Condition: The Institute’s Data Collection form was late for the years ended December 31, 2022, and 2023. Cause: Delays in completing the audits resulted in the Data Collection forms being submitted after 9 months from the end of the audit report. Effect: The Institute was not in compliance with single audit reporting requirements. Recommendation: Internal controls and processes should be implemented to ensure audits are completed in a timely manner to meet federal reporting deadlines. Institute Action Plan: • Hire new finance and accounting senior management [completed November 2024]. o Hired new CFO (October 2024; started January 02, 2025) o Hired new Controller (November 2024; starts February 17, 2025) Establish timeline for review and acceptance of 2024 audit [initiated December 2024]. o By May 01, 2025: Institute submits 2024 General Ledger and Trial Balance to auditor o May 01, 2025 – May 11, 2025: Auditor sends sample and other requests for information o May 12, 2025 – May 23, 2025: Audit fieldwork o Week of July 07, 2025: Auditor sends draft audit report to Institute management for review. o Week of July 21, 2025: Institute management reviews draft audit report and notes areas needing clarification and/or corrections. o By Week of August 11, 2025: Auditor provides a final revised audit report to Institute management. o Week of August 18, 2025: Institute management sends audit report to the Institute Board’s Audit and Finance Committee for review. o By week of September 1, 2025: The Audit and Finance Committee meets to review and accept final audit report on behalf of the Board. o By September 15, 2025: Data Collection Form is submitted to the Federal Audit Clearinghouse (i.e., well in advance of the September 30, 2025, submission due date for the Data Collection Form). o October 29, 2025: The Institute Board ratifies the Audit and Finance Committee’s acceptance of final audit report. • Q1-Q2 2025: Perform gap analysis evaluation of existing Accounting staff and address any gaps in coverage and provide access to and training on financial systems and historical data archives [initiated and ongoing]. Corrective Action Contact Person(s): Maryana Geller, Chief Financial and Administrative Officer Planned Completion Date for Corrective Action Plan: September 15, 2025
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