Corrective Action Plans

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Management’s Response All participant eligibility documents are now in house and stored in a secure location on the NIBC server Contact Person Responsible for Corrective Action: Whitney Wardell Anticipated Completion Date: 7/1/2024
Management’s Response All participant eligibility documents are now in house and stored in a secure location on the NIBC server Contact Person Responsible for Corrective Action: Whitney Wardell Anticipated Completion Date: 7/1/2024
Finding 2023-002: Internal Control Over Financial Reporting – Internal Control Evidence Management’s Response Now that disbursements are 100% in-house, the President & CEO provides final written approval on all timecards and payables. Chairman of the Loan & Finance Committee remotely reviews journal...
Finding 2023-002: Internal Control Over Financial Reporting – Internal Control Evidence Management’s Response Now that disbursements are 100% in-house, the President & CEO provides final written approval on all timecards and payables. Chairman of the Loan & Finance Committee remotely reviews journal entries in accounting software monthly. Contact Person Responsible for Corrective Action: Whitney Wardell Anticipated Completion Date: 7/1/2024
Finding 2023-001: Internal Control Over Financial Reporting – Account Reconciliations Management’s Response In 2021, senior management contracted with a CPA firm to handle all accounting functions. Processes and procedures that were expected to be completed by contractor were not. As of 7/1/23, mana...
Finding 2023-001: Internal Control Over Financial Reporting – Account Reconciliations Management’s Response In 2021, senior management contracted with a CPA firm to handle all accounting functions. Processes and procedures that were expected to be completed by contractor were not. As of 7/1/23, management brought accounting functions in house to gain control of books, provide more oversight and ensure accuracy. Contact Person Responsible for Corrective Action: Whitney Wardell Anticipated Completion Date: 7/1/2024
Management agrees with the finding. The Organization will implement procedures to monitor reporting deadlines and assign responsibility for the timely submission of the single audit reporting package and Data Collection Form to the Federal Audit Clearinghouse. Management will also establish a review...
Management agrees with the finding. The Organization will implement procedures to monitor reporting deadlines and assign responsibility for the timely submission of the single audit reporting package and Data Collection Form to the Federal Audit Clearinghouse. Management will also establish a review process to ensure all future filings are completed within the required timeframe. Anticipated Completion Date: September 30, 2026.
Finding No. 2023-010: Lack of Management Oversight to Ensure Retention of Cash Disbursements and Expenses Approval The Health Center has moved to a cloud portal for submitting and processing invoices for approval and payment as well for maintaining vendor files. Under the cloud portal, any requests ...
Finding No. 2023-010: Lack of Management Oversight to Ensure Retention of Cash Disbursements and Expenses Approval The Health Center has moved to a cloud portal for submitting and processing invoices for approval and payment as well for maintaining vendor files. Under the cloud portal, any requests for payments cannot be processed without an invoice and or any other sufficient supporting documents. Approvals of invoices is now also reflected in the portal to indicate readiness for payment. The Health Center does not anticipate to charge expenses to the awards that are not in accordance with budgeted amounts as submitted to its funding sources.
Finding No. 2023-009: Lack of Management Oversight to Ensure Retention of Timesheets Grant timesheets are now being maintained with appropriate charging of time that is related programmatic or administrative functions. The timesheets are signed off by the employee and their related supervisor and ma...
Finding No. 2023-009: Lack of Management Oversight to Ensure Retention of Timesheets Grant timesheets are now being maintained with appropriate charging of time that is related programmatic or administrative functions. The timesheets are signed off by the employee and their related supervisor and maintained in the shared file for immediate availability and reference.
Finding No. 2023-008: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will rec...
Finding No. 2023-008: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will recognize a “full discount” for individuals and families with annual incomes at or below 100% FPL with only nominal fees charged, three levels of discount between 100% and 200%, and no discounts for copays for individuals and families earning over 200% FPL. This policy will be in accordance with Section 330(k)(3)(G) of the PHS Act and 42 CFR Part 51c.303(f) and 42 CFR Part 51c.303(u) which are incorporated herewith. We will charge a nominal fee to individuals and families with annual incomes at or below 100% of the Federal poverty level (FPL). Patients whose incomes are above 100% and at or below 200% of the FPL will be charged according to our sliding fee scale based on income and family size. Discounts will be provided to patients with incomes up to 200% of the FPL for medical visits. Discounts will be provided to patients with incomes up to 250% of the FPL for family planning visits. Staff will assess patients’ incomes based upon a sliding fee scale and no patient will be denied care based upon their inability to pay. The organization also has a policy of non-discrimination in the delivery of health care as stated in its Patient Bill of Rights. Also, the Board of Directors define the income and family size, and has defined the family size to be all parents, minors or guardians that are financially responsible for the household. The tracking and documentation of sliding fees is now maintained with the deposit record of each fee received in the shared file for immediate availability and reference.
Finding 2023-006: Lack of Management Oversight over Drawdown Requests As the previous employees responsible for these functions did not perform them effectively, the organization now has such in place, whereas a drawdown process has been implemented. As the organization’s drawdowns are typically des...
Finding 2023-006: Lack of Management Oversight over Drawdown Requests As the previous employees responsible for these functions did not perform them effectively, the organization now has such in place, whereas a drawdown process has been implemented. As the organization’s drawdowns are typically designated to cover payroll costs, this process now includes the following: • A drawdown allocation schedule for the employee’s making up the amount requested • A budget breakdown by department for the amounts making up the drawdown request • A supporting schedule and related invoices for amounts to be reimbursed (e.g., malpractice insurance, etc.) • A completed Standard Form (SF) 270 that tracks the applicable grant amounts previously drawdown that also specifies the amount to be currently drawn.
Management acknowledges the auditors’ findings and will develop and implement a formal internal control over the preparation and review of the Schedule of Expenditures of Federal Awards to ensure accuracy and compliance with Uniform Guidance. SEFA preparation will be assigned to designated staff, wi...
Management acknowledges the auditors’ findings and will develop and implement a formal internal control over the preparation and review of the Schedule of Expenditures of Federal Awards to ensure accuracy and compliance with Uniform Guidance. SEFA preparation will be assigned to designated staff, with a separate supervisory review to verify completeness, proper classification, and reconciliation to the general ledger. Written procedures, checklists, and documented reviews will be established, along with staff training on federal award requirements. These actions will reduce the risk of errors and strengthen the reliability of the Town’s federal award reporting
August 20, 2026 To: Clausell & Associates, P.C. From: Mary Harrison, Executive Director of CSRA Economic Opportunity Authority, Inc. Below is the Authority’s corrective action plan as it relates to the findings for the fiscal year ending September 30, 2023, Single Audit Act audit. Comment #2023-001 ...
August 20, 2026 To: Clausell & Associates, P.C. From: Mary Harrison, Executive Director of CSRA Economic Opportunity Authority, Inc. Below is the Authority’s corrective action plan as it relates to the findings for the fiscal year ending September 30, 2023, Single Audit Act audit. Comment #2023-001 INTERNAL CONTROLS OVER FINANCIAL STATEMENT PREPARATION, GRANT CLOSE-OUT, AND COMPLIANCE WITH RELATED PROVISIONS OF GRANTS AND CONTRACTS SHOULD BE IMPROVED GENERAL Views of Responsible Officials and Planned Corrective Actions: We concur with this finding. Management is in the process of assessing the organizational structure and capacity to provide adequate financial reporting. With Board review and approval of the Authority’s financial funding sources, the Authority will require additional specialize training for fiscal staff and improve in the segregation of duties to ensure adequate internal controls are fully implemented. The Executive Director will have the overall responsibility of properly reconciling and closing out the accounting system and grant activity each month in an efficient and timely manner to eliminate the risk of significant errors occurring. Budget-to-actual schedules will be an integral part of the grant accountant analyst’s basic responsibilities. The fiscal policies and procedures will be updated with the enhancements implemented within the fiscal department. Staff will be trained on revised policies and procedures and Uniform Guidance regulations. The Executive Director will take the lead in financial reporting to ensure that all reporting meet GAAP and GAS requirements and to provide informative reports for Board and Management. All enhancements will be implemented by September 30, 2026. Concerning the preparation of external reports required by various funding sources (i.e., SF-425, DHS’s reports for LIHEAP, etc.), the Authority will ensure adequate training is performed to improve the skills and knowledge of key personnel. Policies and procedures will also be revised to support external reporting. Implementation Date: The plan correction date will be completed no later than September 30, 2026 Responsible Person: Mary Harrison, Executive Director, will be responsible for the corrective action. Comment #2023-002 INTERNAL CONTROLS OVER FINANCIAL STATEMENT PREPARATION, GRANT CLOSE-OUT, AND COMPLIANCE WITH RELATED PROVISIONS OF GRANTS AND CONTRACTS SHOULD BE IMPROVED HEAD START AND SUPPORTIVE SERVICES FOR VETERAN FAMILIES PROGRAM FAL # 93.600 AND 64.003 (Questioned Costs - None) Views of Responsible Officials and Planned Corrective Actions: We concur with the finding. Management and staff are in the process of assessing and updating the policies and procedures over the accounting and reporting of federal and state grants and contracts. In connection with training staff on grant accounting, we are providing ongoing training on the requirements of the Uniform Guidance and the specific requirements for each individual grant award as outlined in each applicable Compliance Supplement issued by Office of Management and Budget (OMB). We are currently reconciling all cash accounts and completing and amending, where necessary, all SF-425 reports and other external reports required by each funding source (state and federal). We anticipate completing this corrective action by September 30, 2026. See also the response to Comment #2023-001. Implementation Date: The plan correction date will be completed no later than September 30, 2026. Responsible Person: Mary Harrison, Executive Director, will be responsible for the corrective action.
Finding No.: 2023-020 AL Program: 93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance Area: Special Tests and Provisions - Key Level Management Questioned Costs: Undeterminable Views of Auditee and Corrective Action Plan: Management’s Position: PSS Manage...
Finding No.: 2023-020 AL Program: 93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance Area: Special Tests and Provisions - Key Level Management Questioned Costs: Undeterminable Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the findings. Financial and Grants Management processes were promulgated in a SOP on September 18, 2024. The SOPs are under review by an external consultant and recommendations made to improve documentation of time and effort allocable under federal awards. (See also 2023-004, 2023-0009) Corrective Action Plan: I. Establishment of Time and Effort SOPs: PSS will finalize and implement a dedicated Time and Effort Reporting SOP. This policy will explicitly define the key management Level of Effort (LOE) requirements by position and mandate the collection of specific supporting records, including Notice of Personnel Action (NOPA) forms, payroll registers, and certified timesheets. The SOP will feature robust internal controls and supervisory review procedures designed to prevent improper payments and ensure accurate labor distribution. II. Standardization of Key Management Records: PSS will obtain and systematically retain NOPA forms or equivalent documentation for all six positions identified in the grant agreement. This documentation will serve as the primary evidence to demonstrate compliance. III. Labor Distribution Monitoring Controls: PSS is implementing ongoing monitoring controls to ensure continued compliance. This includes a periodic internal review of payroll registers against the original grant agreements to verify that the labor costs charged to the award remain consistent with the approved personnel budget and documented effort. Proposed Completion Date: August 2026 Name of Contact Person and Title: Contact: Jacqueline Che, Federal Programs Officer Email Address: jacqueline.che@cnmipss.org
Finding No.: 2023-017 AL Program: COVID-19 84.425A/84.425X Education Stabilization Fund Area: Special Tests and Provisions - Private School Participation Questioned Costs: Undeterminable Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management disagrees with the finding. PS...
Finding No.: 2023-017 AL Program: COVID-19 84.425A/84.425X Education Stabilization Fund Area: Special Tests and Provisions - Private School Participation Questioned Costs: Undeterminable Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management disagrees with the finding. PSS asserts that timely and meaningful consultations were conducted with private school officials prior to making decisions regarding the size, scope, and funding of equitable services for FY2023. Calculations for the equitable share under the Education Stabilization Funds were performed in accordance with federal regulations, ensuring that per-pupil allocations for eligible private school students and teachers were equitable relative to public school expenditures. PSS maintains that consultation timelines, meeting records, and allocation formulas were maintained. While PSS is continuously refining its administrative workflows, the existing documentation and controls were sufficient to satisfy the requirements of 34 CFR § 299.7. Proposed Completion Date: Resolution in progress and on track for completion by August 2026. Name of Contact Person and Title: Contact: Jacqueline Che, Federal Programs Officer Email Address: jacqueline.che@cnmipss.org
Finding No.: 2023-016 AL Program: COVID-19 84.425A/84.425X Education Stabilization Fund Area: Special Tests and Provisions - Wage Rate Requirement Questioned Costs: Undeterminable Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the audit findings. We a...
Finding No.: 2023-016 AL Program: COVID-19 84.425A/84.425X Education Stabilization Fund Area: Special Tests and Provisions - Wage Rate Requirement Questioned Costs: Undeterminable Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the audit findings. We acknowledge that our current procurement and contract administration processes did not consistently incorporate the mandatory Davis-Bacon Act labor standard clauses or the subsequent collection of certified payrolls. PSS is committed to implementing a rigorous compliance framework for all federally funded construction and repair projects. Financial, Procurement, and Grants Management policies procedures were promulgated in a SOPs on September 18, 2024. The financial management system was subsequently changed to Tyler Munis to conform with CNMI central government requirements which will enhance capabilities. The SOPs and the Tyler Munis implementation are under review by an external consultant and recommendations made to improve documentation of cost allowability have been received. Payment procedures are being addressed in a separate SOP. Corrective Action Plan: To ensure full compliance with 29 CFR 5.5 and federal wage rate requirements, PSS will implement the following: I. Standardized Construction Contract Template: PSS Legal Counsel and the Procurement Office will develop a standardized "Federal Construction Contract Addendum." This addendum will contain all mandatory Davis-Bacon Act clauses required by 29 CFR 5.5(a)(1)-(10). Effective immediately, no contract or purchase order exceeding $2,000 for construction, alteration, or repair will be executed without the inclusion of this addendum. II. Mandatory Certified Payroll Submission Protocol: PSS will update its "Notice to Proceed" and project management guidelines to explicitly state that progress payments will be withheld until the contractor submits the required weekly certified payrolls. Contractors will be provided with the Form WH-347 (or an equivalent) to ensure they are using the correct reporting format. III. Pre-Construction Compliance Meetings: For all future Davis-Bacon covered projects, PSS will hold a mandatory pre-construction meeting with contractors to clearly communicate their obligations regarding certified payrolls and the posting of the applicable wage decision at the job site. IV. Document Retention and Review Audit: PSS will implement a "Project Close-out Checklist." Finance will not process the final retention payment for any construction project until the Labor Compliance Monitor certifies that all weekly certified payrolls have been received, reviewed, and filed. V. Updated Standard Operating Procedures and Training: PSS will finalize SOPs and policies internal controls with updated internal controls and procedures for required contract clauses and oversight. Checklists will be updated to include a specific control for Davis-Bacon reporting. Require all current contractors and those identified in this audit to submit certified payrolls for 2023 through the span of their contracts for all Davis-Bacon covered work. PSS Procurement and Supply staff will receive refresher training on cost principles annually regarding required contract clauses and documentation to support compliance with requirements. Proposed Completion Date: September 2026 Name of Contact Person and Title: Contact: Michael Jason A. Babauta, Chief Procurement & Supply Officer Email Address: michael.jason.babauta@cnmipss.org
Management Response: SWIWC concurs with the auditor's finding that adequate supporting documentation was not provided during the audit for 14 of the 40 expenditure transactions selected for testing. SWIWC recognizes that federal expenditures must be supported by sufficient documentation to demonstra...
Management Response: SWIWC concurs with the auditor's finding that adequate supporting documentation was not provided during the audit for 14 of the 40 expenditure transactions selected for testing. SWIWC recognizes that federal expenditures must be supported by sufficient documentation to demonstrate that costs were authorized, incurred for an allowable program purpose, properly allocated to the award, and adequately supported by underlying source documentation. SWIWC respectfully distinguishes, however, between a cost that is questioned because sufficient documentation was not available during the audit and a cost that has been affirmatively determined to be unallowable. The $70,587 reported as questioned costs relates to transactions for which the documentation provided during audit testing was considered insufficient. The finding does not state that the auditors determined that the underlying goods or services were not received, that the expenditures were outside the objectives of the award, or that the expenditures were otherwise affirmatively determined to be unallowable. Corrective Actions Implemented Since the FY2023 period under audit, SWIWC has strengthened its expenditure-processing and documentation controls. SWIWC requires expenditure transactions to be supported by documentation appropriate to the nature of the transaction, which may include invoices, receipts, contracts, agreements, travel documentation, purchasing documentation, evidence of receipt of goods or services, and evidence of required approval. Finance reviews transactions for appropriate funding source, supporting documentation, authorization, and consistency with applicable grant and organizational requirements. SWIWC has strengthened its accounts payable procedures so that supporting documentation is associated with the corresponding accounting transaction and maintained electronically. Documentation deficiencies identified during processing or subsequent review are followed up with the responsible employee or program before the transaction is considered fully documented. SWIWC has also strengthened grant expenditure monitoring through budget-to-actual review and centralized grant records. Grant and financial documentation is maintained in a manner designed to permit transactions to be traced from the accounting records to the underlying supporting documentation and, where applicable, to grant reporting and reimbursement records. Preventive Controls To prevent recurrence, SWIWC has implemented or strengthened the following controls: • Standardized expenditure documentation requirements; • Documented review and approval of expenditures; • Centralized electronic retention of supporting records; • Identification of the applicable funding source; • Review of expenditures for grant allowability and allocability; • Procurement documentation requirements; • SAM.gov verification when applicable; • Budget-to-actual grant monitoring; • Periodic Finance review of supporting documentation; • Staff training regarding expenditure and grant-documentation requirements in February 2026; and • Maintenance of records in an audit-ready format to be completed by 9/30/2026. Resolution of Questioned Costs SWIWC understands that the ultimate resolution of questioned costs rests with the applicable awarding or pass-through entity through the audit-resolution process. SWIWC will therefore maintain the $70,587 as questioned costs pending completion of the applicable resolution process and will not characterize the entire amount as either allowable or unallowable solely on the basis of the audit finding. For transactions for which sufficient supporting documentation is identified or reconstructed, SWIWC will provide that documentation as appropriate to support resolution of the questioned amount. If the awarding or pass-through entity ultimately determines that any portion of the questioned costs is unallowable, SWIWC will take the corrective action required by that determination, including repayment or other financial adjustment if required. Anticipated Completion Date: September 30, 2026, for completion of the historical transaction review; enhanced expenditure controls are currently in effect and will continue on an ongoing basis. Responsible Party: Chief Financial Officer and Director of Finance, with applicable Program Managers responsible for providing programmatic documentation.
The Village acknowledges the recommendation and will continue to strengthen its procedures for identifying and tracking grant activity. Management plans to implement additional review procedures over grant funding sources and related expenditures for purposes of SEFA reporting. The Village will also...
The Village acknowledges the recommendation and will continue to strengthen its procedures for identifying and tracking grant activity. Management plans to implement additional review procedures over grant funding sources and related expenditures for purposes of SEFA reporting. The Village will also consider providing the SEFA and supporting expenditure information to its external engineering consultants for review to help ensure all grant activity administered on behalf of the Village is properly identified and reported.
AUDITEE’S CORRECTIVE ACTION PLAN As required by Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost principles, and Audit Requirements for Federal Awards (UG), the Hazlehurst City School District has prepared and hereby submits the following corrective ...
AUDITEE’S CORRECTIVE ACTION PLAN As required by Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost principles, and Audit Requirements for Federal Awards (UG), the Hazlehurst City School District has prepared and hereby submits the following corrective action plan for the findings included in the Schedule of Findings and Questioned Cost for the year ended June 30, 2023: Finding 2023-001 Corrective Action Plan Details A. Contact person responsible for corrective action: Name: Sherry Terry Title: Chief Financial Officer B. Description of corrective action planned: The district will strengthen its internal control systems over reporting to ensure single audit reporting package and data collection form are submitted to the Federal Audit Clearinghouse within established timeframe and financial statements are prepared timely. C. Anticipated completion date of corrective action: Immediately
Corrective Action Taken or Planned: 1. The Finance Office composed a specific "Federally Funded" Request for Proposal (RFP) document to be used going forward for contracts funded by federal awards. The Appendix section of this RFP template lists all of the specific provisions cited in Appendix II to...
Corrective Action Taken or Planned: 1. The Finance Office composed a specific "Federally Funded" Request for Proposal (RFP) document to be used going forward for contracts funded by federal awards. The Appendix section of this RFP template lists all of the specific provisions cited in Appendix II to 2 CFR Part 200 that may apply. 2. The Finance Office will work to educate departmental individuals invovled in procurement regarding the use of the "Federally Funded" RFP when composing a request for proposal for which the funding of the contract would come from a federal award. The Appendix section of this RFP template will serve as a procurement checklist for the Appendix II, 2 CFR Part 200 requirements, and sample language for contract language is provided in the RFP template for RFP respondents to include in any proposed agreement. 3. The Finance Office will review contracts funded by federal awards and, if certain required contractual provisions cited in Appendix II to 2 CFR Part 200 were excluded in the executed contract, the Office shall work with the particular vendor and the Commissioners Office to have contract amendments (that incorporate the missing federally required provisions) composed and agreed to by both parties as soon as possible after the discovery of non-compliance. Implementation date of corrective action: December 08, 2025 Person responsible for corrective action: Charles Nickerson, Senior Director of Finance
Condition: The Organization did not submit the budget to HUD within 30 days of the start of its fiscal year. Planned Corrective Action: Management has implemented a new review and oversight process related to the process for the documentation submissions to HUD to ensure timely submissions of items ...
Condition: The Organization did not submit the budget to HUD within 30 days of the start of its fiscal year. Planned Corrective Action: Management has implemented a new review and oversight process related to the process for the documentation submissions to HUD to ensure timely submissions of items and to ensure documentation of review of submitted information is retained on a goforward basis. Contact person responsible for corrective action: Louise Arzu, Vice President, Finance Anticipated Completion Date: 9/30/2026
Finding Reference Number 2023-001 Finding The Hospital’s internal control processes regarding usage of funds received under the Provider Relief Fund allocation within the American Rescue Plan Act, 2021, did not provide for adequate segregation of duties. Internal controls around approving, tracking,...
Finding Reference Number 2023-001 Finding The Hospital’s internal control processes regarding usage of funds received under the Provider Relief Fund allocation within the American Rescue Plan Act, 2021, did not provide for adequate segregation of duties. Internal controls around approving, tracking, and reporting expenses were not sufficient. Management agrees with the finding. Corrective Action Plan In September 2023, the Hospital implemented a policy regarding the usage of grant funding received through HRSA. This policy includes review of program guidelines, education of responsible staff, maintenance of separate general ledger accounts for program expenditures, approval of purchase orders by appropriate levels of management, and establishment of logs for program expenditures. It also provides for review of general ledger accounts and review of reports submitted to granting agencies. These changes were implemented to ensure allowable costs are properly approved, tracked, reviewed, and reported in accordance with federal requirements and to provide for adequate segregation of duties in these responsibilities. Responsible Personnel Lisa Hart, former Chief Executive Officer (responsible for implementation of corrective action). Megan Corbin, Chief Executive Officer (current contact for any follow-up regarding corrective action). Completion Date Corrective action was completed in September 2023.
Recommendation We recommend that Management enhance its internal control structure, including financial close and reporting, to ensure timely filing of future federal Uniform Grant Guidance reporting packages. Management Response Corrective Action The District acknowledges the finding. The FY23 Sing...
Recommendation We recommend that Management enhance its internal control structure, including financial close and reporting, to ensure timely filing of future federal Uniform Grant Guidance reporting packages. Management Response Corrective Action The District acknowledges the finding. The FY23 Single Audit reporting package was not timely filed due to the delayed audit, prior-year close issues, turnover, and incomplete audit preparation. Corrective action includes implementing an audit calendar, preparing the SEFA timely and on the required basis, tracking audit requests, assigning responsibility for federal reporting items, and monitoring the Federal Audit Clearinghouse filing deadline. The District will submit future Single Audit reporting packages within the required timeframe. Due Date of Completion: In progress; procedures to be implemented for the FY26 audit cycle and ongoing thereafter. Responsible Party(ies) Superintendent, Director of Finance/Business Office, and contracted finance support.
Procurement Recommendation: We recommend that management develop, adopt, and implement written procurement and conflict-of-interest policies that comply with Uniform Guidance requirements. These policies should address procurement standards, including methods of procurement and oversight, and establ...
Procurement Recommendation: We recommend that management develop, adopt, and implement written procurement and conflict-of-interest policies that comply with Uniform Guidance requirements. These policies should address procurement standards, including methods of procurement and oversight, and establish standards of conduct governing conflicts of interest for employees, officers, and agents involved in the administration of federal awards. Management should also ensure that these policies are communicated to relevant personnel and applied consistently. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In 2024 new maintenance staff was employed 3 bids are required for capital projects. If one contractor has personal relationship with employee conflict of interest form is filed. Name(s) of the contact person(s) responsible for corrective action: Kristin Cowan Planned completion date for corrective action plan: July 2024
Reporting Recommendation: We recommend that the auditee implement procedures to ensure that Form 19-lA reimbursement requests are reviewed prior to submission to confirm that expenditures are charged to the correct approved budget line items. This may include maintaining a reconciliation between the...
Reporting Recommendation: We recommend that the auditee implement procedures to ensure that Form 19-lA reimbursement requests are reviewed prior to submission to confirm that expenditures are charged to the correct approved budget line items. This may include maintaining a reconciliation between the general ledger, the approved grant budget, and the Form 19-lA, as well as implementing supervisory review and approval of reimbursement submissions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. 2026 Action taken in response to finding: Reoccurring bills such as utilities, loan payments, contract services and credit card payments do not require an expense request to be included for on going bills. We will review our procedures and update our financial policy. 2023 Our financial process includes at least two reviews prior to creating a bill in our accounting system, payments are reviewed by the director or the Deputy Director when signed. We do not use a auto signature all checks are reviewed. 2023 The Grantor billing is a P&L detailed report for that grant and provides reconciliation monthly This is sorted into grant line items designated billable and non-billable for compliance. Total program cost and billable to grant are tracked every month, by the grant finance manager for compliance prior to billing any grants. Timecards are reviewed, expense requests are reviewed and payments are reviewed. Prior to submission of the invoice to grantor. 2023 Grant finance manager pulls copy of timecards, bills and checks to ensure compliance with reimbursements are accurate. Name(s) of the contact person(s) responsible for corrective action: Cora Alyea Planned completion date for corrective action plan: July 2023
Allowable Costs/Payroll Disbursements Recommendation: We recommend that the auditee implement procedures to ensure that: all employee pay rates charged to Federal awards are appropriately approved and documented, and complete and accurate timesheets or equivalent time-and-effort records are maintain...
Allowable Costs/Payroll Disbursements Recommendation: We recommend that the auditee implement procedures to ensure that: all employee pay rates charged to Federal awards are appropriately approved and documented, and complete and accurate timesheets or equivalent time-and-effort records are maintained for all payroll costs charged to Federal awards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Most Federal grants are renewed annually and have not requested any salary rate adjustments. Payroll line items are a lump sum. Serenity House since 2020 performs annually in May a market rate survey for all job positions to ensure wage rates are equitable to fair market for our County and Non-Profit job type. The sources are documented in the workbook that the annual raise percentages; wage adjustments are calculated for board approval. Our annual performance raises and adjustments is a pool of 1 to 5%, and 3 to 6 employees are below market rate each year. People with a market adjustment do not receive a merit increase. 2023 Merit increase is% that is allocated based on performance scores and management team comparison to everyone in that job category. People are scored by manager this score is reviewed by all managers that have employees in that grouped job class. The reviewing managers agreed highest performer with a 5% and lowest performer 1% Raise distribution is based on the performance review score. 2022 Employees are hired for a specific job when they are given their first time card grant line items for the grant they work on are on the time sheet. That time sheet is reviewed and corrected by the immediate supervisor then reviewed by the operations manager. Turned into the main office receptionist who checks submission against the employee list. Checks math and signatures, initials the times card takes up to payroll. 2023 Payroll double checks each time card when entering time into the payroll module. After all time is enter another employee checks the system addition to timecard. 2020 When Checks are manually signed the time is on the timecard and each check is reviewed. Each employee Name(s) of the contact person(s) responsible for corrective action: Kristin Cowan Planned completion date for corrective action plan: July 1 2023
Finding 1224626 (2023-001)
Material Weakness 2023
The City has elected to have the auditors draft the financial statements and related notes, as they do not believe the risk of material misstatement outweighs the cost of implementing additional controls.
The City has elected to have the auditors draft the financial statements and related notes, as they do not believe the risk of material misstatement outweighs the cost of implementing additional controls.
Finding No.: 2023-047 AL Program: 93.778 – Medical Assistance Program (Medicaid; Title XIX) Area: Special Tests and Provisions – Provider Eligibility (Screening and Enrollment) Questioned Costs: $28,448,121 Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: The Commonwealth...
Finding No.: 2023-047 AL Program: 93.778 – Medical Assistance Program (Medicaid; Title XIX) Area: Special Tests and Provisions – Provider Eligibility (Screening and Enrollment) Questioned Costs: $28,448,121 Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: The Commonwealth Medicaid Agency (CMA) respectfully disagrees with the auditor’s finding. CMA does not believe the finding fully reflects the Agency's efforts to comply with provider screening and exclusion requirements during the audit period. While documentation supporting certain screening activities was not readily available for auditor review, the Agency has historically performed provider eligibility and exclusion reviews as part of its enrollment and oversight processes. To further strengthen compliance and documentation practices, CMA has developed provider enrollment and screening procedures, conducted retrospective exclusion reviews where documentation was unavailable, and continues to enhance monitoring activities. In addition, the Agency has expanded staffing resources and continues to recruit and assign personnel dedicated Finding No.: 2023-047, continued AL Program: 93.778 – Medical Assistance Program (Medicaid; Title XIX) Area: Special Tests and Provisions – Provider Eligibility (Screening and Enrollment) Questioned Costs: $28,448,121 Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: to provider enrollment, compliance, and program integrity functions to ensure federal screening requirements are consistently performed, documented, and monitored. Proposed Completion Date: Ongoing
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